Being dissatisfied with one’s appearance is normal, but BDD is different. Someone with BDD
is preoccupied with their appearance, is excessively self-conscious, and experiences marked
distress and handicap.
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They are typically preoccupied by perceived or slight flaws. The most common
preoccupations in BDD are around the face, especially the nose, skin, hair, eyes, eyelids,
mouth, lips, jaw and chin, but the preoccupation frequently focuses on several body parts.
The location of the main defect may change over time. Both genders are most commonly
concerned with their skin, followed by hair and nose. Man are significantly more concerned
with hair thinning or baldness and their genitals (too small penis). Women are more likely to
be preoccupied with their breasts, hips, weight, and legs, usually believing that they are too
large of fat and their labia being too large. Men are more likely to be preoccupied with body
build and believe that their body is too small, skinny, or not muscular enough (muscle
dysmorphia). Those men are unusually muscular and large and spend hours on their muscles.
DSM IV criteria for BDD:
1 Preoccupation with an imagined defect in appearance. If a slight physical anomaly is
present, the person’s concern is markedly excessive.
2 The preoccupation causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
3 The preoccupation is not better accounted for by another mental disorder.
The cornerstone of the diagnosis of BDD is preoccupation with an imagined or minor defect
in appearance.
Preoccupation should be at the forefront of the mind for at least an hour a day, but:
- Some individuals seek cosmetic surgery.
- Some individuals are not preoccupied as they can avoid others viewing them.
- Misuse of substances may prevent the individual thinking about it.
- Some individuals their avoidance is high depressed about their appearance.
Preoccupation: excessive, self-focused attention on body image, ruminating and comparing
features with those of others. Excessive worrying or thinking about one’s appearance are
emphasized in the process of engagement. The preoccupation often covers multiple locations
and may fluctuate over time and shift to another area of the body.
The term imagined defect can be problematic, because:
- The defect(s) is very real to the individual and telling a client that he has an ‘imagined
defect’ does not assist in engagement or building a therapeutic alliance.
- Aesthetic judgments partly depend on personal aesthetic standards and there is
evidence that clients with BDD may be slightly more aesthetically sensitive than
average and have lost a self-serving positive bias in judgments about their appearance.
Most clients with BDD acknowledge that they are not disfigured, but believe themselves to be
ugly or very unattractive. They might accept that they look normal to others but are
preoccupied by self-disgust.
,All BDD individuals share a preoccupation with one or more aspects of their appearance
which is not shared by others and is excessive and very distressing or handicapping.
BDD by proxy: an individual is excessively preoccupied with the imagined defects of another
individual, such as a partner or close relative.
BDD is at the extreme end of dissatisfaction leading to significant distress or handicap.
78% of the individuals with BDD had lifetime suicidal ideation and 27.5% had made suicide
attempts.
The onset of BDD tends to develop in adolescence, but patients are usually diagnosed on
average 15 years later.
Delusional and non-delusional variants of BDD have many more similarities than differences.
BDD clients are not just disturbed by what their appearance is, but by what it is not or what is
should be.
ICD-10: BDD is not separately classified but is subsumed under hypochondriacal disorder. An
important distinction is that if the beliefs about being defective are considered delusional, then
a client would receive an alternative diagnosis. This in contrast to DSM, which allows an
additional diagnosis of delusional disorder to BDD.
The most common comorbid diagnoses are major depressive episode, social phobia, obsessive
compulsive disorder, and alcohol or substance abuse.
The distinction between a major depressive episode and BDD is difficult, because a
depressive episode is frequently comorbid but typically develops after the onset of symptoms
of BDD. (Depression is the most common additional Axis I disorder) high suicide risk.
Social phobia: someone with social phobia believes that they will behave in a way that is
unacceptable and that this will lead to rejection, loss of worth or status, or failure to achieve
important goals. This is confined to situations in which others will evaluate them negatively.
People with BDD believe they look unacceptable, whether in social or non-social situations.
A comorbid diagnosis of social phobia in BDD can only be made when there is a broader fear
of one or more social and performance situations in which the person is exposed to unfamiliar
people or to possible scrutiny by others and the individual fears that he will act in a way, or
show anxiety symptoms, that will be humiliating or embarrassing.
BDD clients frequently misuse alcohol and illegal substances as a way of coping with distress
and preoccupation. Like other disorders, clients need help to stop drinking or using substances
before BDD treatment, as substances may interfere with therapy and cognitive and emotional
processing.
An additional diagnosis of obsessive compulsive disorder is only given when the obsessions
or compulsions are not restricted to concerns about appearance. The onset of BDD usually
precedes OCD. People with BDD are more likely to have lifetime suicidal ideation, major
depressive disorder and substance use disorder than people with OCD.
,True comorbidity of BDD and eating disorder occurs when a client is preoccupied by
imagined defects in his appearance unrelated to weight and shape. The most common
preoccupations for people with anorexia nervosa were not body parts that were ‘too fat’ or
body parts that are somehow affected by the patient’s weight, but with the nose, skin, hair,
chin, lips, and eyes, like BDD clients without anorexia. The patients with anorexia nervosa
and BDD had significantly lower overall functioning and higher levels of delusionality.
Trichotillomania: reinforced by tension reduction and a sense of gratification that usually
occur with the hair pulling. Individuals may then become ashamed of the consequences of
hair pulling and bald patches, which they try to cover. This is not usually BDD as they are not
preoccupied with an imagined defect or minor physical anomaly. It represents the shame that
stems from an adjustment disorder or another Axis I disorder.
Olfactory reference syndrome: preoccupation with their body odor or halitosis and feels
persistent shame. Sometimes regarded as part of BDD or OCD.
Comorbidity of schizophrenia and BDD is uncommon, because of the presence of
hallucinations, thought disorder, or more bizarre delusions in schizophrenia.
Body integrity identity disorder: individuals who desire one or more digits or limbs to be
amputated. They feel that one or more limbs are not part of their ‘self’ and that amputation
will lead to them becoming more able-bodied. It is a preoccupation which derives not from a
feeling of defectiveness of inadequacy but the expectation that they would be so much more
comfortable in one or more limbs or digits were amputated. Although such individuals are
preoccupied with becoming disabled, they do not believe (as in BDD) their limbs to be
defective or ugly, nor they wish cosmetically to alter their limb. They feel that their
fundamental identity will be ‘set right’ by have the part of body removed or modified. A core
feature is as much the desire for a particular identity as the modification itself.
Body modification or self-mutilation: modify or mutilate their body as a form of art (like ear
scalping, tongue splitting, lobe stretching) or transform their body into an animal (like
Tigerman or Lizardman). This is sometimes confused with BDD.
Koro: also known as genital retraction syndrome. Refers to the fear or belief that one’s penis
is shrinking or retracting into the body. Mainly occurs in Asia. The main differences between
Koro and BDD is that in Koro others in the immediate family share the beliefs and usually it
consists of a transient state of marked anxiety.
Cluster C (anxious or fearful) is the most common personality disorder in BDD patients. In
descending order, avoidant, paranoid, obsessive compulsive, dependent and borderline
personality disorders were the most common.
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BDD was originally termed dysmorphophobia (Morselli): sudden appearance and fixation in
the consciousness of the idea of one’s own deformity; the individual fears that he has become
deformed or might become deformed, and experiences at this thought a feeling of an
inexpressible disaster. When this idea occupies someone’s attention repeatedly on the same
day, and aggressively and persistently returns to monopolize his attention, refusing to remit by
any conscious effort; and when in particular the emotion accompanying it becomes one of
fear, distress, anxiety, and anguish, compelling the individual to modify his behavior and to
act in a predetermined and fixed way, then the psychological phenomenon has gone beyond
the bounds of normal, and may validly be considered to have entered the realm of
psychopathology.
