Body Dysmorphic Disorder (BDD)

Body Dysmorphic Disorder (BDD) is a clinically recognised condition defined as a preoccupation with a perceived defect in one’s appearance. If a slight defect is present, which others hardly notice, then the concern is regarded as markedly excessive. 
 
In 1891, an Italian doctor, Enrico Morselli, first coined the term dysmorphophobia, from the Greek word ‘dysmorph’ meaning misshapen. He described it as a subjective feeling of ugliness despite a normal appearance. Freud once described a patient whom he called the ‘Wolf man’ who had classical symptoms of BDD. The patient believed that his nose was so ugly that he avoided all public life and work. The media sometimes refer to BDD as ‘Imagined Ugliness Syndrome’ although for the person with BDD, the ugliness is very real. BDD was not published in the Diagnostic and Statistical Manual of Mental Disorders until 1987. It was subsequently renamed Body Dysmorphic Disorder in 1997 in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) under the somatoform disorders. 
 
In order to obtain a diagnosis of BDD, the preoccupation must cause significant distress or handicap in social, school or occupational life. The degree to which people experience BDD varies so that some people will acknowledge that they may be blowing things out of all proportion. Others are so firmly convinced about their defect that they are regarded as having a delusion. 
 
Whatever the degree of insight into their condition, people with BDD often realise that others think their appearance to be ‘normal’ and have been told so many times. They usually distort these comments to fit in with their views (for example, “They only say I’m normal to be nice to me” or “They say it to stop me being upset”). Alternatively, they may firmly remember one critical comment about their appearance and dismiss 100 other comments that are neutral or complimentary. 
 
According to the NICE guidelines, it is estimated that approximately 0.5-0.7% of the UK population have BDD. Clinical samples tend to have an equal proportion of men and women across all age groups. In children and young people, body dysmorphic disorder usually has an early-adolescence onset at about age 13. Although symptoms can be found in children as young as 5, it is rare for children under 12 to be diagnosed with BDD. It is important for parents and physicians to recognise debilitating nature of BDD and not dismiss it as simply a passing phase.

There are various proposed causes of BDD but no definite answer. A psychological explanation would argue certain stresses or life events such as teasing or bullying during adolescence may precipitate the onset and would emphasize a person’s low self-esteem and the way they judge themselves almost exclusively by their appearance as a contributing factor to the disorder. 
Alternatively, some people with BDD have high aesthetic standards and an impossible ideal. There seems to be certain environmental triggers which contribute to the disorder and an individual’s personal psychology. Alternatively researchers have argued that there is a genetic link and possibly genes which predispose someone to BDD, hence the large number of individuals who have family members also suffering the same disorder or a related one. Finally a chemical biological explanation would emphasize low levels of serotonin, a chemical in the brain which is thought to regulate mood, pain and anxiety. Finally sometimes the use of drugs such as Ecstasy may be associated with the onset. Although the causes of BDD are still unknown it is more important to recognise its treatability. 

There are various proposed causes of BDD but no definite answer. A psychological explanation would argue certain stresses or life events such as teasing or bullying during adolescence may precipitate the onset and would emphasize a person’s low self-esteem and the way they judge themselves almost exclusively by their appearance as a contributing factor to the disorder. Alternatively, some people with BDD have high aesthetic standards and an impossible ideal. There seems to be certain environmental triggers which contribute to the disorder and an individual’s personal psychology. Alternatively researchers have argued that there is a genetic link and possibly genes which predispose someone to BDD, hence the large number of individuals who have family members also suffering the same disorder or a related one. Finally a chemical biological explanation would emphasize low levels of serotonin, a chemical in the brain which is thought to regulate mood, pain and anxiety. Finally sometimes the use of drugs such as Ecstasy may be associated with the onset. Although the causes of BDD are still unknown it is more important to recognise its treatability. 

BDD has a high rate of co-morbidity, which means that people diagnosed with the disorder are highly likely to have been diagnosed with another psychiatric disorder; most commonly associated disorders are major depression, social phobia, or obsessive compulsive disorder (OCD), alcohol/substance misuse or eating disorders. According to the NICE guidelines, co-morbidity also includes people with mild disfigurements or blemishes attending dermatology clinics or seeking cosmetic surgery. 
 
Other conditions that frequently exist in combination with BDD or are confused with BDD include Anorexia Nervosa: This is a disorder where individuals are more preoccupied by self control of weight and shape but still have anxiety regarding their image. Skin picking and trichotillomania: Skin picking is self explanatory; trichotillomania involves an urge to pluck one’s hair or eyebrows repeatedly. If the skin picking or hair plucking is out of concern with one’s appearance then BDD is the main diagnosis; Obsessive Compulsive Disorder (OCD). 

A separate diagnosis of OCD should only be made if the obsessions and compulsions are not restricted to concerns about appearance; Hypochondriasis: The suspicion or conviction that s/he is suffering from a serious illness which leads a person to avoid certain situations and to check their body repeatedly. 
 
It is important to recognise that the disabling nature of the disorder can lead to feelings of futility and depression. Suicidality is higher in people who are experiencing body dysmorphia. While studies have shown that if BDD is not treated correctly in adolescence, it can become chronic, when it is treated appropriately most people eventually get better. 

For support, information and advocacy please call 0845 390 6232 
 
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