Description

Body dysmorphic disorder (BDD) is an obsessive compulsive and related disorder in which individuals have pervasive and intrusive feelings regarding an imagined or slight flaw in his or her appearance causing impairment in daily functioning.

• Diagnostic criteria according to the DSM-5 are as follows (all must be met for diagnosis) (1):
  • Preoccupation with a perceived defect or flaw in physical appearance. If a noticeable defect is present, the patient’s perception is grossly exaggerated.
  • The preoccupation results in clinically significant distress or impairment in social, occupational, or other important areas of function.
  • The patient has performed repetitive behaviors or mental acts in response to the appearance concerns at some point during their disease.
  • The preoccupation is not secondary to concerns about body fat or weight that meet diagnostic criteria for an eating disorder.
• Specifiers of BDD include:
  • BDD with muscle dysmorphia: The individual is preoccupied with the idea that his or her body build is insufficiently muscular, regardless of preoccupation with other body areas.
  • Specification by degree of insight:
    • BDD with good or fair insight: The individual understands that the BDD beliefs are not true or that they may or may not be true.
    • BDD with poor insight (27–60%): The individual thinks that the BDD beliefs are probably true.
    • BDD with absent insight/delusional beliefs: The individual is completely convinced that the BDD beliefs are true.

Epidemiology

• Disease onset usually begins during adolescence, with a mean age of onset of 16.4 years (2).
• Dissatisfaction in appearance starts earlier (12.9 years) (2).
• Women are more commonly affected than men (1.5:1) (3).
• Muscle dysmorphia occurs almost exclusively in males.
• Men are more likely to perceive defects with the genitals, body mass, or hair (balding), whereas women are more likely to be concerned about their skin, stomach, weight, breasts, buttocks (4). Disease can occur in childhood, presenting commonly with refusal to attend school or suicidal thoughts.
• Onset is usually gradual but can be abrupt.
• There is often a delay in diagnosis of 10 to 15 years or more after the onset of symptoms.
• Estimates show that 71% of patients with BDD seek and 61% receive cosmetic treatments (2).

Prevalence

• Point prevalence estimated at 1.9–2.7% in the general adult population (3)
• Prevalence in the pediatric population estimated at 2.2% (2)
• More common in women (2.5%) than men (2.2%)
• Significantly higher prevalence in cosmetic surgery (6–20%) and dermatology patients (8–15%) (2)

Etiology and Pathophysiology

• Complex etiology but assumed to be multifactorial involving genetic, biologic, and environmental factors (1)
• Studies have shown various differences in brain anatomy in patients with and without BDD. This includes volume changes in the orbitofrontal and anterior cingulate cortex and asymmetry of the caudate. Studies also show hyperactivity of the left orbitofrontal cortex and bilateral heads of the caudate nuclei. These changes are thought to represent a similar pathophysiologic mechanism to obsessive-compulsive disorder (OCD) (4).
• Dopamine D2/3 receptor availability is lower in patients with BDD compared to healthy patients.
• A cognitive behavioral model describes reinforcement-based operant conditioning and social learning pertaining to attractiveness that leads to development of maladaptive appearance-related behaviors, beliefs, and values, especially traits of perfectionism. Attractiveness is very important to patients with BDD, but they feel unattractive, leading to poor self-esteem.

Risk Factors

• Genetic predisposition—estimated heritability of 43%
• Appears to be clustered with OCD and hoarding disorder
• Anxiety disorder or social phobia
• Pathologic skin picking
• Shyness, perfectionism, or anxious temperament
• Childhood adversity including:
  • Abuse or neglect
  • Teasing or bullying, particularly appearance-based teasing
  • Poor peer relationships
  • Social isolation
• History of dermatologic or other physical stigmata
• Being more aesthetically sensitive than average
• Low self-esteem
• First-generation immigrant status

Commonly Associated Conditions

• Major depressive disorder (36–90%) (2)
• OCD (30–91%)
• Social anxiety disorder (34%)
• Panic attacks (29%)
• Attempted suicide (22%)
• Eating disorders (7–14%)
• Substance-related disorders (25–49%)
• Bipolar disorder
• Delusional disorder