Overview
Categorised under Obsessive Compulsive Disorder in DSM-5, Body Dysmorphic Disorder is characterised with intense preoccupation with oneโs appearance. This obsession may be over a perceived flaw or a slight defect. A person with this disorder might engage in compulsive behaviours such as skin picking, over exercising, reassurance seeking, etc.
While the causes of Body Dysmorphic Disorder are not known, it has overlapping symptoms with somatic disorders, eating disorders and obsessive compulsive disorders. People with eating disorders along with body dysmorphic disorder often obsess over their weight and body shape.
However, people with body dysmorphic disorder may be preoccupied with a specific body part. They may engage in ritualistic actions such as checking in the mirror, excessive grooming, etc. relating the symptoms to those of obsessive compulsive disorder.ย
Several theories of Body Dysmorphic Disorder link negative affectivity i.e feelings of anxiety, self dissatisfaction, and sadness with onset of Body Dysmorphic Disorder. Theories also link traumatic childhood incidents such as being bullied over appearance, critical family members and low self esteem with it.
Body Dysmorphic Disorder is also related to executive dysfunction and visual processing abnormalities, where they are biased towards processing details rather than holistic or configural aspects of visual stimuli.ย
Common Signs and Symptoms
People with Body Dysmorphic Disorder are often self conscious and report feeling โuglyโ. They may exhibit these symptoms:
- Preoccupation (3-8 hours per day) with a part(s) of the body. This often includes skin imperfections: acne, wrinkles, scars or blemishes; stomach or chest, penis size in men, muscles, facial features, hair or thinning of hair, thighs, butts, etc.
- These parts may be perfectly normal but perceived as abnormal and defective or they may have a slight (not commonly) noticeable defect.
- They engage in repetitive behaviours showing concern over their appearance. These behaviors include comparing oneโs appearance to that of the others, repeatedly checking perceived defects in the mirror or other reflective surfaces, excessive grooming (styling, shaving plucking), finding ways to conceal the defect (using clothing, hats, make up), etc.
- Constant reassurance seeking, touching the area of the defect, skin picking are also common behaviours.
- Some people try to seek surgery or other cosmetic procedures to change the defect. They may try to perform these surgeries themselves and make it worse. Excessive exercising and weight lifting are also common among men who perceive themselves as lean and having lesser muscles.
- These behaviours cause significant distress and impairment in their daily functioning.
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Risk Factors
There are both genetic as well as environmental factors associated with the development of Body Dysmorphic Disorder. First relatives of patients who have OCD are at risk of developing Body Dysphoric Disorder.
Although studies on environmental factors warrant more research, some have been able to link them to childhood maltreatment and abuse. Almost 79% of adults with Body Dysmorphic Disorder reported childhood abuse.
Bullying and peer victimisation are also associated with development of Body Dysmorphic Disorder symptoms in adolescents. 80% of patients suffering from Body Dysmorphic Disorder complain about suicidal ideation amd 24-28% have attempted suicide.
Although the exact number is not known, completed suicide rate among people with Body Dysmorphic Disorder are also high.ย
Diagnosis
To be diagnosed with Body Dysmorphic Disorder, following symptoms must be present:
- Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others.
- The individual has performed repetitive behaviours in response to appearance concerns.
- The preoccupation causes significant impairment in social, occupational and other important areas.
Clinical psychologists often give the diagnosis for Body Dysmorphic Disorder. They are to rule out if the symptoms are related to body fat and weight concerns. They are required to specify if the preoccupation is with the body being too small or lean (muscle dysmorphia). They have to specify the insight that the person has with regards to their dysmorphic beliefs.
Treatment
Treatment includes both medication and psychotherapy. Cognitive Behavioural therapy is often recommended and documented with empirical evidence to help in the management of Body Dysmorphic Disorder.
12-22 sessions of CBT are conducted with specific strategy being exposure with response prevention. In this strategy, the client is exposed to the feared object in a slow, controlled manner and clients are prevented from engaging in safety seeking behaviours.
Other goals include neutralising distress, motivational enhancement techniques, psychoeducation, etc.ย
Selective Serotonin Reuptake Inhibitors are often prescribed to reduce intrusive thoughts and repetitive behaviours. Studies suggest a dosage slightly higher than that used for the treatment of depression. Pharmacotherapy options still need to be explored.
However, a study on the use of Escitalopram to prevent relapse found that SSRIs must be continued long term to prevent relapses.ย ย
Differential Diagnosis
1. Eating disorders: The concern of being fat or overweight is a symptom of eating disorders and body dysmorphic disorder. Eating disorders and body dysmorphic disorder can be comorbid, in which case both should be diagnosed.
2. Other obsessive-compulsive and related disorders: The preoccupations and repetitive behaviors of body dysmorphic disorder focus only on appearance. These disorders have other differences, such as poorer insight in body dysmoฯhic disorder. When skin picking is intended to improve the appearance of perceived skin defects, body dysmorphic disorder is diagnosed instead of excoriation. When hair removal (plucking or pulling) is done to improve perceived defects in the appearance of facial or body hair, body dysmoฯhic disorder is diagnosed rather than trichotillomania.
3. Illness anxiety disorder: Individuals with body dysmorphic disorder are not preoccupied with having or acquiring a serious illness.
4. Major depressive disorder: The prominent obsession with appearance and repetitive behaviors in body dysmorphic disorder differentiate it from major depressive disorder. However, depressive symptoms are common in individuals with body dysmoฯhic disorder, due to the distress and impairment that body dysmorphic disorder causes. Body dysmoฯhic disorder should be diagnosed in depressed individuals only if diagnostic criteria for body dysmoฯhic disorder are met.
5. Anxiety disorders: Social anxiety and avoidance are common in body dysmorphic disorder. However, body dysmorphic disorder includes consistent concern about appearance, which may be delusional. Unlike generalized anxiety disorder, anxiety and worry in body dysmoฯhic disorder focuses only on appearance flaws.
6. Psychotic disorders: Many individuals with body dysmorphic disorder have delusional appearance beliefs which are diagnosed as body dysmoฯhic disorder, with absent insight/ delusional beliefs, not as delusional disorder. Appearance-related ideas or delusions of references are common in body dysmorphic disorder.
Comorbidity
The highest comorbidity being with major depressive disorder, body dysmorphic disorder is also comorbid with OCD, substance-related disorders and social anxiety disorder.
Specialists
Clinical psychologists and psychologists must be approached to help with Body Dysmorphic Disorder.
In Conclusion
It is good to be conscious about our body appearance in a healthy way, but the problem arises when the subtle consciousness turns into an obsession. Individuals start observing minute or made-up flaws in themselves and are so embarrassed by their appearance that they avoid any sort of social contact.
Although there is no guaranteed way of preventing or curing Body Dysmorphic Disorder, it is advisable to start therapy and consult a professional at an early stage. Usually, this condition stems in the early teens of an individual and if not treated at an early stage can turn into eating disorders that eventually cause extreme physical & mental harm.
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