Body Dysmorphic Disorder

Another mental disorder that is not that well-known, nor talked about, yet creates tremendous distress is body dysmorphic disorder, or BDD.  From the Greek words dys (disturbance) and morph(shape).  There is also a sub type called muscle dysmorphia, relating to obsessive fears concerns to one’s musculature.

About 1 to 2 % of the general population suffer from BDD, equally involving both males and females.   The diagnose can easily be missed, because patients may be ashamed to admit to the ritualistic behaviors involved.   It usually starts in early or late adolescence.

The primary symptom of BDD is a preoccupation with a perceived imperfection or flaw of their appearance.   They are convinced that their imperfection is immediately noticeable by others and in their eyes constitute a disfigurement.  Although it can be anything to do with their body, the most common fears are related to the face, skin,nose and hair.

Another diagnostic criteria is the ritualistic behaviors associated with their appearance.  These can be excessive efforts to conceal  or camouflage with makeup and other means. With muscle dysmorphia patients, you will see excessive working out in gyms.  This is not to be confused with eating disorder patients, who do the same thing.       There is also repeatedly looking in mirrors  and or constantly seeking reassurance .  In a minority of patients is even avoidance of mirrors all together.

These fixated beliefs are so out of proportion to whatever perceived imperfection there is, it can appear delusional.   Most of the time it is not even noticeable to others.   Nevertheless they have obsessional fears of being rejected , pointed out, and or talked about.

The fear associated with this perceived imperfection produces tremendous social anxiety .   Social phobia  and avoidance of social situations out of fear of humiliation is quite common.   It can be very crippling for adolescents, who by nature already have multiple body image fears.     

As you can imagine, they often seek plastic surgery to change their appearance.   The fear of rejection is magnified with these patients because of their self-image, so they will go to great lengths to rectify or change their appearance.  They offer seek multiple procedures as they are rarely satisfied with the initial results.

Recently there was a young man in the news who committed suicide because he had uncontrollable blushing, or erythrophobia.    Although the disease can not be categorised as the same,  the distress and obsessional fears are the same in BDD patients, and often lead to severe depression and suicidal ideation.

Although BDD and obsessive compulsive disorder are different, all dysmorphic patients have ocd symptoms, but solely around their appearance.  OCD  does run in families and those with ocd tendencies, have a higher chance of developing dysmorphia.

In my own practice, I treated a young man around 18 years old, whose mother had  very severe and crippling OCD.  He was very introverted  and social anxious due to his conviction that his nose was deformed, though that was not perceivable to me nor others. He displayed much social avoidance and depression .  I remember there was also quite a bit of family problems relating to his father and jealously with his brother.

With psychotherapy and antidepressants he improved overall, but nevertheless went on to have cosmetic surgery on his nose.  In my opinion, with all obsessional thoughts and fears, there is an underling psychological avoidance going on of other issues.   That is why medication alone is never sufficient with these patients.

Another case of mine,  involved a very pretty woman in her twenties who had obsessional fears about her facial appearance, particularly her eyes, brows and lashes.  Her fears and concern were to the degree that she spent 2 to 3 hours in the morning applying makeup. She also suffered from severe social anxiety and depression.

I remember asking what aspect of make up required the most of her time, and she went into specific detail to how she had to have each lash in a certain place and all diagonal.  In order to accomplish this to her level of perfection, it required repetitive applications.

She would refuse to go out in public without her long makeup ritual.   With cognitive behavioral therapy  and medication, she was able to shorten her makeup routine to under an hour, and improved in all aspects.

SSRI’s or selective reuptake inhibitors are effective in reducing  the obsessive compulsivity in these patients, as serotonin  seems implicative in ocd behavior.  The majority of BDD patients have a high degree of perfectionism and unrealistic expectations, therefore they usually respond well to a combination of psychotherapy and medication.

Though many seek plastic surgery, studies indicate that only 25% approve of the outcome of their fixed part and in the longterm only 2 % show overall improvement of symptoms.  Some who feel surgery has resolved one imperfection, will go on to develop another one. Therefore plastic surgery should really be of last resort with these patients.

Unfortunately with the popularity of cosmetic surgery and the reality of unscrupulous clinicians, these patients are often taken advantage.   I would hope that most surgeons will take the time to evaluate prospective candidates to rule out BDD, but I doubt this is done very often.