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In 1891, an Italian physician by the name of Enrique Morselli first identified "dysmorphophobia" as "the fear of having a deformity, a subjective feeling of ugliness or of a physical defect."1
Today, "dysmorphophobia" is called Body Dysmorphic Disorder (BDD), and it is defined as a somatoform disorder "characterized by extreme dissatisfaction and preoccupation with a perceived appearance defect that often leads to significant functional impairment."2
Individuals living with BDD obsess over their perceived "ugliness," may withdraw from social society, and suffer from depression and/or anxiety. BDD is a disorder that encompasses the characteristics of many other disorders such as obsessive compulsive disorder (OCD), major depressive disorder, social anxiety disorder, agoraphobia, trichotillomania, and schizophrenia.3
Due to the similarities of the characteristics patients display that suffer from this range of diagnoses, BDD is often misdiagnosed and under diagnosed by health care professionals. It is very important health care professionals are able to accurately identify the signs and symptoms of BDD in order to prevent the potential complications related to misdiagnosis, such as inappropriate and ineffective treatment options and the possible manifestations of other symptoms.
Diagnostic Criteria for BDD
In order for a patient to be diagnosed with BDD, the Diagnostic and Statistical Manual of Mental Disorders (DSM IV) includes three criteria which must be present:
- A preoccupation with an imagined or slight defect in physical appearance; if a slight physical anomaly/defect is present, the person's degree of concern is considered extreme
- The preoccupation causes marked distress or impairment in social, occupational or other areas of functioning
- The preoccupation is not attributable to the presence of another psychiatric disorder
The distress and dysfunction associated with BDD can lead to repeated hospitalizations, suicidal ideation and attempts to commit suicide. Avoidance of usual activities may lead to extreme social isolation or attempts to camouflage the "defect" by doing such things as growing a beard to hide imagined facial scars or wearing a hat to hide imagined hair loss, as stated in the DSM IV.
 Important clinical features health care providers should look for are impairments in social functioning, which include avoiding school, work, dating, and other social interactions.2
Unfortunately, patients with BDD avoid social situations because they are insecure, ashamed and constantly feel ugly and afraid others will notice and make fun of their "defect."4
Katharine Phillips, MD, a major author and contributor to research regarding BDD, found many patients spend a significant amount of time performing behaviors and routines to hide or improve their perceived appearance flaws. These behaviors include checking mirrors, wearing heavy make up to camouflage the defect, excessive grooming, touching the defect, comparing themselves to others, seeking constant reassurance from others about their defect, changing clothes, and extreme dieting.4
These acts and rituals BDD patients perform day after day are similar to rituals performed by patients with OCD, making BDD more difficult to diagnosis and differentiate from OCD. Phillips and her colleagues proposed "BDD is a member of the OCD-spectrum, a group of disorders that may be related to OCD, or a variant of OCD."5
Patients with OCD obsess over contamination, pathological doubt, and a need for symmetry and exactness, as compared with BDD patients who obsess over contamination, symmetry/exactness, and hoarding.5
Causes & Contributing Factors
Biological, psychological and sociocultural factors can contribute to the diagnosis of BDD. Regarding the biological aspect of BDD, Phillips et al conducted a study on 200 participants, of which 40 had at least one first-degree family member with BDD.5 Serotonin and dopamine function also may contribute to BDD because it has been proven that patients with BDD respond well to medications that alter the levels of both these neurotransmitters.2
Results of two research studies found damage to the frontal temporal region of the brain can cause the onset of BDD.6
Research done by David Sarwer, PhD, another pioneer in the study of BDD, states that, psychologically, "BDD arises from an unconscious displacement of sexual or emotional conflict or feelings of inferiority, guilt or poor self image onto a body part." 2
Psychiatric mental health nurse Candice Knight, PhD, EdD, APN, said she found 100 percent of her patients with BDD went through some kind of past trauma or history related to body image, and that was the reason for the somatization of their anxiety and depression onto a body part.
Lastly, sociocultural factors for BDD arise from the social histories of these people. If a patient was raised in a family that was neglectful and critical, the patient could develop BDD. Another reason a patient could develop BDD is if they were already predisposed to anxiety and anxious behaviors growing up, and are then teased or humiliated about some distinguishable physical characteristic later on in their life possibly at school, work or another social settings.1
Positive and supporting relationships with family, friends and lovers, therefore, play a major role in how one develops their sense of self esteem in relation to their body image.
Media Influences
It is interesting to note the impact that living in Western society has on the importance people place on their looks in general. For example, the fear of obesity in American culture has made many people extremely concerned with their body weight; physical attractiveness, especially in women, is almost always linked to being thin.7
Young girls often grow up playing with their Barbie doll, and boys with their superhero action figures; it seems harmless, but even this has implications for developing a poor self image. Research shows girls who play with Barbie have lower body esteem and a desire for a thinner shape.8 A frightening fact is if Barbie were a real woman with those proportions, her waist would be 39 percent smaller than that of anorexic patients and her body weight would be so low she would not be able to menstruate.8
Negative perceptions of one's own body image, combined with the pressure from various media outlets to look a certain way, is learned early on. Children in elementary school were reported to feel that being obese was worse than being handicapped.9 Health care professionals are at an advantage where we can serve as educators, and teach our patients how to live a healthy lifestyle and maintain a positive self image.
Demographics of the BDD Population
There are differing data pertaining to the ratio of males to females that BDD affects. Crerand and others found BDD affects men and woman equally,2 while the research conducted by Phillips and others stated "the ratio of females to males is in the range of 1:1 to 3:2."4
Among different ethnic groups, no significant differences have been discovered in terms of the severity of body image concerns.10 Current research findings reveal between 1.7 and 2.4 percent of the general population suffer from BDD, and yet most researchers believe the disorder is still underdiagnosed and underreported. 11
The onset of BDD is usually during adolescence, the time when individual's bodies are physically changing, hormones are racing, and peer pressure is at an all time high. Famed psychoanalyst Erik Erikson believed the main conflict during adolescence was to form an ego identity versus identity confusion. The eight tasks of that period included: searching for one's identity, appreciating one's achievements, growing independent from your parents, forming close relationships with peers, developing analytical thinking, evolving one's own value system, developing a sexual identity and beginning to choose a career.
In one of the largest studies conducted on BDD, the average onset of BDD was 16.4 years of age, plus or minus 7 years.2
This is a significant fact to take into consideration if working with the pediatric population because these health care professionals are better able to hone in on the signs of symptoms of possible BDD in their patients.
Valeria Dworkowitzgraduated from Rutgers University in 2010. She is a staff nurse on the TBI unit at the Kessler Institute for Rehabilitation, West Orange, NJ.
References
1. Hunt, T.J, Thienhaus, O., & Ellwood, A. (2008). The mirror lies: body dysmorphic disorder. The American Academy of Family Physicians,78(2), 217-218.
2. Crerand, C.E., Franklin, M.E. & Sarwer, D.B. (2006). Body dysmorphic disorder and cosmetic surgery. The American Society of Plastic Surgeons. Retrieved November 16, 2011, from the World Wide Web: http://journals.lww.com/plasreconsurg/Abstract/2006/12000/Body_Dysmorphic_Disorder_and_Cosmetic_Surgery.21.aspx
3. Phillips, K.A. (2006). The presentation of body dysmorphic disorder in medical settings. Prim Psychiatry,13(7), 51-59.
4. Phillips, K.A., Didie, E.R., Feusner, J., & Wilhelm S. (2008). Body dysmorphic disorder: treating an underrecognized disorder. The American Journal of Psychiatry,55, 1111-1114.
5. Phillips, K.A., Pinto, A., Menard, W., Eisen, J.L., Mancebo, M., & Rasmussen, S.A. (2007). Obsessive-compulsive disorder: a comparison study of two possibly related disorders. NIH Public Access,24(6), 399-409.
6. Pavan, C., et al. (2008). Psychopathologic aspects of body dysmorphic disorder. Aesthetic Plastic Surgery,32(3), 473-484.
7. Bearman, S.K., Martinez, E. & Stice, E. (2006). The skinny on body dissatisfaction: A longitudinal study of adolescent girls and boys. Journal of Youth and Adolescence,35(2): 217-22.
8. Dittmar, H., Halliwell, E., & Ive, S. (2006). Does Barbie make girls want to be thin? The effect of experimental exposure to images of dolls on the body image of 5-8-year-old girls. Developmental Psychology, 42, 283-29.
9. Byrd-Bredbenner, C., Murray, J., and Schlussel, Y.R. (2005). Temporal changes in anthropometric measurements of idealized females and young women in general. Women & Health,41(2):13-30.
$10. Marques, L., Weingarden, H., LeBlance, N.J., & Wilhelm, S. (2011). Treatment utilization and barriers to treatment engagement among people with bdd symptoms. Journal of Psychosomatic Research,(70)3, 286-293.
11. Buhlmann, Ulrike, & Winter, A. (2011). Perceived ugliness: an update on treatment-relevant aspects of body dysmorphic disorder. Current Psychiatry Report, 13(4), 283-288.
12. Phillips, K.A., & Dufresne, R.G. (2002). Body dysmorphic disorder: a guide for primary care physicians. Prim Care,29(1), 99-vii.
13. Phillips, K.A., & Grant, J.E. (2005). Recognizing and treating body dysmorphic disorder. Ann Clin Psychiatry,17(4), 205-210.$0 $0
14. Carlock, C. (2008). Flawed perceptions: Virginia RNs on lookout for body dysmorphic disorder symptoms. Nursing Spectrum/NurseWeek. Retrieved April 25, 2009 from http://nurse.com.
15. Hofmann, S.G., & Heinrichs, N. (2003). Differential effect of mirror manipulation on self-perception in social phobia subtypes. Cognit Ther Res,27(2), 131-142.
16. Morgan, A.J., & Jorm, A.F. (2008). Self help interventions for depressive disorders and depressive symptoms: a systematic review. Annals of General Psychiatry,7(13), 1-23.
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