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What is your understanding of body dysmorphic disorder?

Introduction

• We live in a media-obsessed world, where the most famous psychiatrist is Raj Persaud, not because of his contribution to our understanding of psychiatric illness, but because he writes for Cosmopolitan magazine, and appears on numerous television shows. It seems that the public gets most of its information on psychiatric illness not from first-hand sources, but from television and newspapers.
• A clear case in point is the recent interest in body dysmorphic disorder, or, according to the tabloid press, "people who want healthy legs cut off", and it seems that there is no shortage of surgeons to oblige, much to the public';s outrage.
• But what is this little understood condition, and how does it fit into mainstream practice? In this essay we will look firstly at the psychopathology of BDD, then the possible aetiological factors, the assessment, and the treatment of this condition.

What is BDD?

• BDD was first described by Morselli in 1886, and he coined the term 'dysmorphophobia';. He defined it as the subjective feeling of ugliness or of a physical defect, combined with shame, despite a normal appearance.
• BDD first entered the European psychiatric nosology in ICD-10 (WHO, 1992).
• According to ICD-10 criteria, the dissatisfaction with appearance must have been present for longer than 6 months, and cause persistent distress or social disability.
• ICD-10 distinguishes between the delusional and non-delusional subtype of the disorder. The delusional subtype is classified as a persistent delusional disorder.
• However, newer concepts tend to view the two subtypes as variations of one disorder, and see the span of dysmorphophobic thinking as a spectrum, which can change in intensity during the course of illness from obsessive thoughts with good insight, to overvalued ideas, and delusions with no insight.

Epidemiology

• Little is known about the prevalence of BDD or its sex distribution. Most people seem to be ashamed of their concerns, and only 38% tell their GPs. Many of these people also tend to present to plastic surgeons or dermatologists rather than psychiatrists.
• Some studies have reported equal sex ratios, and others have reported higher rates in men and others in women. In small studies, the M:F ratio tends to be about 1:1.
• The disorder seems to develop in mid-late adolescence and tends to be chronic. The age of onset of non-delusional and delusional types is equal. The majority of patients have never married, and around 50% are unemployed, indicating the difficulties that patients with BDD have in maintaining relationships and the impact on occupational functioning.

Aetiology

• Initial reports of the disorder by Morselli, Kraepelin, and Janet saw BDD as being related to obsessive-compulsive neurosis. There is recent evidence to support the view that BDD can be seen as an obsessive-compulsive spectrum disorder:

1. there are phenomenological similarities between the two disorders
2. BDD responds, like OCD, preferentially to SSRIs and Clomipramine
3. there is increased incidence of OCD in the families of patients with BDD (Hollander, 1991)

• Psychodynamic theories emphasise the importance of sexual inhibitions and suggest that BDD arises from the unconscious displacement of feelings of guilt and inferiority to certain parts of the body.
• A cognitive model, similar to that of the development of social phobia, explains the disorder in terms of selective focused attention on negative aspects of appearance.

Clinical features

• The core symptoms of the disorder are outlined above. BDD is often comorbid with other psychiatric conditions and it is not known which are primary, which are secondary, and which coexist with BDD.
• Depressive symptoms are common, with up to 94% of BDD patients reporting a history of depression. The mood symptoms most commonly follow the onset of BDD.
• BDD preoccupations are often experienced as repetitive intrusive thoughts associated with anxiety or distress, which are resisted. In this way, the thoughts are similar to OCD, but quite often the ideas are not associated with insight into their senselessness. Compulsive behaviours such as checking in mirrors, skin picking, and grooming can occur.

Treatment

• Recent media furore resulted from the fact that two well-publicized patients with BDD were treated surgically with amputation for their symptoms. A number of studies have looked at surgical intervention and found that initially most patients were happy with the results. However, after several months the dysmorphophobic concerns shifted to another part of the body, and the requests for surgical treatment restarted. Surgery therefore does not appear to be a sensible treatment.
• Uncontrolled studies have come out in favour of treatment with SSRIs or clomipramine. Between 63-86% of patients treated with one of these drugs experience a partial or total remission. SSRIs reduce the obsessional thoughts, the emotional distress associated with the thoughts, and the associated compulsive behaviour.However, these studies are uncontrolled, and double-blind RCTs have yet to be done.
• There is little or no evidence that neuroleptics alone are effective in the treatment of BDD. Pimozide has been tried in the delusional subtype of BDD, but many studies'; results have not been confirmed.
• Behaviour therapy seems to be an effective psychotherapeutic approach to BDD. In a similar approach to OCD, systematic exposure to avoided situations coupled with response prevention has been found to reduce social avoidance and anxiety. Cognitive therapy has also reported similar benefit.

Conclusions

• BDD is a little-understood condition which shares symptomatology with both psychotic disorders and obsessive-compulsive disorder. Few cases come to psychiatric attention, partly due to the shame of the patient concerned, and partly due to the preferential attendance at cosmetic surgeons, many of whom probably do operate on patients with BDD without knowing the extent of their symptoms.
• We live in an image-obsessed culture where seeing a plastic surgeon is almost considered to be normal behaviour. Clearly, patients with BDD can be differentiated due to the form (rather than the content) of their symptoms, and their impaired social functioning, but one does have to think about the complex interaction between psychiatric illness and the context in which it develops. For example, a women who is tearful, has poor self-esteem, is anxious about going out, and who has an impaired marital relationship due to concern over the size of her breasts would probably be considered by most to be justified in going to a plastic surgeon for breast augmentation. However, a young man who has few friends, poor social contacts, and is concerned that his foot is decidedly ugly and wants it surgically removed, is probably likely to be diagnosed with a psychiatric illness. Arguably, the form of both ideas may be very similar, but one is culturally condoned as 'normal'; behaviour, whilst the other is considered to be an illness.
• Psychiatrists will always have a role in the diagnosis and treatment of psychiatric illness, but perhaps we need to look at the bigger picture to know where the boundaries really lie.