Body Dysmorphic Disorder
The essential feature of this disorder is preoccupation with an imagined defect in appearance or a markedly excessive concern with a minor anomaly (see Table 54.1). In body dysmorphic dis-order, a person could be preoccupied with an imagined defect while she or he actually had some other anomaly and was not normal appearing. To exclude conditions with trivial or minor symptoms, the preoccupation must cause clinically significant distress or impairment. By definition, body dysmorphic disorder is not diagnosed if symptoms are limited to preoccupation with body weight, as in anorexia nervosa or bulimia nervosa, or to perceived inappropriateness of sex characteristics, as in gender identity disorder.
Preoccupations most often involve the nose, ears, face, or sexual organs. Common complaints include a diversity of imag-ined flaws of the face or head, including defects in the hair (e.g., too much or too little), skin (e.g., blemishes), and shape or sym-metry of the face or facial features (e.g., nose is too large and deformed). However, any body part may be the focus, including genitals, breasts, buttocks, extremities, shoulders and even over-all body size.
Body dysmorphic disorder has been well described in the European and Japanese literature, generally designated dys-morphophobia, often under the rubric of the monosymptomatic hypochondriacal psychoses. Until recently, it had been virtually ignored in the US literature as well as clinically.
The definition of the disorder was reexamined for DSM-IV on several counts, but especially as to its relationship to other psychiatric disorders (Phillips and Hollander, 1996). After much deliberation, it was determined that body dysmorphic disorder, although often comorbid with anxiety and mood disorders, was sufficiently discrete to be maintained as a separate disorder. As discussed in the differential diagnosis section, it can be distin-guished from depressive disorders and from most anxiety dis-orders, although it resembles obsessive–compulsive disorder in phenomenology, course and even response to treatment. It was also decided to keep it with the somatoform disorders grouping, although it does not share much with the other disorders in this grouping (with the exception of hypochondriasis), beyond the fact that affected patients are generally referred to psychiatrists from other physicians and that they also present with medically unexplained physical complaints (defects in appearance in body dysmorphic disorder).
As De Leon and colleagues (1989) pointed out, it is ex-tremely difficult to determine whether a dysmorphic concern is delusional as in that with body dysmorphic disorder, for a continuum exists from clearly nondelusional preoccupations to unequivocal delusions such that defining a discrete boundary between the two ends of the spectrum would be artificial. Fur-thermore, individual patients seem to move back and forth along this continuum. Support for rejecting the exclusion is prelimi-nary evidence that dysmorphic preoccupations may respond to the same pharmacotherapy (SSRIs), regardless of whether the concerns are delusional. Perhaps as a reflection of the state of knowledge at this point, both body dysmorphic disorder and de-lusional disorder, somatic type, can be diagnosed on the basis of the same symptoms, in the same individual, at the same time. Thus, the definition of body dysmorphic disorder differs from hypochondriasis, which is not diagnosed if hypochondriacal concerns are determined to be delusional.
Knowledge of such parameters is still incomplete. In general, patients with body dysmorphic disorder first present to nonpsy-chiatrists such as plastic surgeons, dermatologists and internists because of the nature of their complaints and are not seen psy-chiatrically until they are referred (De Leon et al., 1989). Many resist or refuse referral because they do not see their problem as psychiatric; thus, study of psychiatric clinic populations may un-derestimate the prevalence of the disorder. It has been estimated that 2% of patients seeking corrective cosmetic surgery suffer from this disorder. Although women outnumber men in this pop-ulation, it is not known whether this sex distribution holds true in the general population.
A number of sociological, psychological and neurobiological theories have been proposed. Body dysmorphic disorder has been explained, at least in part, as an exaggerated incorporation of societal ideals of physical perfection and acceptance of cos-metic plastic surgery to attain such goals. A high frequency of insecure, sensitive, obsessional, schizoid, anxious, narcissistic, introverted and hypochondriacal personality traits in body dys-morphic patients have been described (Phillips, 1991). Various psychodynamic mechanisms and symbolic meanings of dysmor-phic symptoms have been suggested (Phillips, 1991), going back to Freud’s case of the Wolfman who had dysmorphic preoccupa-tions regarding his nose.
Some interesting neurobiological possibilities have emerged, particularly concerning observations that hypochon-driasis, body dysmorphic disorder and a number of other con-ditions involving compelling repetitive thoughts or behaviors may respond preferentially to SSRIs, not to other antidepressant drugs. An obsessive–compulsive spectrum disorders grouping, the pathological process of which is mediated by serotoninergic dysregulation, has been suggested. As further evidence, symp-toms of body dysmorphic disorder as well as those of obsessive– compulsive disorder may be aggravated by the partial serotonin agonist m-chlorophenylpiperazine.
The preoccupations of body dysmorphic disorder must first be differentiated from usual concerns with grooming and appear- ance. Attention to appearance and grooming is universal and socially sanctioned. However, diagnosis of body dysmorphic disorder requires that the preoccupation cause clinically sig-nificant distress or impairment. In addition, in body dysmor-phic disorder, concerns focus on an imaginary or exaggerated defect, often of something, such as a small blemish, that would warrant scant attention even if it were present. Persons with histrionic personality disorder may be vain and excessively concerned with appearance. However, the focus in this disor-der is on maintaining a good or even exceptional appearance, rather than preoccupation with a defect. Such concerns are probably unrelated to body dysmorphic disorder. In addition, by nature, the preoccupations in body dysmorphic disorder are essentially unamenable to reassurance from friends or fam-ily or consultation with physicians, cosmetologists, or other professionals.
Next, the possibility of an explanation by a general medi-cal condition must be considered (see Figure 54.1). As mentioned, patients with this disorder often first present to plastic surgeons, oral surgeons and others, seeking correction of defects. By the time a mental health professional is consulted, it has generally been ascertained that there is no physical basis for the degree of concern. As with other syndromes involving somatic preoccupa-tions (or delusions), such as olfactory reference syndrome and delusional parasitosis (both included under delusional disorder, somatic type), occult medical disorders, such as an endocrine dis-turbance or a brain tumor, must be excluded.
In terms of explanation on the basis of another psychi-atric disorder, there is little likelihood that symptoms of body dysmorphic disorder will be intentionally produced as in ma-lingering or factitious disorder. Unlike in other somatoform disorders, such as pain, conversion and somatization disor-ders, preoccupation with appearance predominates. Somatic preoccupations may occur as part of an anxiety or mood disor-der. However, these preoccupations are generally not the pre-dominant focus and lack the specificity of dysmorphic symp-toms. Because patients with body dysmorphic disorder often become isolative, social phobia may be suspected. However, in social phobia, the person may feel self-conscious gener-ally but will not focus on a specific imagined defect. Indeed, the two conditions may coexist, warranting both diagnoses. Diagnostic problems may present with the mood-congruent ruminations of major depression, which sometimes involve concern with an unattractive appearance in association with poor self-esteem. Such preoccupations generally lack the fo-cus on a particular body part that is seen in body dysmorphic disorder. On the other hand, patients with body dysmorphic disorder commonly have dysphoric affects described by them variously as anxiety or depression. In some cases, these affects can be subsumed under body dysmorphic disorder; but in other instances, comorbid diagnoses of anxiety or mood disorders are warranted.
Differentiation from schizophrenia must also be made. At times, a dysmorphic concern will seem so unusual that such a psychosis may be considered. Furthermore, patients with this disorder may show ideas of reference in regard to defects in their appearance, which may lead to the consideration of schizophre-nia. However, other bizarre delusions, particularly of persecu-tion or grandiosity, and prominent hallucinations are not seen in body dysmorphic disorder. From the other perspective, schizo-phrenia with somatic delusions generally lacks the focus on a particular body part and defect. Also in schizophrenia, bizarre interpretations and explanations for symptoms are often present, such as “this blemish was a sign from Jesus that I am to pro-tect the world from Satan”. Other signs of schizophrenia, such as hallucinations and disorganization of thought, are also absent in body dysmorphic disorder. As previously mentioned, the preoc-cupations in body dysmorphic disorder appear to be on a con-tinuum from full insight to delusional intensity whereby the pa-tient cannot even consider the possibility that the preoccupation is groundless. In such instances, both body dysmorphic disorder and delusional disorder, somatic type, are to be diagnosed.
Body dysmorphic disorder is not to be diagnosed if the con-cern with appearance is better accounted for by another psychiat-ric disorder. Anorexia nervosa, in which there is dissatisfaction with body shape and size, is specifically mentioned in the crite-ria as an example of such an exclusion. Although not specifically mentioned in DSM-IV, if a preoccupation is limited to discomfort or a sense of inappropriateness of one’s primary and secondary sex characteristics, coupled with a strong and persistent cross-gender identification, body dysmorphic disorder is not diagnosed.
The preoccupations of body dysmorphic disorder may resemble obsessions and ruminations as seen in obsessive– compulsive disorder. Unlike the obsessions of obsessive–com-pulsive disorder, the preoccupations of body dysmorphic disor-der focus on concerns with appearance. Compulsions are limited to checking and investigating the perceived physical defect and attempting to obtain reassurance from others regarding it. Still, the phenomenology is similar, and the two disorders are often comorbid. If additional obsessions and compulsions not related to the defect are present, obsessive–compulsive disorder can be diagnosed in addition to body dysmorphic disorder.
Age at onset appears to peak in adolescence or early adulthood. Body dysmorphic disorder is generally a chronic condition, with a waxing and waning of intensity but rarely full remission. In a lifetime, multiple preoccupations are typical; in one study, the average was four (Phillips et al., 1993). In some, the same preoc-cupation remains unchanged. In others, new perceived defects are added to the original ones. In others still, symptoms remit, only to be replaced by others. The disorder is often highly in-capacitating, with many patients showing marked impairment in social and occupational activities. Perhaps a third becomes housebound. Most attribute their limitations to embarrassment concerning their perceived defect, but the attention and time-consuming nature of the preoccupations and attempts to inves-tigate and rectify defects also contribute. The extent to which patients with body dysmorphic disorder receive surgery or medi-cal treatments is unknown. Superimposed depressive episodes are common, as are suicidal ideation and suicide attempts. Actual suicide risk is unknown.
In view of the nature of the defects with which patients are preoccupied, it is not surprising that they are found most com-monly among patients seeking cosmetic surgery. Preoccupations persist despite reassurance that there is no defect to correct surgi-cally. Surgery or other corrective procedures rarely if ever lead to satisfaction and may even lead to greater distress with the per-ception of new defects attributed to the surgery.
First, the generic goals and treatments as outlined for the so-matoform disorders overall should be instituted. These are beneficial in interrupting an unending procession of repeated evaluations and the possibility of needless surgery, which may lead to additional perceptions that surgery has resulted in fur-ther disfigurement.
Traditional insight-oriented therapies have not generally proved to be effective. Results with traditional behavioral tech-niques, such as systematic desensitization and exposure therapy, have been mixed. At least without amelioration with effective pharmacotherapy, the preoccupations do not extinguish as would be expected with phobias. A cognitive–behavioral approach similar to what was recommended for hypochondriasis may be more effective. This includes response prevention techniques whereby the patient is not permitted repetitively to check the perceived defect in mirrors. In addition, patients are advised not to seek reassurance from family and friends, and these persons are instructed not to respond to such inquiries. Some patients adopt such behaviors spontaneously, avoiding mirrors and other reflecting surfaces, refusing even to allude to their perceived de-fects to others. Such “self-techniques” may be encouraged and refined.
Biological treatments have long been used but until re-cently were of limited benefit to patients with body dysmorphic disorder. Approaches have included electroconvulsive therapy, tricyclic and MAOI antidepressants, and neuroleptics, particu-larly pimozide. In most reports of positive response to tricyclic or MAOI antidepressant drugs, it is unclear whether response was truly in terms of the dysmorphic syndrome or simply represented improvement in comorbid depressive or anxiety syndromes. Re-sponse to neuroleptic treatment has been suggested as a diagnos-tic test to distinguish body dysmorphic disorder from delusional disorder, somatic type. The delusional syndromes often respond to neuroleptics; body dysmorphic disorders, even when the body preoccupations are psychotic, generally do not. Pimozide has been singled out as a neuroleptic with specific effectiveness for somatic delusions, but this specificity does not appear to apply to body dysmorphic disorder.
An exception to this uninspiring picture is the observa-tion of a possible preferential response to antidepressant drugs with serotonin reuptake blocking effects, such as clomipramine, or SSRIs, such as fluoxetine and fluvoxamine (Hollander et al., 1992). Phillips and coworkers (1993) reported that more than 50% of patients with body dysmorphic disorder showed a partial or complete remission with either clomipramine or fluoxetine, a response not predicted on the basis of coexisting major depres-sive or obsessive–compulsive disorder. As with hypochondria-sis, effectiveness is generally achieved at levels recommended for obsessive–compulsive disorder rather than for depression (e.g., 60–80 mg rather than 20–40 mg/day of fluoxetine). The SSRIs appear to ameliorate delusional as well as nondelusional dysmorphic preoccupations. Successful augmentation of clomi-pramine or SSRI therapy has been suggested with buspirone, another drug with serotoninergic effects. Neuroleptics, particu-larly pimozide, may also be helpful adjuncts, particularly if de-lusions of reference are present. Little seems to be gained with the addition of anticonvulsants, or benzodiazepines to the SSRI therapy.
As yet, rigorous studies have not been conducted, but anecdotal observations and open-label studies show promise for effective treatment with SSRIs and other serotoninergic agents for this, until now, therapeutically exasperating disor-der. If such approaches fulfill their initial promise, integratedapproaches using pharmacotherapy and other modalities such as cognitive–behavioral therapy may provide effective treat-ment options.