BODY DYSMORPHIC DISORDER

BDD is characterized by an unusually exaggerated degree of worry or concern about a specific part of the face or body, rather than the general size or shape of the body. It is distinguished from anorexia nervosa and bulimia nervosa , to the extent that patients with these disorders are preoccupied with their overall weight and body shape. For example, an adolescent who thinks that her breasts are too large and wants to have plastic surgery to reduce their size but is otherwise unconcerned about her weight and is eating normally would be diagnosed with BDD, not anorexia or bulimia. As many as 50% of patients diagnosed with BDD undergo plastic surgery to correct their perceived physical defects.

Causes and symptoms
NEUROBIOLOGICAL CAUSES. Research indicates that patients diagnosed with BDD have serotonin levels that are lower than normal. Serotonin is a neurotransmitter— a chemical produced by the brain that helps to transmit nerve impulses across the junctions between nerve cells. Low serotonin levels are associated with depression and other mood disorders.

PSYCHOSOCIAL CAUSES. Another important factor in the development of BDD is the influence of the mass media in developed countries, particularly the role of advertising in spreading images of physically "perfect" men and women. Impressionable children and adolescents absorb the message that anything short of physical perfection is unacceptable. They may then develop distorted perceptions of their own faces and bodies.

A young person's family of origin also has a powerful influence on his or her vulnerability to BDD. Children whose parents are themselves obsessed with appearance, dieting, and/or bodybuilding; or who are highly critical of their children's looks, are at greater risk of developing BDD.

An additional factor in some young people is a history of childhood trauma or abuse. Buried feelings about the abuse or traumatic incident emerge in the form of obsession about a part of the face or body. This "reassignment" of emotions from the unacknowledged true cause to another issue is called displacement. For example, an adolescent who frequently felt overwhelmed in childhood by physically abusive parents may develop a preoccupation at the high school level with muscular strength and power.
Symptoms
The diagnosis of BDD in children and adolescents is often made by physicians in family practice because they are more likely to have developed long-term relationships of trust with the young people. With adults, it is often specialists in dermatology, cosmetic dentistry, or plastic surgery who may suspect that the patient suffers from BDD because of frequent requests for repeated or unnecessary procedures. Reported rates of BDD among dermatology and cosmetic surgery patients range between 6% and 15%. The diagnosis is made on the basis of the patient's history together with the physician's observations of the patient's overall mood and conversation patterns. People with BDD often come across to others as generally anxious and worried. In addition, the patient's dress or clothing styles may suggest a diagnosis of BDD.

Treatments

The standard treatment regimen for body dysmorphic disorder is a combination of medications and psychotherapy . Surgical, dental, or dermatologic treatments have been found to be ineffective.
Medications

The medications most frequently prescribed for patients with BDD are the selective serotonin reuptake inhibitors, most commonly fluoxetine (Prozac) or sertraline (Zoloft). Other SSRIs that have been used with this group of patients include fluvoxamine (Luvox) and paroxetine (Paxil). In fact, it is the relatively high rate of positive responses to SSRIs among BDD patients that led to the hypothesis that the disorder has a neurobiological component related to serotonin levels in the body. An associated finding is that patients with BDD require higher dosages of SSRI medications to be effective than patients who are being treated for depression with these drugs.
Psychotherapy

The most effective approach to psychotherapy with BDD patients is cognitive-behavioral therapy , of which cognitive restructuring is one component. Since the disorder is rel

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ated to delusions about one's appearance, cognitive-oriented therapy that challenges inaccurate self-perceptions is more effective than purely supportive approaches. Relaxation techniques also work well with BDD patients when they are combined wih cognitive restructuring.
Hospitalization

BDD patients have high rates of self-destructive behavior, including performing surgery on themselves at home (liposuction followed by skin stapling, sawing down teeth, and removing facial scars with sandpaper) and attempted or completed suicide. Many are unable to remain in school, form healthy relationships, or keep steady jobs. In one group of 100 patients diagnosed with BDD, 48% had been hospitalized for psychiatric reasons, and 30% had made at least one suicide attempt.

Prognosis

As of 2002, researchers do not know enough about the lifetime course of body dysmorphic disorder to offer a detailed prognosis. The DSM-IV-TR notes that the disorder "has a fairly continuous course, with few symptom-free intervals, although the intensity of symptoms may wax and wane over time."

Prevention

Given the pervasive influence of the mass media in contemporary Western societies, the best preventive strategy involves challenging those afflicted with the disorder and who consequently have unrealistic images of attractive people. Parents, teachers, primary health care professionals, and other adults who work with young people can point out and discuss the pitfalls of trying to look "perfect." In addition, parents or other adults can educate themselves about BDD and its symptoms, and pay attention to any warning signs in their children's dress or behavior.

See also Aromatherapy ; Yoga

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