Body dysmorphic disorder

History

In 1886, Enrico Morselli reported a disorder he termed dysmorphophobia, describing a feeling of being ugly despite no apparent physical abnormality. The American Psychiatric Association recognized the disorder in 1980, categorizing it as an atypical somatoform disorder in the DSM-III. The 1987 revision of the DSM-III changed the term to body dysmorphic disorder. The DSM-IV, published in 1994, defined BDD as a preoccupation with an imagined or trivial defect causing social or occupational dysfunction.

The DSM-5, published in 2013, shifted BDD to the obsessive–compulsive spectrum, added operational criteria, and noted the muscle dysmorphia subtype. The term 'dysmorphic' comes from the Greek 'dusmorphíā', with 'dys-' meaning abnormal and 'morphḗ' meaning shape. Sigmund Freud referred to a patient with classical BDD symptoms as 'Wolf Man'.

Signs and symptoms

Individuals with BDD hold extreme misperceptions about their physical appearance, often focusing on the face, skin, stomach, arms, or legs, though nearly any body part can be involved. The concern is usually an overvalued idea rather than a delusion, but about one in three cases is delusional. A subtype called muscle dysmorphia involves perceiving one's body as too thin despite being muscular. Sufferers typically ruminate for several hours daily, engage in repetitive checking, social avoidance, camouflaging with cosmetics or clothing, and may seek reassurance.

Some avoid mirrors, change outfits repeatedly, groom excessively, or restrict eating. BDD involves more depression and social avoidance than obsessive–compulsive disorder, and often co-occurs with social anxiety disorder. Some individuals experience delusions that others are covertly pointing out their flaws. Cognitive testing and neuroimaging indicate a bias toward detailed visual analysis and emotional hyper-arousal.

Severity waxes and wanes, with flare-ups leading to absences from school or work, protracted social isolation, and sometimes becoming housebound. Social impairment is usually the greatest, and distress often exceeds that of major depressive disorder.

Causes

The cause of BDD is likely biopsychosocial, involving genetic, developmental, psychological, social, and cultural factors. It usually develops in early adolescence, though many patients report earlier trauma, abuse, neglect, teasing, or bullying. Social anxiety often precedes BDD. One twin study estimated heritability at 43%.

Other contributing factors include introversion, negative body image, perfectionism, heightened aesthetic sensitivity, and childhood abuse or neglect. A 2021 study found that more than 75% of adults with BDD had experienced some form of childhood maltreatment, with emotional neglect being a particularly strong risk factor. As children grow into adulthood, they may visualize the abuse done to their bodies and seek to hide or change it to avoid reminders of the trauma.

Diagnosis

Body dysmorphic disorder first appeared in the DSM in 1987, but its formal diagnostic criteria were added in the DSM-IV. Many clinicians, especially general practitioners, still know little about it. People often hide their symptoms due to shame about their appearance concerns and fear of being seen as vain. Because its symptoms overlap with other conditions, BDD is frequently mistaken for social anxiety disorder, obsessive-compulsive disorder, major depressive disorder, or social phobia.

Social anxiety disorder and BDD are highly linked: among people with BDD, 12 to 68.8 percent also have social anxiety disorder. The Body Dysmorphic Disorder Questionnaire correctly identifies all cases (100 percent sensitivity) and mistakenly flags 7.5 percent of healthy people (92.5 percent specificity). BDD also co-occurs with eating disorders in up to 12 percent of cases. The DSM-5 classifies BDD as an obsessive-compulsive disorder.

Early treatment is crucial because BDD carries a suicide rate 2 to 12 times higher than the national average. It frequently accompanies anxiety, depression, psychotic, or bipolar spectrum disorders.

Did You Know?

• A large systematic review and meta-analysis estimated the global prevalence of BDD in the general population at approximately 17%, with the highest rates in Latin America (31%) and the lowest in Oceania (10%).
• Among patients seeking plastic surgery, the estimated prevalence of BDD is 24%; among psychiatric patients, 18%; and among dermatological patients, 16%.
• A treatment manual developed by Dr. Sabine Wilhelm and colleagues for BDD symptoms resulted in improved symptoms with no asymptomatic decline.