Introduction
Body dysmorphic disorder (BDD) is an obsession with imagined ugliness or physical defect. It is distinguished from eating disorders like bulimia or anorexia nervosa in that BDD involves no heightened anxiety with body shape or weight. Philips et al. (320-324) suggest that BDD is rather common, having been diagnosed with the aid of the Yale-Brown Obsessive-Compulsive Scale (as modified for BDD) in 0.7–1.1% of community samples, a range of from 2–13% among nonclinical samples, and 13% of psychiatric inmates.
The Diagnosis
The major symptom of BDD goes beyond regular adult vanity or adolescent anxiety about appearance to embrace an obsession, an inability to stop thinking about an imagined or exaggerated flaw in physical appearance.
A synonym frequently used is “imagined ugliness”, one well-known example perhaps being a patient of Sigmund Freud, the Russian blueblood Sergei Pankejeff nicknamed “The Wolf Man” for being so preoccupied with his over-prominent nose that he became essentially dysfunctional.
Thus BDD is chronic mental illness characterized much time in a kind of narcissistic self-examination of the imagined defect for many hours each day.
The self-torture is compounded by such pronounced shame as to impel constant visits to cosmetic surgery clinics and otherwise completely inhibit social contact. And no surgical procedure or assurances by intimates works to relieve the destructive distress that attends BDD (Butcher, Mineka and Hooley 284-288; Mayo Foundation for Medical Education and Research 2).
Crippling dissatisfaction may center around one’s nose, hair, complexion, moles and other facial blemishes, thinning hair/baldness, lack of muscles or the size of one’s breast and genitalia. Since the anxiety is deep-seated, even a “miracle” transformation of one problem area merely transfers the neurosis to another bodily part.
Beyond the observation that BDD commonly develops during the juvenile life stage, when anxiety about appearance and social acceptance is at its height anyway, researchers have variously ascribed the disorder to genetic predisposition, environmental factors, chemical imbalances in the brain, even brain structure abnormalities or some combination of these (Moore 151-6). On balance, no one really knows.
Prior success at treating depression and mood swings with serotonin reuptake inhibitors (SSRIs) – a drug class normalized the supply of serotonin to other nerve cells, had lead psychiatrists to speculate that the deficient brain chemical could similarly be augmented in BDD. Though positive response by some BDD patients to seemed encouraging, other patients actually got worse. It can therefore be argued that SSRIs are no more effective than placebos if they “work” in such random fashion. Imbalances of other neurotransmitters like Dopamine and Gamma-aminobutyric acid are also under investigation (Philips 162-164).
The investigation into possible genetic “predisposition” for BDD was spurred by the observation that one in five of those afflicted by BDD have at least one other first-degree relative similarly diagnosed. While twin studies have shown that genes may be a factor for other psychiatric disorders, such has not been empirically proven for BDD.
Other neurological deficits have been studied but conclusive evidence for the role of abnormalities in brain structure and perceptual deficits seems elusive. The preliminary basis appears about as reliable as “anecdotal” data. Some BDD patients respond well to SSRIs in reporting that, say, their misshapen nose is gone, observer reports to the contrary.
This suggests either perceptual or visual processing gaps. As well, preliminary studies using magnetic resonance imaging (MRI) have uncovered vague evidence for brain region abnormalities, a characteristic of those suffering from obsessive-compulsive disorder (OCD).
Close affinity and observed co-morbidity with OCD and generalized anxiety disorder are also under investigation, if only for the intuitively appealing logic that the latter precipitates crippling worries and delusional anxieties that can include the physical flaws on which BDD centers.
Other presumed etiologies include the environment, personality predispositions and media. The latter explanation – that the overwhelming flood of perfect faces and physiques in advertising predisposes to BDD – is the most readily disposed of since the condition has been reported even in remote areas where media penetration is poor.
As to personality make-up, it has been proposed that such personality traits as those measured in the widely-used Five-Factor Model and the 16 Personality Factor inventory – perfectionism, introversion / shyness, neuroticism, hypersensitivity to rejection or criticism, unassertiveness, avoidant and schizoid personality profiles – may be contributing factors.
However, studies employing the 16PF have shown merely that those afflicted by BDD are too diverse in this respect.
As to environmental factors, it has been hypothesized that extreme teasing, abuse, bullying, psychological torture and unthinking parenting that holds up near-impossible ideals of beauty may be important precipitating factors to those already genetically predisposed to BDD. These bear thinking about since school ground teasing is something everyone encounters as part of growing up. As well, the common experiment where psychology students are exposed to good- versus plain-looking lecturers merely underlines how ingrained are social criteria for desirable appearance even in nonclinical populations.
The Treatment
The aforementioned trials with SSRIs are common to clinical treatment regimens, as are tricyclic antidepressants. Psychotherapy – chiefly involving cognitive behavioral therapy and behavior therapy – appear to be successful in restoring self-esteem and at least breaking the cycle of destructive, obsessive habits.
Works Cited
Butcher, James N., Susan Mineka and Jill M. Hooley. Abnormal Psychology (14th Ed.) New York: Allyn & Bacon.
Mayo Foundation for Medical Education and Research. 2009. Body Dysmorphic Disorder – Symptoms/Causes. Mayo Clinic.
Moore D. P., et al. “Body dysmorphic disorder.” In: Moore DP, et al. Handbook of Medical Psychiatry. (2nd ed.) Philadelphia, PA.: Mosby, Inc., 2004.
Phillips, K. A. The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder. New York: Oxford University Press, 1996.
Phillips, K. A., W. Menard, C. Fay, & R. Weisberg. “Demographic Characteristics, Phenomenology, Comorbidity, and Family History in 200 Individuals with Body Dysmorphic Disorder.” Pyschomatics 46: 2006: 317–25.