Body Dysmorphic Disorder

Body dysmorphic disorder (BDD) is a somatoform disorder characterized by the patients

excessive concern with an imagined or minor defect in physical appearance. (Pavan et al., 2008)

In DSM V, BDD has been included in the new OCRDs chapter due to similarities between BDD

and OCD. While the core feature of BDD has remained unchanged - that is distressing or

impairing preoccupation with perceived appearance defects or flaws that are not observable or

appear slight to others - there have been added new features to this condition (Phillips et al.,

2010). The new criterion (Criterion B) emphasises the similarities between OCD and BDD,

referring to the repetitive behaviours (Saxena S., 2011). Other notable changes are represented

by the inclusion of a muscle dysmorphia criterion (Grohol, 2013) and of the delusional form of

the disorder (absent/delusional beliefs). (Phillips et. al., 2012) Clinical literature has suggested

that BDD is characterized by poorer insight than OCD, an important similarity to OCD. In terms

of treatment, BDD, as OCD, is using pharmacological treatment with SRIs and psychological

treatment in the form of CBT (Williams, Hadjistavropoulos, and Sharpe, 2006).

Diagnostic Features

According to criterion A, individuals with body dysmorphic disorder are preoccupied with one or

more perceived defects or flaws in their physical appearance, which they believe look ugly,

unattractive, abnormal, or deformed, even though the perceived flaws are not observable or

appear only slight to other individuals. The preoccupations are intrusive, unwanted, time-

consuming (occurring, on average, 3-8 hours per day), and usually difficult to resist or control.

Criterion B involves the fact that excessive repetitive behaviours or mental acts are performed in

response to the preoccupation. These acts are time-consuming, difficult to resist or control and

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are not pleasurable, increasing anxiety and dysphoria. Also, the preoccupation must cause

clinically significant distress or impairment in social, occupational, or other important areas of

functioning, according to Criterion C. The last criterion states that appearance preoccupation is

not better explained by concerns with body fat or weight in an individual whose symptoms meet

diagnostic criteria for an eating disorder. Body dysmorphic disorder must be differentiated from

an eating disorder. Muscle dysmorphia, a form of body dysmorphic disorder occurring almost

exclusively in males, consists of preoccupation with the idea that one's body is insufficiently lean

or muscular. Body dysmorphic disorder may be associated with three levels of insight regarding

body dysmorphic disorder beliefs: good or fair , poor and absent insight. (Association, 2013)

Course of illness

Subclinical concerns usually evolve gradually to the full disorder, although some individuals

experience abrupt onset of body dysmorphic disorder. The disorder appears to usually be chronic,

although improvement is likely when evidence-based treatment is received. The disorder's

clinical features appear largely similar in adolescents and adults. (Pavan et al., 2008)

Epidemiology

The most common age at onset is 12-13 years. Regarding gender distribution, BDD appears to be

largely similar in females and males; however, men are more likely to be preoccupied with their

small body build (muscle dysmorphia), whereas women are more likely to be preoccupied with

weight. Considering the comorbidity, major depressive disorder is the most common comorbid

disorder, with onset usually after that of body dysmorphic disorder. Comorbid social anxiety

disorder , OCD, and substance-related disorders are also common.( Phillips et. all, 2015)

Etiology

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Genetic Factors: Several twin studies similarly suggest that there is a genetic overlap between

BDD and OCD, although they examined the broad concept of dysmorphic concern rather than

the disorder BDD (e.g., Monzani et al., 2012b). One small candidate gene study found an

association for the GABA-A-2 (5q31.1-q33.2) receptor gene (Phillips et al., 2010a).

Neurobiological Factors: BDD is associated with abnormal visual processing. Preliminary data

also suggest abnormalities in executive functioning (e.g., Dunai et al., 2010). One study found a

leftward shift in caudate asymmetry and one found smaller orbitofrontal cortex and anterior

cingulate and larger thalamic volumes (Phillips et al., 2010a). Small studies suggest that BDD

may be characterized by compromised white matter fibres and inefficient connections or poor

integration of information between different brain areas, which is associated with poorer BDD-

related insight (Buchanan et al., 2013; Feusner et al., 2013). Another study found relative

hyperactivity in the left orbitofrontal cortex and bilateral head of the caudate when subjects

viewed their own face versus a familiar face, which may possibly reflect obsessional

preoccupation while viewing their own face (Feusner et al., 2013).

Psychological Factors: Individuals with BDD appear to have difficulty identifying emotional

facial expressions and have a bias toward interpreting neutral faces and scenarios as threatening

(Buhlmann et al. 2006; Phillips, 2009).

Social/Environmental Factors: BDD may be associated with lower-than-average levels of

parental care, a history of teasing, and childhood neglect and/or abuse (Phillips, 2009).

Neural substrates

Regarding the neural substrates associated with the BDD, using functional MRI and a face-

viewing task, there were discovered abnormalities in functional connectivity in visual processing

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systems in BDD that were not present in other disorders (Anorexia Nervosa) (Zhang et al.,

2016).

Neuropsychological profile

Using the Repeatable Battery for the Assessment of Neuropsychological Status, studies provided

a broad neuropsychological characterisation of BDD. Comparable cognitive impairment, as

measured by total RBANS, was established in BDD and OCD groups relative to the Healthy

Control group. On the whole, the BDD group tended to do worse than the OCD group. For

Immediate Memory and Attention, BDD participants performed at roughly one standard

deviation below the mean, whereas respective deficits in OCD participants constituted about half

a standard deviation below the mean. Given substantial clinical overlaps between these disorders,

albeit with poorer insight and greater delusional ideation in BDD (Eisen, Phillips, Coles, &

Rasmussen, 2004), such trends are perhaps not surprising. (Toh, Castle, and Rossell, 2015)

Treatment

Somatic Treatments: Psychiatric treatment of BDD envisages the use of selective serotoninergic

antidepressants (fluoxetine and fluvoxamine) and tricyclics (e.g., clomipramine). SRI treatment

often decreases core BDD symptoms and associated features such as depression, anxiety, anger-

hostility, psychosocial functioning, and quality of life (Rosen et al., 1995; Veale et al., 1996;

Wilhelm et al., 2013). Small open-label trials suggest that the SNRI venlafaxine and the

antiepileptic medication levetiracetam may be helpful for BDD; however, these medications are

not currently recommended as first-line treatments for BDD (Phillips & Hollander, 2008)

Psychosocial Treatments: Cognitive behavioral therapy (CBT) is currently considered the

psychotherapy of choice for BDD (Phillips, 2009). Motivational interviewing techniques are

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often needed to enhance motivation for treatment initially and at later points during treatment.

Treatment ends with relapse prevention; booster sessions may be provided if needed. Patients

should continue to practice CBT skills after treatment has ended. (Pavan et al., 2008)

Combined Treatments: The efficacy of combined pharmacotherapy and CBT versus either

treatment alone has not been investigated. From a clinical perspective, combined treatment is

especially recommended for more severely ill patients. (Pavan et al., 2008)

Treatment-Refractory Patients: Despite the lack of empirical data, combined treatments may be

considered for treatment-refractory cases. Case series suggest that low doses of typical or

atypical antipsychotics may be useful in the augmentation of SSRIs in TTM (Stein & Hollander,

1992).

Response to treatment

The study by Hollander demonstrated that improvement in symptoms was greater for subjects

treated with clomipramine, fluoxetine, or fluvoxamine. The most effective psychological

intervention is cognitive- behaviour therapy used to change specific beliefs and assumptions

thought to underlie both BDD and maladaptive behaviour patterns.

Overall prognosis

After 1 year, the probability of complete spontaneous remission was 9% and that of partial

remission was 21%, without significant gender or ethnic differences. BDD had an extremely low

probability of remission compared with mood, personality, and anxiety disorders.

Bibliography

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1. Ameringen, M. V., Patterson, B., & Simpson, W. (2014). Dsm-5 Obsessive-

Compulsive And Related Disorders: Clinical Implications Of New Criteria. Depression

and Anxiety, 31(6), 487-493. doi:10.1002/da.22259

2. Diagnostic and statistical manual of mental disorders: DSM-5. (2013).

Washington, D.C.: American Psychiatric Association.

3. Pavan, C., Simonato, P., Marini, M., Mazzoleni, F., Pavan, L., & Vindigni, V.

(2008). Psychopathologic Aspects of Body Dysmorphic Disorder: A Literature Review.

Aesthetic Plastic Surgery, 32(3), 473-484. doi:10.1007/s00266-008-9113-2

4. Phillips, K. A., & Stein, D. J. (2015). Obsessive-Compulsive and Related

Disorders: Body Dysmorphic Disorder, Trichotillomania (Hair-Pulling Disorder), and

Excoriation (Skin-Picking) Disorder. Psychiatry, 1129-1141.

doi:10.1002/9781118753378.ch58

5. Toh, W. L., Castle, D. J., & Rossell, S. L. (2015). Examining neurocognition in

body dysmorphic disorder using the Repeatable Battery for the Assessment of

Neuropsychological Status (RBANS): A comparison with obsessive-compulsive disorder.

Psychiatry Research, 228(3), 318-324. doi:10.1016/j.psychres.2015.05.094

6. Zhang, A., Leow, A., Zhan, L., Gadelkarim, J., Moody, T., Khalsa, S., . . . Feusner,

J. D. (2016). Brain connectome modularity in weight-restored anorexia nervosa and body

dysmorphic disorder. Psychological Medicine, 46(13), 2785-2797.

doi:10.1017/s0033291716001458