Body dysmorphic disorder Health Article

Causes

The causes of BDD fall into two major categories, neurobiological and psychosocial.

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 brainthat 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 obsessionabout 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 central symptom of BDD is excessive concern with a specific facial feature or body part. Research done in the United Kingdom and the United States indicates that the features most likely to be the focus of the patient's attention are (in order of frequency) complexion flaws (acne, blemishes, scars, wrinkles); hair (on the head or the body, too much or too little); and facial features (size, shape, or lack of symmetry). The patient's concerns may, however, involve other body parts, and may shift over time from one feature to another.

Other symptoms of body dysmorphic disorder include:

• Ritualistic behavior. Ritualistic behavior refers to actions that the patient performs to manage anxiety and that take up excessive amounts of his or her time. Patients are typically upset if someone or something interferes with or interrupts their ritual. In the context of BDD, ritualistic behaviors may include exercise or makeup routines, assuming specific poses or postures in front of a mirror, etc.
• Camouflaging the "problem" feature or body part with makeup, hats, or clothing. Camouflaging appears to be the single most common symptom among patients with BDD; it is reported by 94%.
• Abnormal behavior around mirrors, car bumpers, large windows, or similar reflecting surfaces. A majority of patients diagnosed with BDD frequently check their appearance in mirrors or spend long periods of time doing so. A minority, however, react in the opposite fashion and avoid mirrors whenever possible.
• Frequent requests for reassurance from others about their appearance.
• Frequently comparing one's appearance to others.
• Avoiding activities outside the home, including school and social events.

The loss of functioning resulting from BDD can have serious consequences for the patient's future. Adolescents with BDD often cut school and may be reluctant to participate in sports, join church- or civic-sponsored youth groups, or hold part-time or summer jobs. Adults with muscle dysmorphia have been known to turn down job promotions in order to have more time to work out in their gym or fitness center. Economic consequences of BDD also include overspending on cosmetics, clothing, or plastic surgery.

Demographics

As was mentioned earlier, BDD is primarily a disorder of young people. Its true incidence in the general population is unknown; however, it has been diagnosed in 1.9% of nonclinical patients and 12% of psychiatric outpatients. The DSM-IV-TRgives a range of 5%–40% for patients in clinical mental health settings diagnosed with anxiety or depressive disorders to be diagnosed with BDD. One community study published in 2001 found that 0.7% of women between the ages of 36 and 44 met the criteria for BDD. The disorder appears to be equally common in men and women.

As a result of gaps in research, little is known as of 2002 about the lifetime course of BDD or its prevalence in different ethnic or racial groups. The majority of patients in research studies to date have been Caucasians, but it is not clear whether this reflects racial patterns in the wider society or whether it represents referral bias, in that most study subjects are patients in private psychiatric hospitals. Anecdotal evidence, however, indicates that Asian Americans and African Americans with BDD are more likely to obsess about facial features or skin color that conflict with appearance ideals that dominate the mass media and have been derived from Caucasian people. Information through research done on the history of the American cosmetics industry reveals the startling statistic that African Americans spend three to five times as much money on personal care products as Caucasian Americans. In addition, successful African American and Asian American models, male as well as female, tend to resemble the Caucasian appearance ideal more than they deviate from it.