Like most mental illnesses, Body Dysmorphic Disorder (BDD) is an extreme exaggeration of a normal behavior, in this case, the desires to look good and be accepted. The problem of BDD usually starts at adolescence, and effects both men and women equally.
What is Body Dysmorphia?
The Body Dysmorphic Disorder has been described by psychiatrists for more than one hundred years, and is found in all cultures around the world. It was first codified by the American Psychiatric Association in the 1980’s in the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) as dysmorphophobia. BDD is a characteristic of “individuals who are preoccupied with some imagined defect in physical appearance that is out of proportion to any actual physical abnormality that may exist.”
The DSM-5 classifies BDD as a form of Obsessive-Compulsive Disorder (OCD) and requires specific criteria including:
- Appearance Preoccupations
- Repetitive Behaviors
- Clinical Significance
- Differentiation From Eating Disorders
Most of us worry about how we look. Preoccupation is defined as thinking about the perceived imperfections at least an hour a day. The unique feature of BDD is the perceived imperfections are small. The physical flaw can range from slight to nonexistent, and the imperfections may not be noticeable to anyone other the the person with BDD. Thinking about obvious flaws is not a form of BDD, but may be classified as form of OCD if it interferes with social interaction.
Repetitive, compulsive behaviors in response to the appearance concerns is another requirement for BDD. Again, these are exaggerations of normal behavior. Behaviors may include excessive grooming, mirror checking, skin picking, reassurance seeking or clothes changing. Mental manifestation may include constantly comparing one’s appearance with that of other people, feeling that others are treating one a certain way because of the perceived flaw or alternatively, that if the flaw were fixed, life would be perfect.
Normal appearance concerns are not treated with medication or therapy. For BDD to be diagnosed, the preoccupation must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. It’s the psychological equivalent of the sporting term, “No harm, no foul.”
Differentiation From Eating Disorders
When the appearance concerns center around being too fat or weighing too much, the problem may be an eating disorder, rather than a body dysmorphic disorder. Concerns with fat or weight in a person of normal weight can be a symptom of BDD, and it is not uncommon for patients to have both an eating disorder and BDD.
Important Features of Body Dymorphic Disorder
There are two specifiers for BDD that are prognostic: Muscle Dysmorphia and the Degree of Insight.
Muscle Dysphoria is a preoccupation that one’s body build is too small or insufficiently muscular. Usually seen in men, this type of behavior is associated with more self-destructive actions and a poorer quality of life. Higher rates of suicidality and substance abuse are found in Muscle Dysphoria than other forms of BDD.
The Degree of Insight is important for both recognition and treatment of BDD. The levels of insight are defined as;
- Good or Fair Insight
- Poor Insight
- Absent Insight or Delusional Beliefs
All sufferers of BDD feel their problem is real. Those with good insight, may be able to recognize that their flaw does not bother everyone or that their preoccupation is wasting a good part of their day or causing social problems. Absent Insight or Delusional Beliefs are much harder to treat. Words like slight or imagined used to describe their defects may just leave them feeling misunderstood, invalidated, alienated or insulted. More information is available on the Interaction OCD Foundations web site, and this article by Katharine Phillips, MD, about the Diagnosis and Clinical Assessment in BDD.
How Common Is Body Dysmorphic Disorder?
It is estimated that 1 to 2% of the population has BDD. Fearing the stigma of vanity, most BDD sufferers hide the preoccupation, so diagnosis is not simple. BDD is likely under diagnosed, and often unsuspected, even by Psychiatrists and Plastic Surgeons. Screening questionnaires have be proposed, but these depend on how forthcoming the person with BDD is and, to a large extent, on the patients’ insight. The Body Dysmorphic Disorder Foundation has an example on their web site here: Do I Have BDD Questionnaire.
BDD and Depression
A history of depression may be a tip-off; however, there are a lot more people with depression than with BDD. Interestingly, the same types of medications indicated for depression, can also help with some cases of BDD. Of course, only a trained professional can make the diagnosis and formulate an appropriate treatment plan. Body Dysmorphic Disorder is difficult to recognize and can be difficult to treat, but the first step is awareness of the disorder.