What is body dysmorphic disorder?
Being self-conscious about one’s looks may be a problem, but
it’s not a psychiatric condition — unless it takes the
distressing and sometimes disabling form of body dysmorphic disorder.
People who have this disorder are preoccupied with what they regard
as defects in their bodies or faces. In about half of the cases, this
concern reaches delusional proportions. Others with the disorder know
that their worries are irrational, but this only makes them feel ashamed
and causes them to suffer in secret.
Since BDD patients often try to hide their problem, experts believe
it is much more common than most people realize. The rate of BDD in the
general population is about 2%. That includes cases seen by general practitioners
and psychiatrists, as well as up to 15% of patients in dermatology and
cosmetic surgery clinics.
BDD is no small problem. Looks become the key to self-esteem, with a
compulsion to examine the perceived defect, or try to repair or hide
it. BDD patients may endlessly seek reassurance or avoid others, with
inevitable effects on their work and personal relationships. Almost half
develop alcohol or drug problems. Sometimes the torment ends in suicide.
Men and women are affected equally, but in men BDD often takes the special
form of “muscle dysmorphia.” These men can never be muscular
enough. No matter how much they work out, they feel puny. They are often
anxious and depressed, compulsive about workouts and diet. They are prone
to eating disorders and may abuse anabolic steroids.
Up to half of people with BDD seek cosmetic surgery or dermatology treatment,
and often they feel worse rather than better afterward. The disappointment
may bring depression, suicidal thoughts, or a desire for revenge on the
doctor. Some sue and a few become violent.
Both temperament and culture contribute to the risk of BDD. People with
the disorder often have aesthetic interests; a surprisingly high proportion
are artists or designers. The culture reflected in our mass media and
advertising emphasizes physical perfection and promotes a favorable view
of cosmetic surgery. A survey showed that American men are more dissatisfied
with their bodies than men in Taiwan, where advertising rarely presents
images of near-naked males.
The American Psychiatric Association classifies body dysmorphic disorder
as a somatoform disorder, that is, one in which psychological problems
take the form of physical symptoms. In that respect, it resembles hypochondriasis.
But BDD may also look like obsessive-compulsive disorder — obsessive
worrying, constant grooming, repeatedly checking mirrors. When the main
concerns are weight and diet, BDD is more like an eating disorder. A
person with BDD who refuses to leave home could be said to have social
anxiety disorder. And some practitioners regard it as a variant of depression.
BDD may turn out to be not one disorder but several with different causes.
BDD is difficult to treat. The first step is recognizing the problem;
screening with a short questionnaire may help. Many patients have trouble
understanding that there is nothing wrong with their bodies or admitting
that they might have a mental disorder. Education about BDD may overcome
their resistance to being referred for mental health treatment. It’s
especially important to avoid unnecessary procedures, such as cosmetic
surgery. A few studies have shown that SSRIs like fluoxetine (Prozac
and others) can be useful when taken at high doses for at least two months.
Adding a low dose of an antipsychotic drug such as risperidone or olanzapine
has not been proved effective in BDD, but theoretically should help patients
with actual delusions. Cognitive behavior therapy is helpful for the
milder (non-delusional) forms of the illness. Above all, people with
BDD must be persuaded to think less about their appearance and concentrate
on the underlying psychological problems.
September 2005 Update
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