Body Dysmorphic Disorder DSM-5 300.7 (F45.22)
DSM-5 Category: Obsessive-Compulsive and Related Disorders
BDD (Body Dysmorphic Disorder) is a DSM-5, (Diagnostic and Statistical Manual of Mental Disorders, fifth edition), diagnosis involving distress due to a perceived physical anomaly, such as a scar, the shape or size of a body part, or some other personal feature. While most individuals feel a degree of doubt or dissatisfaction with their appearance at times, (NHS, 2012) individuals with BDD will experience persistent and intrusive thoughts about the imagined flaw (ADAA, 2014). Other people will not be concerned with, or even notice the anomaly, but the individual with the perceived flaw will alter their interpersonal and professional interactions on the basis of the imagined flaw. BDD can be differentiated from the distorted body image which is a defining feature of eating disorders, in that distorted body image involves a preoccupation with overall body mass, whereas BDD involves focusing on a specific part or feature. Individuals with eating disorders may also be preoccupied with certain, body parts, - e.g. thighs or stomach, but this will be accompanied by excessive concern about one's body mass. Body dysmorphia is a concern with body mass, but the preoccupation centers around inadequate mass or muscularity definition, and may be global or confined to a specific muscle group- e.g,, my medial triceps are too small (American Psychiatric Association, 2013). BDD can cause distress, excessive self-consciousness, and avoidance of social situations and intimacy, leading to depression, isolation, and potentially suicidality (Kenny, Knott, & Cox, 2012),or excessive compensatory behaviors to compensate for the perceived flaw- e.g., narcissism regarding other personal qualities. People with BDD will undergo unneeded cosmetic surgery, dental procedures, or dermatological procedures to correct the perceived flaw (Kenny, Knott, and Cox, 2012), but are typically not satisfied with the results, as this is an internal perceptual problems. Some clinicians and researchers believe BDD is a type of OCD (Obsessive Compulsive Disorder) but this is uncertain if BDD is a part of the OCD spectrum (Kenny, Knott, & Cox, 2012). The DSM-5 currently classifies BDD as a discrete disorder.
Symptoms of Body Dysmorphic Disorder
According to the DSM-5, Body Dysmorphic disorder is defined by four diagnostic criteria, with five specifiers the clinician can add: 1. The person is preoccupied with a physical features which they perceive as flawed, though this is not apparent or a matter of concern to objective observers.. 2. There is a history of a repetitive behavioral component focused on the perceived physical anomaly, such as obsessively examining oneself in the mirror, or grooming to hide or fix the perceived flaw, or seeking reassurance from others about their appearance without satisfaction. Specifiers can include 1. Body dysmorphia- obsession regarding musculature, in which an individual believes they are lacking the desired muscle mass or definition- this specifier can include fixation on a specific muscle or muscle group. The other three specifiers define the degree of insight the person has- 2. Good or fair, e.g., the individual will respond favorably to reassurance for a period of time, or be distractable form their preoccupation, 3. Poor - e.g., the individual will need constant reassurance or have to check frequently on their appearance, but will have moments of insight or 4. Absent/delusional, e.g., in which the person is convinced beyond a doubt of the imperfection, and will not respond to reassurance, or even corrective surgery (American Psychiatric Association, 2013).
The DSM -5 indicates that the typical age of onset of Body Dysmorphic Disorder is ages 12-13, with an average onset of 16-17. (American Psychiatric Association, 2013).
According to DSM-5 data, the incidence of body dysmorphic disorder in the United States is 2.5% in males, and 2.2. % in females. (American Psychiatric Association, 2013) There is a 1% prevalence in the population of the UK (NHS, 2012).
The DSM-5 indicates that child maltreatment is a risk factor for BDD. There is also an increased risk of BDD in first degree relatives with OCD. (American Psychiatric Association, 2013). Sexual trauma can be a risk factor (Buhlmann, Marques, & Wilhelm, 2012). Trauma can result in self-disgust for sexual parts, or a part favored by the attacker- e.g.- hair. Peer abuse, or bullying and teasing may b a contributing factor in BDD (NHS, 2014), however, one must consider the statistical concept of base rate: not all children who are molested, abused, or bullied by peers or otherwise maltreated will develop BDD, so there must be other causes at work . Serotonin insufficiency or imbalance is one culprit that has been identified (see treatment options).
The DSM-5 identifies Depressive Disorder, OCD and substance use as disorders co-morbid with Body Dysmorphia Disorder (American Psychiatric Association, 2013). Individuals with BDD may use drugs or alcohol to reduce anxiety in social situations. BDD can result in depression and in some cases, suicidality (Kenny, Knott, and Cox, 2012),
Treatment for Body Dysmorphic Disorder
BDD is chronic, but responds favorably to treatment (Greenberg & Wilhelm, 2014) CBT (Cognitive Behavioral Therapy) is an effective and evidence based method of treating BDD by challenging irrational beliefs and perceptions regarding body features (American Psychiatric Association, 2013 ; Kenny, Knott, and Cox, 2012), However, initiating treatment may be difficult, as people with BDD may not believe there excessive fixation on what they are convinced is a flawed body part is a psychological disorder. It is noted that SSRI's combined with CBT produce very favorable treatment outcomes (Kenny, Knott, & Cox, 2012; NHS, 2014).
Impact on Functioning
BDD can have a substantial impact on social and occupational functioning. Individual with BDD may believe they are the object of attention when they enter a room, that they are hideous, and anticipate rejection by others (American Psychiatric Association, 2013). They may annoy others and appear insecure or vain by frequently asking others about their appearance, as they do not retain reassurance (ADAA, 2014; NHS, 2012). People with BDD may incur excessive health care costs from unnecessary cosmetic surgery, and dental and dermatological procedures (Greenberg,& Wilhelm, 2014).
Diagnostic rule-outs outlined in the DSM-5 include Eating Disorders, OCD, somatic anxiety, Major Depressive disorder, Anxiety disorders, and psychotic disorders, There are also several non DSM-5 disorders and syndromes which are either rare, or culturally specific, such as gender dysmorphia, olfactory reference syndrome, body identity integrity disorder, Koru, and dysmorphic concern. (American Psychiatric Association, 2013).
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders. (5th Edition). Washington, DC.
ADAA. (2014). Body Dysmorphic Disorder. Anxiety and Depression Association of America. Retrieved February 28, 2014, from http://www.adaa.org/understanding-anxiety/related-illnesses/other-related-conditions/body-dysmorphic-disorder-bdd
Buhlmann, U., Marques, L.M., and Wilhelm, S. ( 2012) . Traumatic Experiences in Individuals With Body Dysmorphic Disorder. Journal of Nervous and Mental Disorders (200) 12. Retrieved February 28, 2014, from http://www.researchgate.net/publication/51973690_Traumatic_experiences_in-individuals_with_body_dysmorphic_disorder
Greenberg,J.L., and Wilhelm, S ( 2014) Treatment for Body Dysmorphic Disorder. International OCD Foundation. Retrieved February 28, 2014, from http://www.ocfoundation.org/eo_bdd.aspx
Kenny, T., Knott, L. and Cox, J. (2012 ). Patient.co.uk. Retrieved February 28, 2014, from http://www.patient.co.uk/health/body-dysmorphic-disorder
NHS. (2012). Body Dysmorphic Disorder. NHS. Retrieved February 28, 2014, from http://www.nhs.uk/conditions/body-dysmorphia/Pages/Introduction.aspx
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