Body Dysmorphic Disorder

Body dysmorphic disorder is a disease that few people know much about. It is not, however, a newly discovered disease. According to Dr. Katharine Phillips, descriptions of people suffering from a preoccupation with their image have been found from up to 100 years ago. (Phillips, Muting the Obsessions) It was officially identified as a distinct condition by the American Psychiatric Association in 1987. (Kirchner, par. 1) Due to the lack of literature on the subject, the disease is both under researched and under diagnosed. (Renshaw, par. 12) Today, improvements in assessment, evaluation, and treatment continue to be developed as scientists are discovering the importance and widespread nature of the disease. It has been found that, as of today, B.D.D has affected more than five million people in the United States alone. (Zal)

The name of this disease was derived from an Italian psychiatrist named Enrique Morselli, who originally created the term “dysmorphophobia.” In literal terms, dysmorphophobia means “fear of ugliness.” (Renshaw, par. 12) An article in U.S. News & World Report claimed that the disorder’s name is also linked to a Greek myth. This associated myth states that a historian named Herodotus once used the word ‘dysmorfia’ to describe the ugliest girl in Sparta. The girls’ appearance was supposedly so grotesque that she was taken to a shrine every day in hopes of having her ugly facial distortions revoked from her body. (Schroff, par. 4)

This disorder is considered to be a psychiatric disease because the people suffering from it do not actually have the “deformed” areas that they believe they have. The Spartan-child-theory is simply connected to today’s definition of dysmorphia because a large number of cases involve people who find faults in their facial features; specifically the nose, mouth, skin, hair and eyes (just like the girl had.) (Schroff, par. 4) Over time, there have been reports of cases where people claim to be suffering from the same discomfort and delusions in different areas of the body, including arms, feet, and genitals. (Schroff, par. 4)

B.D.D is a disease that generally affects adolescence, and is most common around the age of 30. However, diagnosis’ of the disease have also been applied to young children and the elderly. (Zal) There are several characteristics that sufferers of B.D.D posses. The first sign is an extreme obsession with body appearance. This can be viewed through constant mirror-checking, skin-picking, (Patterson) asking others about their appearance, and overall excessive grooming. In most cases, sufferers believe that a specific area on their body is either deformed or extremely ugly when in reality there is little to nothing wrong with the appearance of this body part. (Schroff, par. 5) These people tend to seek approval from others regarding their appearance, and may even ask about specialists to get “help” with the areas they suffer from delusions with.

The term that makes up this disease as well as plays a major role in the lives of B.D.D victims is what is known as “body image.” The body image is defined in three parts; first it is based upon the way a person perceives their own appearance, then how this perceived image is reflected on others, and then, lastly, the general accuracy of this perception. People with B.D.D obviously have an unbalanced body image. (Cororve and Gleaves 950) Other unwanted characteristics that come along with B.D.D include general anxiety, social anxiety, shyness, insomnia, perfectionism, difficulty holding intimate relationships, and extreme sensitivity to rejection or criticism. (Zal)

Many sufferers tend to avoid social situations or even leaving the house at all. It may also affect their work and personal lives because of the extreme depression that B.D.D leads to. Along with this comes severe self-consciousness and constant worry about how others perceive them and their appearance. The symptoms of B.D.D can become worse and even life-threatening to victims in times of stress. (Zal) In some cases, B.D.D sufferers have resorted to attempting suicide due to the “tormenting” and “devastating” nature of the disease. (Patterson) Statistics claim that “Up to 40 percent of BDD sufferers consider suicide, and some 17 to 33 percent attempt suicide.” (Bryant) While it is true that not all sufferers have every symptom, and some patients hold unique characteristics, psychologists claim the aforementioned as symptoms seen in the vast majority of B.D.D victims.

No form of B.D.D was mentioned in the Diagnostic and Statistical Manual of Mental Disorders (DSM) until 1980, when the book began to include the term “dysmorphophobia,” defined as an atypical somotoform disorder. (Zal) It was originally stated to be a non psychotic disorder, but changes were made once it was discovered that victims suffer from dysmorphic and delusional beliefs. (Cororve and Gleaves 952) The book officially listed body dysmorphic disorder as a disease in 1987. The description of the disease stated that “a diagnosis for B.D.D can be made concurrently with a diagnosis of delusion disorder. Some patients may fluctuate between delusional and non delusional thinking. BDD can coexist or overlap with many other psychiatric illnesses, including mood disorders, anxiety disorders, and schizophrenia.” (Zal) The book’s criteria for a B.D.D patient is someone who has “A preoccupation with an imagined defect and, if a slight physical anomaly is present, the person’s concern is marked excessively. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of function.” (Jordan)

As the disease becomes more and more profound, psychiatrists are now discovering that many patients are suffering from B.D.D and not another disease that has been linked to it in the past. These “linked diseases” include somatoform disorders such as OCD (Obsessive Compulsive Disorder) and hypochondria, as well as eating disorders like anorexia nervosa and bulimia nervosa. Before B.D.D was at all prominent in the science and psychology world, it was typical for doctors to diagnose their patients with one of these similar disorders.

OCD has many equivalent symptoms to BDD – sufferers tend to be “preoccupied with perfection, symmetry, and a concern that ‘something isn’t right.'” (Cororve and Gleaves 953) This can result in repetitive, time-consuming behaviors. Some of the medications that have been used with OCD patients have shown positive effects on those suffering from body dysmorphic disorder. (Kirchner, par. 3) The two are also both commonly linked to depression. However, it has been found that BDD patients are more closely related to depression than OCD victims because they have a harder time with social phobia, and a greater rate of suicide attempts. (Cororve and Gleaves 953) Because of this, almost all BDD patients have at least a mild form of depression. In retrospect, fifteen percent of patients with OCD also suffer from B.D.D (Zal)

It is common for people to believe that BDD can be placed into the same category as an eating disorder because, on the surface, these diseases appear to be virtually the same. Sufferers of both BDD and eating disorders hold deep concerns over their appearance, experience dillusions, tend to avoid social situations, and search for beauty remedies to cure their so-called “ailments.” Patients of both diseases also have difficulty in explaining their appearance. B.D.D patients are only slightly more accurate in such descriptions because they experience delusions in specific areas of the body, whereas those with eating disorders face a general discomfort in their appearance. (Schroff, par. 8) There are some major differences that set the two apart, however. Patients with eating disorders tend to be much more focused on weight loss and eating, while BDD patients focus on a particular area of their body. BDD victims also tend to avoid social situations much more than someone with an eating disorder. Another very significant characteristic that separates the two is the fact that the number of men and women suffering from BDD is almost equal, while a much greater percentage of women tend to endure eating disorders than men. (Cororve and Gleaves 953)

Another disease that is oftentimes linked to body dysmorphic disorder is hypochondria, which is also classified as a somotoform disorder. The two diseases are similar considering that patients of both diseases suffer from intense delusions, and are both linked to depression and OCD. Hypochondriacs, however, use their disease as a means for seeking out attention. They willingly seek out a “cure” and try to make others (as well as themselves) believe that they are in fact sick. Body dysmorphic sufferers are very different in that they keep almost all their feelings inside. Very rarely does a B.D.D victim wish to draw any attention to themselves. (Jordan) B.D.D patients who visit medical doctors like dermatologists or cosmetic surgeons are looking to find an answer to their deformities. They are not seeking out the attention it brings. If anything, psychologists almost wish that patients of B.D.D would seek out the attention so that there disease can be diagnosed. (Schroff, par. 8)

Researchers are hoping that as more positive results are obtained from newly created treatments, that a large number of people will come forward and admit to their problems with B.D.D. Due to the fact that those with the condition have such a great shame in their feelings, it is hard for people to admit that the problem they are suffering from is mental and not actually physical. (Schroff, par. 8) For this reason, B.D.D is also the underlying cause for a great majority of medical visits. It is necessary for doctors and medical professionals to understand what body dysmorphic disorder is so that they can identify it when a patient comes to them in search of a physical diagnosis. The result of an uninformed medical practitioner is unnecessary diagnosis and ingestion of medications, leading the victim to actually become physically sick while maintaining their original delusions. (Zal)

As the classification system has thoroughly developed for of this condition, a necessary and vast improvement in treatment for patients with body dysmorphic disorder has come about as well. Specific treatments for body dysmorphic disorder have evolved that do not encompass all the ailments that come with other linked diseases, but are far more focused on the delusions that the patients suffer from with BDD. In early cases, psychiatrists used methods of pharmacotherapy and psycho dynamic therapy to treat patients. (Cororve and Gleaves 960) A mixed review of outcomes came from these methods, and further development lead scientists to create different types of cognitive and behavioral treatments. This treatment includes things like rating which parts of their body they found most distressing, hiding or removing mirrors, limiting the time they spend getting ready, and doing their best to refrain from asking others about their appearance – all at a gradual pace. (Schroff, par. 12)

Most psychologists use therapy to stop their patients’ destructive behavior, and boost their self-esteem. Most importantly, though, psychologists wish to have their patients understand that their behavior is not ensuing any positive outcomes. (Patterson) A key element in therapy is something psychologists call “vivo exposure.” This is when the psychologist actually exposes the patient to their fears and continues to present the fearful objects until they become comfortable dealing with this fear. Some examples of vivo exposure include going out in public, meeting new people, or speaking to others. (Zal) Over time, this cognitive method has also incorporated skill training, reverse role-plays, and psycho education. (Cororve and Gleaves 961) If nothing else, this type of therapy does help to improve the low self-esteem, depression, shame, and guilty feelings that come along with B.D.D. (Zal) New methods of therapy are continually being adapted every day.

Lastly, psychologists have found that some drugs, although not able to completely revoke the symptoms a B.D.D victim is forced to live with, are at least able to calm their fears dramatically. Antidepressants have been used, as the effect is a bombardment of the brain’s receptor cells which have been proposed as a possible cause for the delusions that come with B.D.D. (Schroff, par. 11) High doses of serotonin, also sometimes taken as SRI’s (Serotonin re-uptake inhibitors) are said to help with “distress and demoralization about your appearance.” These types of drugs are often prescribed to people with obsessive compulsive disorder and, for this reason, are more effective in helping patients reduce obsessive thoughts, depression, and overall severity of the illness, however not as greatly effective in reducing the delusions patients experience. (Patterson) Due to the fact that the use of drugs has not been proven to be any more effective then simple cognitive therapy, it is suggested that B.D.D patients try to work without medication until a more developed drug has been made. (Patterson)

While the origins of body dysmorphic disorder remain unclear, several theories and ideas have come about in the last few decades. It has been suggested that the disease may in fact come from “an underlying brain disorder.” This theory is based upon the fact that, in addition to their ailments, BDD sufferers have been known to complain of hypersensitivity, and extreme shyness. (Schroff, par. 9) Because B.D.D patients have been somewhat responsive to serotonin, a chemical that plays a major role in the brain’s thoughts or preoccupations, it is also possible that there is a lack of the chemical in a victim’s brain. (Renshaw, par. 15) Dopamine, another chemical in the brain, has been proposed as a possible connection to body dysmorphic disorder as well. (Zal)

The general feeling, however, is that B.D.D is completely based on psychological factors. Early works of literature on the subject suggest that victims of the disorder may become disgusted
with certain parts of their body to express their inner personality difficulties. (Cororve and Gleaves 956) Most psychologists agree that these difficulties may stem from a traumatic event in a person’s life, such as the loss of a family member or the end of a relationship. (Schroff, par. 9) Other factors that may influence someone’s development of body dysmorphic disorder include cultural elements and childhood experiences. An example of culture influence may be the tendency for a specific group of people to place great enthusiasm on the appearance of a particular body part or the overall body image. Those who have deformities or are not entirely confident in their appearance can develop the B.D.D mind-set. For instance, some cultures consider deformity to be evil and will even go so far as to starve children who are born with any form of abnormality. (Jordan) Much like this, childhood experience has the tendency to create an extreme self-consciousness in people who are B.D.D susceptible. Being teased by peers, adults, or parents because of physical problems like acne or obesity can lead to the development of B.D.D (Cororve and Gleaves 956)

In the past decade, several new innovative forms of testing for B.D.D have come about. One of the earliest was called “The B.D.D Examination” (BDDE). This test entails a 30-minute interview by a clinician who bases the result on preoccupation with self appearance, self-consciousness, embarrassment, activities, and body checking. (Cororve and Gleaves 958) Some of the basic questions asked on this examination include things like: “Does the concern about your appearance ever preoccupy you? ,” “Do you wish you could worry about your appearance less? ,” “Does your preoccupation with your appearance ever affect your personal, social, or work life? ,” “Does your concern affect friends or family? ,” “Do you avoid anything because of the way you look?” (Zal) Other examinations that have developed include: The Brown Assessment of Beliefs Scale (BABS) where the patient is asked about the world around them; The Overvalued Ideas Scale (OVIS) where a rating of primary obsessive belief is calculated; The Dysmorphic Concern Questionnaire (DSQ) which assesses the overall concern of physical appearance. (Cororve and Gleaves 959)

One aspect of B.D.D that many people have recently taken an interest in is how it links to
cosmetic surgery. Perhaps if cosmetic surgery were available many years ago, there would be a
larger array of knowledge about B.D.D today. It has been shown that 5-15% of all people looking into cosmetic surgery suffer from the disease. (Bryant) Almost 50% of B.D.D victims go through with cosmetic surgery. (Kirchner, par. 1) They resort to surgery in hopes that it will stop the dillusions they face toward particular parts of their body. However, in most cases of victims who undergo such surgeries, the result is dissatisfaction or a diversion of attention to a different part of their body. (Bryant)

If cosmetic surgeons were to screen their potential clients using a basic psychological examination, more people could be diagnosed and treated for B.D.D before they undergo self-mutilation of their bodies. David B. Sarwer, Ph.D., assistant professor of psychology at the University of Pennsylvania, gives several examples of ways that an office can examine their clients for the disorder. The first thing to watch out for is if the client is asking for help with something they can’t visualize or describe. He states that cosmetic surgeons should be aware that almost all B.D.D patients will wear some type of camouflage on or around the body part they take discomfort in such as excessive clothing, or thick makeup. He also says that asking the client if they have been affected in their personal or work lives in any way by their distaste for this body part can disclose if they are suffering from B.D.D. Lastly, Sarwer suggests that doctors take notice of repeated requests for surgery. (Bryant)

Psychologists also suggest that cosmetic surgeons question their clients about the motivation for these surgeries. If their answer pertains to an external factor, such as problems in marriage, cosmetic surgery tends not to solve the issue. If the answer is internal, such as a general dissatisfaction with the appearance of a body part, surgeons should be very careful as to determining why their clients feel this way. (Jordan)

B.D.D is on its way to becoming an epidemic in our society. At this point, it is hard for psychologists and scientists to point a finger at any particular point and say it is what has caused the epidemic. It is possible that our culture and media has played a significant in the development of the disease, but the chance of an underlying brain disorder and the vast history can not be ruled out. Medical doctors, psychologists and scientists are continuing their research to find out more on the history, causes, and possible treatments to help the millions of Americans suffering from severe delusions involving their body image.