July 21, 2011
Body dysmorphic disorder, also known as dysmorphophobia, is a mental illness characterized by “imagined” defects in appearance, or by exaggerated or excessive preoccupations with a real physical defect. Any part of the body can be involved, but the obsession usually focuses on the skin, hair or a facial feature such as eyelids, nose, lips, mouth, jaw or chin. Typically, the complaint is asymmetry, or a feature felt to be “out of proportion.” These complaints may be associated with distorted beliefs. For example, a person with a large nose may feel they will always be alone and unloved. Persons with Body dysmorphic disorder (BDD) become obsessed with improving their appearance through exercise, surgical or dermatological procedures and other beauty therapies. They spend unhealthy amounts of time in an anxious state over their “unacceptable” appearance. Patients often show obsessional features and BDD may be related to Obsessive Compulsive Disorder. Persons with BDD also suffer from depression and have an increased risk of suicide. They may become socially isolated or agoraphobic. Patients with BDD frequently describe receiving bullying or abuse as children, and they may have suffered from an eating disorder such as bulimia or anorexia. This condition may affect up to 1% of the population in the United States. The onset of Body dysmorphic disorder is usually in late adolescence, but diagnosis, when made by a mental health provider, does not usually occur for ten to fifteen years after onset.
Persons with Body dysmorphic disorder are often entangled in repeated treatments with a cosmetic surgeon. Initially, they arrive with unrealistic expectations. A warning sign to the evaluating physician is obsessional fixation on a minor defect in appearance, or statements that the surgery will “fix” their unhappiness or make their life so much better. If BDD is not identified, and the patient undergoes surgery, the outcome is frequently unsatisfactory, irregardless of good surgical results. These patients will return after surgery, still unhappy or depressed, their unrealistic expectations unfulfilled. Surgery itself can cause new onset of depression (post-surgical), or worsening of an existing mood disorder in patients without BDD. Accordingly, a patient with BDD is at increased risk. Even if the person with BDD is happy with their surgical outcome, they may become obsessed with a different part of their body afterwards.
Body dysmorphic disorder is difficult to identify and manage, but a significant number of patients respond to selective serotonin reuptake inhibitors. Psychoanalytic therapy and Cognitive Behavioral Therapy (CBT) are also effective. CBT involves working with body imagery to lessen the distortion and fixation. Unfortunately, BDD is not picked up very easily, because persons with BDD present initially for aesthetic treatments and their diagnosis is often missed or overlooked. It is only after failure of beautification, or progression of co-existing depression or other psychological disorder that the person with body dysmorphic disorder seeks psychological or psychiatric help.