Recognizing Body Dysmorphic Disorder (Dysmorphophobia)

How to recognize a case of BDD?

Typically, the patients suffering from this disorder are the ones who present with unusually overwhelming concerns with the self-perceived defects in their face or other body parts at the clinics of dermatologists or plastic surgeons. However, these defects are usually not recognized by the onlookers or are ignorable or slight. Also, peculiar is their preoccupation with these defects that are evident in their narrations or information by their family members. These patients are so centered on their facial or body defects that they ignore other more important aspects of life such as work or family or even their health and well-being. The worry associated with the “imagined” or “slight” defects is so deep-rooted and troublesome for these patients that they spend nearly all their time distressing over it or making unsatisfying attempts to hide it with make up or hair. They indulge in fruitless behaviors such as repeated mirror checking or asking others “how bad do I look?”. Such patients are frequently found comparing their appearance to others and almost always feel that they are at the losing end. The constant belief of being “ugly” or “unattractive” or even “repulsive” surmounts their entire thought process and no amount of reassurance or negation of the defect can convince or appease them. They usually avoid public gatherings, and when they are forced to go to any they feel everyone is staring at their defects and are ridiculing them. Many such patients of BDD are housebound and prefer to avoid the imagined scrutiny of their appearance even if it costs them their jobs or studies. More than 20% patients are unemployed[5] and 55% are unmarried.[6] The overall distress and dysfunction is very significant in these patients. But the real plight of their negative emotional state is best understood by the realization of the fact that one fifth of patients of dysmorphophobia attempt suicide, and some succeed! BDD increases the likelihood of suicide.[57]

So much pain for just a slight or even nonexistent bodily defect seems so trivial a cause for disturbing one's life so much, let alone for ending it! This brings one to the pertinent question — why is physical appearance most important for these patients? Psychoanalysts argue that “it is not actually” and that the body part perceived as defective is only a symbol of underlying emotional conflict that is complexly referred and reflected to a random body part. Other theorists with psychosocial understanding explain that our concepts of what is beautiful and what is ugly are conditioned by our families and culture and may be stringent or stereotypical. Individuals with low self-esteem or poor development of a stable sense of self, get anxious when they find themselves not meeting descriptions of beauty accurately. They confuse beauty with acceptability and feel that unattractive people are hated by all. Biological sciences and the current diagnostic criteria given in the DSM-5 consider BDD to be a part of the obsessive compulsive disorder (OCD) spectrum, wherein the neurotransmitter serotonin is specifically implicated and response to drugs used in OCD, which are selective serotonin reuptake inhibitors (SSRIs), is significant. Functional neuroimaging studies (fMRIs) in a recent study suggest that the fault lies in the visual processing of images in the patients of BDD.[89]

However, it must be understood that dysmorphophobia or BDD is a rather poorly studied condition. A significant reason is also because very few patients suffering from BDD actually reach the psychiatrist. Most are only frequent visitors and treatment seekers coming to dermatologists, cosmetologists, and plastic surgeons. And because of the relatively sparse understanding of this disorder among these doctors, it prevents an objective recognition and thereafter psychiatric referrals of patients of BDD.

In more ways than one, the onus lies on the doctors of these specialties (that the patient seeks for the correction of aesthetic defects), to timely identify and refer patients of dysmorphophobia for psychiatric intervention. As much as a medical concern, dermatologists and plastic surgeons are also ethically obligated to refer these patients to psychiatrists before indulging in costly and usually multiple procedures for these patients.

The diagnostic criteria in the DSM-5[10] for BDD by the American Psychiatric Association are given in Table 1.

Table 1 DSM-5 criteria for body dysmorphic disorder

Apart from being a major diagnostic criteria, DSM-5 criteria also help to understand the concern with the defect especially a specific facial feature (usually the nose), or more than one feature (such as a crooked nose and a short forehead), or a vague and incomprehensive feature (such as a scrunchy chin or a feeble smile). The patient's complaint may be a general, nonspecific “ugliness” of the face or may include “defects” of other body parts such as breasts, calves, bottoms, skin, and genitalia. The body part with defect may remain constant or may change over a period of time. Males may be obsessed with an “unmuscular” body with a need to “bulk up.”[11] Another peculiar feature is the unusually dramatic expectation that these patients have from the corrective procedures/surgeries, which is usually unmet after the surgery as a result many patients may request for repetitive corrective procedures. Literature is abundant with cases in which patients opt for multiple surgeries, repeated number of times, to attain the “perfect look” that they can never attain as satisfaction with one's appearance is essentially absent in such cases. Such patients take the risk of surgical complications multiple times and continue to remain unsatisfied no matter what the real outcome of the procedure is. Repetitive procedures make their appearance suffer further but that does not limit their obsession with their imagined facial defect. No one can convince these patients that their concerns about their appearance are baseless or unnecessary not even doctors or plastic surgeons. The only hope and response rests in psychiatric intervention.

BDD is not very difficult to diagnose but there are a few important considerations in doing that. One has to make sure that it is not confused with a genuine concern regarding a genuinely significant defect in appearance for which patient wants correction. As per the diagnostic criteria, the defect in appearance should be either “imagined” or only “slight” and not prominent. Also the concerns with excessive weight point toward eating disorders and not BDD. One must try and make sure that the negative self-image is not a function of depression alone from which the patient is suffering (depression could be a result of BDD but should not be the cause essentially). Also the patient must not be suffering from psychosis that alters his judgment and perception.

The focus of BDD patients is by definition on physical appearance. Data exist on patients with BDD having obsessional concerns about odor. Given the significant overlap between halitosis and BDD, one can postulate that halitosis is a variant of BDD and the diagnostic criteria of BDD should be extended to include the concerns about odor.[12] Whether halitosis or olfactory reference syndrome is a truly unique disorder, or merely a part of symptomatology of other psychiatric conditions, remain controversial.[13]

Patients suffering from dysmorphophobia may have other comorbidities such as depression, social phobia, and OCD and delusional disorder.[14]

The course of BDD may be protracted and undulating. The asymptomatic period may be sparse.[15]

How to approach a case of BDD?

While approaching such patients, one needs to be cautious so as to not scare them away by labeling their concerns with their appearance as “baseless” and their complaints as purely psychological. One has to first try and develop a rapport with the patient and his family, which is possible only after patiently listening to their complaints, in an understanding and empathetic manner. After reassuring and answering all queries of the patient, one must make an earnest attempt of bringing the focus of the discussion from the physical defect to the distress and dysfunction the patient has been actually suffering. Thereafter, the patient and his family should be explained about the disorder, BDD, and the suggestion to meet a psychiatrist should be made so that their condition can improve properly after that.

Management of BDD

Management of BDD is essentially done by a psychiatrist and his team. There is a role of medications as well as psychotherapy in the treatment of BDD. SSRIs are a group of antidepressants that are known to reduce symptoms in at least 50% of patients of BDD.[1] Augmentation with antipsychotics may improve response in more resistant cases.[16] There are studies that report of a positive response to psychotherapies such as cognitive behavior therapy.[171819] Some studies recommend the combination of medications and psychotherapy.

Why to refer to psychiatrist?

Let us now come to why is it important for dermatologists to recognize and diagnose and refer BDD? It is because first, such patients will never be satisfied with any procedure. Second, because the defect is not physical but essentially psychological in nature, and treatment of the disorder and response are expected with psychiatric interventions only. Also, it is ethically incorrect to take advantage of a person's mental illness and charge him for procedures that he does not need. And importantly, to prevent malpractice suits as unsatisfied patients are more likely to sue. Finally referring BDD patients to a psychiatrist will contribute to a better understanding and research about this disorder.

When to refer a case of BDD to a psychiatrist?

1. In case of a diagnostic dilemma.

2. When the presentation convincingly meets the diagnostic criteria mentioned earlier in this article.

3. When a patient is persistently unsatisfied after repeated treatments or cannot be reassured.

4. When a patient's life seems to revolve around his slight defect.

5. Ideally a psychiatrist's opinion should be sought before treating the dermatological defect of any such patient whose defect is slight and his concern is out of proportion.

As it is often said that “beauty lies in the eyes of the beholder” in this case it is the invisible ugliness that lies in the eyes of such persons when they look at the mirror. The mirror reflects not what is present in appearance, but what is missing in the soul.

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Conflicts of interest

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