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Psychiatric Clinics of North America

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BODY DYSMORPHIC DISORDER - 06/09/11

Doi : 10.1016/S0193-953X(05)70184-2 
Andrea Allen, PhD *, Eric Hollander, MD *

Resumen

In 1886, Morselli described patients who were obsessed about their ugliness and were convinced that others perceived them as ugly, even though their appearance was objectively normal.37 This seemingly rare and distressing disorder, dysmorphophobia, received periodic coverage in the psychiatric literature of Europe while going largely unmentioned in the United States; the first English language article on dysmorphophobia was published in 1970.22 In 1987, approximately a century after the disorder was first described, it was recognized as a distinct disorder in the DSM-III-R under the name body dysmorphic disorder (BDD). Since then, discussion of BDD in the literature and systematic research on it has exploded so that, while much remains to be learned, knowledge of the characteristics, comorbidities, and treatment of BDD has increased dramatically.

The essential feature of BDD is preoccupation with an imagined defect in appearance in a normal-appearing person or markedly excessive concern about a slight imperfection. To meet diagnostic criteria, the preoccupation must cause clinically significant distress or impairment in functioning, and the symptoms cannot be better accounted for by another mental disorder, such as preoccupation with being fat in anorexia nervosa or distress about physical sexual characteristics in gender identity disorder. BDD is classified as a somatoform disorder (DSM-IV).2

Facial flaws are the most common focus of BDD, but any part of the body can be of concern, and abnormalities of body size or shape and deformity of sexual body parts are also common.5, 25, 43, 44 The perceived defect may be specific, such as a large nose, or general, such as being ugly.25 In an attempt to examine, hide, or change the perceived defect in appearance, most BDD patients perform compulsive or repetitive behaviors, such as frequent mirror checking, excessive grooming, skin picking, or excessive physician visits.25, 43, 44 They also may compulsively seek reassurance from family and friends.

BDD is relatively common. Although no studies of its prevalence in community samples are available, as many as 1.9% of nonclinical samples47 and 12% of psychiatric outpatients57 may have BDD.

The criteria regarding degree of distress and functional impairment distinguish BDD from the lesser degrees of dissatisfaction with appearance that are common in this culture.19 From childhood, fairy tales tell us that beautiful women marry handsome princes and live happily ever after and that the wicked are ugly, whether they be witches or stepmothers. Modern media continue with similar messages: being beautiful or handsome is the key to happiness; good things come most readily to those who are beautiful. Contemporary research supports the proposition that attractiveness enhances social, educational, and occupational opportunities. Although attractive people do have the advantage of being perceived positively, this advantage is modest, inconsistent, influenced by the context. The advantage is greatest at the extremes of attractiveness, and important primarily in initial impressions but lessening as more information becomes available.15, 16

Given the emphasis put on the importance of attractiveness in the media, it is not surprising that physical unattractiveness may represent a risk factor for psychopathology. Dissatisfaction with body image seems to be a stronger risk factor for psychopathology than is actual unattractiveness.10, 17 Consistent with these data, little if any relationship has been found between physical attractiveness and happiness or life satisfaction.14 Physical attractiveness as judged by others has a modest relationship, at best, with seeing oneself as attractive,18 and a person's body image can change without any actual change in appearance.10 Also, the majority of people are dissatisfied in some way with their appearances.13, 19 Some distortion of body image is common among the general public, and the factors underlying this distortion are complex. For example, research has shown that, among a general sample, people who are depressed negatively distort their body image, and those who are not depressed positively distort their body image.36

BDD is an extreme manifestation of body image distortion and dissatisfaction. It is a grave, disabling disorder. Unlike the appearance concerns that occur in the general population, the concerns of patients with BDD create severe distress, with their preoccupations being described as intensely painful, tormenting, or devastating. Patients with BDD have high rates of psychiatric hospitalization, suicidal ideation, and suicide attempts.25, 43, 44, 51 In one sample,44 more than half of patients with BDD reported psychiatric hospitalizations, and 30% had attempted suicide.

Impairment in social and occupational functioning is often extreme. BDD can have a devastating impact on a person's life, with hours each day being consumed by worry, rituals, and efforts at camouflage. Because of preoccupation with and distress regarding the imagined flaw, young patients with BDD may refuse to go to school; older patients may find it impossible to go to work or be unable to go to work, and patients of all ages may avoid social situations and relationships. As many as one third of patients may become housebound.3, 37, 43 Functional disability is a severe problem in patients with BDD because these patients commonly avoid situations that may expose or exacerbate the perceived defect.37, 44, 51 Consequently, many patients with BDD withdraw from interactions with others, which drastically limits their social lives and their school and occupational performance.

Many patients with BDD, as many as 50% by some accounts, turn to surgical procedures in a futile attempt to correct the perceived defect.5, 25, 44 In a survey, the authors found that, on average, patients with BDD are somewhat less satisfied with the outcome of cosmetic procedures than cosmetic surgery patients in general (unpublished observations, 1999). In the authors' experience, patients with BDD may be fully satisfied with the results of surgery but remain just as dissatisfied with their appearances because a new or remaining perceived flaw leaves them as devastated and preoccupied as before.

BDD has frequently been categorized as an obsessive-compulsive spectrum disorder in part because its intrusive obsessive thoughts and repetitive behaviors are similar to those that characterize obsessive-compulsive disorder (OCD).40 BDD has numerous similarities with OCD and other obsessive-compulsive spectrum disorders and seems to lie at the compulsive, risk-averse end of the spectrum. BDD and OCD have an early onset, typically chronic course and, in clinical samples, occur approximately equally in men and women.38 A relatively high comorbidity exists between BDD and OCD. In the DSM-IV OCD Field Trial,51 12% of the patients with OCD had a lifetime comorbid diagnosis of BDD. Also, 37% of patients with BDD have histories of OCD.43 The symptoms of the two disorders are similar. Patients with either disorder may engage in checking; for example, a man with OCD may check doors and windows to make sure they are locked; a man with BDD may check his appearance in mirrors to see whether he looks okay. The preoccupation with appearance typically is considered an obsession, but the diagnosis of OCD is not given if a patient's obsessions focus only on appearance.

This differentiation, establishing BDD as distinct from OCD, is supported by the presence of characteristic differences between the disorders. Notably, the insight of patients with BDD seems to be significantly more impaired than that of patients with OCD.51 Among patients with OCD in the DSM-IV Field Trials,51 30% were completely or mostly lacking in insight regarding their OCD, whereas 49% of those with BDD were completely or mostly convinced that their defects were real.25 These patients were significantly less insightful regarding their BDD than their OCD.51 Phillips et al44 found that of the first 100 cases of BDD, none had excellent insight and 52 were delusional. This lack of insight can lead to a delay in seeking psychiatric treatment. Instead, because they consider their perceived defects to be real, many people with BDD present to specialists such as plastic surgeons, dermatologists, or dentists. When patients consult with mental health professionals, it is most often for depression or anxiety and, because of their extreme secrecy and self-consciousness, careful questioning may be required to uncover their dysmorphic concerns.

As with OCD,27 patients with BDD may be conceptualized as varying along a continuum of insight or certainty. The distinction between insight and delusional certainty was at the center of debate as this disorder was being formally defined. An important issue is whether this difference in insight reflects two different disorders1, 54, 55 or two variants of the same disorder.8 Evidence increasingly supports a single disorder with widely varying levels of insight.23, 29, 41, 44, 51 This developing understanding of the disorder was recognized in DSM-IV, with the diagnosis of BDD being applied to all patients who are preoccupied with an imagined or exaggerated defect in appearance, and the additional diagnosis of delusional disorder, somatic type, being allowed for patients who hold their beliefs with delusional intensity. Phenomenologically, a continuum may exist, but additional biological mechanisms may occur when patients reach the delusional end and when concerns become fixed beliefs. This characteristic may explain the partial efficacy of pimozide,32 a dopamine-receptor blocker, in changing certainty to uncertainty, but more recent research has demonstrated that two potent serotonin reuptake inhibitors (SRIs), fluvoxamine39, 42 and clomipramine,24 are equally effective among delusional and nondelusional patients with BDD.

BDD also has been found to have high comorbidity with social phobia, major depression, and trichotillomania.4, 7, 44, 45, 53, 56 Brawman-Mintzer et al7 found concurrent BDD in 11% of patients with social phobia and 8% of patients with OCD, although they did not find BDD among patients with major depression or other anxiety disorders. For social phobia and major depression, the primary disorder can be difficult to determine: BDD may lead to fear of rejection and depression. Some behaviors, common in patients with BDD, also develop in patients with other disorders. For example, face picking is common among patients with BDD46 and also occurs in patients with trichotillomania.

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 Address reprint requests to Andrea Allen, PhD, Department of Psychiatry, Box 1230, Mount Sinai School of Medicine, One Gustave L. Levy Place, New York, NY 10029, e-mail: andrea.allen@mssm.edu


© 2000  W. B. Saunders Company. Publicado por Elsevier Masson SAS. Todos los derechos reservados.
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Vol 23 - N° 3

P. 617-628 - septembre 2000 Regresar al número
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  • HYPOCHONDRIASIS AND ITS RELATIONSHIP TO OBSESSIVE-COMPULSIVE DISORDER
  • Brian A. Fallon, Altamash I. Qureshi, Gonzalo Laje, Brian Klein
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  • PATHOLOGICAL GAMBLING
  • Eric Hollander, Alison J. Buchalter, Concetta M. DeCaria

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