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Michael Craig Miller, M.D., is editor-in-chief of the Harvard Mental Health Letter and an assistant professor of psychiatry at Harvard Medical School. Dr. Miller has an active clinical practice and has been on staff at Beth Israel Deaconess Medical Center for more than 25 years.
Question:
Can you give me more information on body dysmorphic disorder?
Answer:
Body dysmorphic disorder (BDD) is an extreme, distressing and sometimes disabling form of self-consciousness about looks. People with BDD become extremely preoccupied with body characteristics that they consider defects. About half the time, this preoccupation reaches delusional proportions; that is, the concerns are completely unrealistic. Often, though, the person knows that the worry is unreasonable — but then the symptoms may become a source of shame.
Since the shame leads BDD patients to cover up the problem, it is not easy for family members or doctors to detect it. Thus, experts estimate that the disorder is much more common than most people think. The rate of BDD in the general population could be as much as 2 percent, and overlaps somewhat with anxiety and depression. That includes plenty of people seen in the offices of general practitioners and psychiatrists, but in dermatology and cosmetic surgery clinics, up to 15 percent of the patients may have BDD.
When appearance becomes the only source of self-esteem, the consequences can be significant. Patients may not be able to resist the compulsion to repeatedly examine the perceived defect, accompanied by the desire to repair or hide it. They may misread the way others perceive them and endlessly seek reassurance or stop socializing. Relationships and work performance may suffer. Almost half of people with BDD develop problems with substance abuse. The torment in some instances ends with suicide; fortunately, such an extreme is uncommon.
Men and women suffer with BDD at the same frequency. Men often have a special form of BDD called "muscle dysmorphia." Unlike the average weightlifter or bodybuilder, the man with this disorder can never be muscular enough. He feels undersized even though he works out constantly. He gets depressed and nervous, and never stops thinking about his diet and exercise routine. Some of these men fall victim to steroid abuse or develop an eating disorder.
Up to 50 percent of people with BDD will pursue dermatology treatment or surgery, but they are often disappointed with the outcome. They feel worse after treatment, even though objectively it appears successful. Depression and suicidal thoughts may follow.
No doubt, culture and temperament influence rates of BDD. People with BDD seem to value aesthetics more than average, and a surprising number have backgrounds in art or design. Our culture, as reflected in media and advertising, places an increasing emphasis on having a certain look and a muscular, athletic body. These same media images make cosmetic surgery seem like an attractive option. In a recent interesting cultural comparison, Westerners were more dissatisfied with their body than Taiwanese men, who live in a culture where a naked male body seldom appears in advertising.
According to psychiatry's diagnostic manual, body dysmorphic disorder is a somatoform disorder, akin to hypochondriasis. One variation on its name is "dermatologic hypochondriasis." But the illness seems to span categories. The obsessive preoccupations and compulsive behaviors — checking the mirror, grooming — are like obsessive compulsive disorder. When the concern over appearance includes excessive attention to weight and diet, it seems like an eating disorder. The homebound person with BDD may be seen as having social phobia. Some practitioners see it as a form of depression.
It is very tough to get people with BDD to accept treatment. Many patients do not recognize that their beliefs about their body are mistaken, or that they may have a mental disorder. A few studies demonstrate that SSRI antidepressants like fluoxetine (Prozac) and others can help. High doses are probably necessary. Compared to treating depression, BDD treatment needs more time — usually eight to10 weeks before the drugs take effect. SSRIs are also useful in the delusional form of the illness. Theoretically, antipsychotics should help delusions, but in this illness they tend not to work if an antidepressant is not also prescribed. Cognitive behavior therapy can help in milder (non-psychotic) forms of the illness.
The first step is recognizing the problem. A short screening questionnaire can help identify people who have this disorder. It is available for adults at: http://www.butler.org/body.cfm?id=236.
One important goal is to avoid unnecessary cosmetic procedures and surgeries. Simple reassurance by family and friends rarely works, so it is essential for the person to pursue mental health care. Such a referral is often resisted, but at that point education about BDD sometimes succeeds in getting the patient to accept a referral to a mental health clinician familiar with the disorder. The best outcome is when the patient learns to focus attention on the underlying psychological problem.