What Physicians Need To Know About Body Dysmorphic Disorder

Medicine and Health Rhode Island, May 2006 by Phillips, Katharine A

PHYSICIANS-ESPECIALLY PSYCHIATRISTS, dermatologists, plastic surgeons, primary care physicians, and pediatricians-need to understand body dysmorphic disorder (BDD). Even though BDD is a mental disorder, a majority of patients with this illness seek surgery or nonpsychiatric medical treatment (e.g., dermatologic treatment) for their symptoms.1-3 Patients tend to be dissatisfied with these treatments.1-1 Some sue, or are even violent towards, the treating physician.4 As a noted dermatologist stated: "I know of no more difficult patients to treat than those with body dysmorphic disorder."4

Individuals with BDD are preoccupied with an imagined or slight defect in their physical appearance (for example, "scarred" skin or a "large" nose).3 They believe that they look abnormal, whereas the appearance defects they perceive are slight or nonexistent. The appearance preoccupations go beyond normal appearance concerns: they cause clinically significant distress or impairment in functioning. While such concerns may sound trivial, on the Medical Outcomes Short Form (SF-36), individuals with BDD have poorer quality of life than patients with depression, type II diabetes, or a recent myocardial infarction.5,6 From 78% to 81% have experienced suicidal thinking; 22%-28% have attempted suicide.7-9 A retrospective study of dermatology patients known to have committed suicide over 20 years found that most of the patients who suicided had acne or BDD.10 In the only prospective study of the course of BDD, the rate of completed suicide was higher than has been reported for any other mental illness.11

The Body Dysmorphic Disorder and Body Image Program at Butler Hospital (www.BodyImageProgram.com or www.butler.org/body.cfmFid= 123) is a leading research center for BDD.

A PATIENT WITH BODY DYSMORPHIC DISORDER

Ms. A, a 27-year-old single white female, presented with a chief complaint of "I see a lot of skin doctors." She had consulted with dozens of dermatologists, to no avail. Convinced that she had severe acne, scars, and "veins" on her face, she frequently checked mirrors, spent hours a day applying makeup, and picked at her skin. She stated that because she so incessantly sought reassurance from dermatologists, "most of the dermatologists in Boston are probably seeing therapists because of me."

Ms. A. had dropped out of college, was unemployed, and was housebound. She had attempted suicide and had been psychiatrically hospitalized. Treatment with numerous antibiotics and isotretinoin had not diminished her concerns. However, treatment with psychotropic medication (fluoxetine [Prozac]) significantly improved her BDD symptoms. Her preoccupation, distress, and suicidality diminished, and her functioning improved.

CLINICAL FEATURES OF BODY DYSMORPHIC DISORDER

BDD occurs in all age groups. It most often begins during early adolescence.9,12 The gender ratio appears to be in the range of 1:1 to 3:2 (female:male). 9,12 Individuals with BDD may describe themselves as ugly, unattractive, "not right," deformed, or abnormal. Some describe themselves as "hideous" or looking like a "freak" or "monster." Patients most often focus on the skin (e.g., acne, scarring, skin color), hair (e.g., hair thinning or excessive facial or body hair), or nose (e.g., size or shape).3,7,9,12 However, they can focus on any body area. The preoccupations are usually difficult to resist or control and occur for an average of 3 to 8 hours a day.3

Nearly all patients perform compulsive, repetitive behaviors which aim to check, hide, or fix the perceived defects.3,9,12 These behaviors are time consuming and are difficult to resist or control. They include checking mirrors and other reflecting surfaces, comparing with other people, excessive grooming, touching the body areas, seeking reassurance about the perceived flaws, changing clothes, and compulsively buying clothes or makeup. Camouflaging the perceived defects -with clothing, makeup, a hat, hair, hand, or body posture - is common. About one quarter of patients tan to cover perceived acne scarring, facial marks, or "pale" skin.13 One third to half of patients pick their skin9,12,14 to try to improve the skin's appearance (e.g., "smooth out" or remove blemishes). However, the picking, particularly with implements like pins, needles, razor blades, or knives, can damage the skin. Thus, some patients with BDD who pick their skin are an exception to the rule that people with BDD look normal. Skin picking is occasionally life-threatening-for example, when major blood vessels are ruptured.14

Level of functioning is typically very poor.3,5,6 A high proportion of patients are unemployed, unable to stay in school, socially isolated, or even housebound.

BODY DYSMORPHIC DISORDER IS RELATIVELY COMMON

The reported prevalence in community and nonclinical student samples ranges from 0.7% to 13%.3 A US study15 found that 12% of 268 patients seeking dermatologic treatment screened positive for BDD. A study from Turkey found that 9% of acne patients had BDD.16 The prevalence of BDD in cosmetic surgery settings has ranged from 6%-15%.3 A study of 122 general psychiatric inpatients found that 13% had BDD, which was more common than schizophrenia, obsessive compulsive disorder, post-traumatic stress disorder, and eating disorders.17 In that study, 81% of patients with BDD said that BDD was their major or biggest problem.