Body dysmorphic disorder: Difference between revisions

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'''For patient information, click [[Body dysmorphic disorder (patient information)|here]]'''
'''For patient information, click [[Body dysmorphic disorder (patient information)|here]]'''


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==Overview==
==Overview==
Body dysmorphic disorder (BDD) is a mental disorder that involves a disturbed [[body image]] where there is an excessive preoccupation with the physical appearance despite the fact there may be no noticeable disfigurement or defect. Common areas of concern in most people suffering from BDD include perceived flaws relating to the face, nose, eyes, skin, and hair. BDD combines obsessive and compulsive aspects, which links it to the [[Obsessive-Compulsive Disorder|OCD]] spectrum disorders. People with BDD may engage in compulsive mirror checking behaviors or mirror avoidance, typically think about their appearance for more than one hour a day, and in severe cases may drop all social contact and responsibilities as they become homebound. The disorder is linked to an unusually high [[suicide]] rate ranging from 17-77% among all mental disorders <ref name="AngelakisGooding2016">{{cite journal|last1=Angelakis|first1=Ioannis|last2=Gooding|first2=Patricia A.|last3=Panagioti|first3=Maria|title=Suicidality in body dysmorphic disorder (BDD): A systematic review with meta-analysis|journal=Clinical Psychology Review|volume=49|year=2016|pages=55–66|issn=02727358|doi=10.1016/j.cpr.2016.08.002}}</ref>
Body dysmorphic disorder (BDD) is a [[mental disorder]] that involves a disturbed [[body image]] where there is an excessive preoccupation with the physical appearance despite the fact there may be no noticeable [[disfigurement]] or [[defect]]. Common areas of concern in most people suffering from BDD include perceived flaws relating to the [[face]], [[nose]], [[eyes]], [[skin]], and [[hair]]. BDD combines [[obsessive]] and [[compulsive]] aspects, which links it to the [[Obsessive-compulsive disorder|OCD]] spectrum disorders. People with BDD may engage in [[compulsive]] mirror checking behaviors or mirror avoidance, typically think about their appearance for more than one hour a day, and in severe cases may drop all social contact and responsibilities as they become homebound. The [[disorder]] is linked to an unusually high [[suicide]] rate among all [[mental disorders]].  
.


==Historical Perspective==
==Historical Perspective==
BDD was first documented in 1886 by the researcher Morselli, who called the condition simply "'''Dysmorphophobia'''". BDD was first recorded/formally recognized in 1997 as a disorder in the [[Diagnostic and Statistical Manual of Mental Disorders|DSM]]; however, in 1987 it was first truly recognized by the [[American Psychiatric Association]].  
BDD was first documented in 1886 by the researcher [[Morselli]], who called the condition simply "'''Dysmorphophobia'''". BDD was first recorded/formally recognized in 1997 as a disorder in the [[Diagnostic and Statistical Manual of Mental Disorders|DSM]]; however, in 1987 it was first truly recognized by the [[American Psychiatric Association]].  


In his practice, [[Sigmund Freud|Freud]] eventually had a patient who would today be diagnosed with the disorder; Russian [[aristocrat]] [[Sergei Pankejeff]], nicknamed "The Wolf Man" by Freud himself in order to protect Pankejeff's identity, had a preoccupation with his nose to an extent that greatly limited his functioning.
In his practice, [[Sigmund Freud|Freud]] eventually had a patient who would today be diagnosed with the disorder; Russian [[aristocrat]] [[Sergei Pankejeff]], nicknamed "The Wolf Man" by [[Freud]] himself in order to protect Pankejeff's identity, had a preoccupation with his nose to an extent that greatly limited his functioning.


==Causes==
==Causes==
The exact etiology of BDD is unclear, but it is likely an interplay in social, psychological, and biological factors.  
The exact etiology of BDD is unclear, but it is likely an interplay in [[social]], [[psychological]], and [[biological]] factors. <ref name="BuhlmannMarques2012">{{cite journal|last1=Buhlmann|first1=Ulrike|last2=Marques|first2=Luana M.|last3=Wilhelm|first3=Sabine|title=Traumatic Experiences in Individuals With Body Dysmorphic Disorder|journal=Journal of Nervous & Mental Disease|volume=200|issue=1|year=2012|pages=95–98|issn=0022-3018|doi=10.1097/NMD.0b013e31823f6775}}</ref>


===Social Factors===
===Social Factors===
Individuals with BDD have suffered from some form of abuse in the past. These experiences comprised emotional neglect in 68%, emotional abuse in 56 %, physical abuse in 34.7%, and sexual abuse in 28% of patients. <ref name="BuhlmannMarques2012">{{cite journal|last1=Buhlmann|first1=Ulrike|last2=Marques|first2=Luana M.|last3=Wilhelm|first3=Sabine|title=Traumatic Experiences in Individuals With Body Dysmorphic Disorder|journal=Journal of Nervous & Mental Disease|volume=200|issue=1|year=2012|pages=95–98|issn=0022-3018|doi=10.1097/NMD.0b013e31823f6775}}</ref> <ref name="DidieTortolani2006">{{cite journal|last1=Didie|first1=Elizabeth R.|last2=Tortolani|first2=Christina C.|last3=Pope|first3=Courtney G.|last4=Menard|first4=William|last5=Fay|first5=Christina|last6=Phillips|first6=Katharine A.|title=Childhood abuse and neglect in body dysmorphic disorder|journal=Child Abuse & Neglect|volume=30|issue=10|year=2006|pages=1105–1115|issn=01452134|doi=10.1016/j.chiabu.2006.03.007}}</ref>
Individuals with BDD have suffered from some form of abuse in the past. These experiences comprised [[emotional]] [[neglect]] in 68%, [[emotional abuse]] in 56 %, [[physical abuse]] in 34.7%, and [[sexual abuse]] in 28% of patients. <ref name="BuhlmannMarques2012">{{cite journal|last1=Buhlmann|first1=Ulrike|last2=Marques|first2=Luana M.|last3=Wilhelm|first3=Sabine|title=Traumatic Experiences in Individuals With Body Dysmorphic Disorder|journal=Journal of Nervous & Mental Disease|volume=200|issue=1|year=2012|pages=95–98|issn=0022-3018|doi=10.1097/NMD.0b013e31823f6775}}</ref> <ref name="DidieTortolani2006">{{cite journal|last1=Didie|first1=Elizabeth R.|last2=Tortolani|first2=Christina C.|last3=Pope|first3=Courtney G.|last4=Menard|first4=William|last5=Fay|first5=Christina|last6=Phillips|first6=Katharine A.|title=Childhood abuse and neglect in body dysmorphic disorder|journal=Child Abuse & Neglect|volume=30|issue=10|year=2006|pages=1105–1115|issn=01452134|doi=10.1016/j.chiabu.2006.03.007}}</ref>
   
   
===Neurobiological Model for BDD===
===Neurobiological Model for BDD===
====Detailed processing and visual processing streams====
====Detailed processing and visual processing streams====
A dysfunction in visual processing systems accounts for the heightened detail processing in BDD patients. This is due to the observed early travel of first-order visual information from V1 and V2 areas to temporal regions in the left hemisphere, where detail and structure are encoded. <ref name="ArienzoLeow2013">{{cite journal|last1=Arienzo|first1=Donatello|last2=Leow|first2=Alex|last3=Brown|first3=Jesse A|last4=Zhan|first4=Liang|last5=GadElkarim|first5=Johnson|last6=Hovav|first6=Sarit|last7=Feusner|first7=Jamie D|title=Abnormal Brain Network Organization in Body Dysmorphic Disorder|journal=Neuropsychopharmacology|volume=38|issue=6|year=2013|pages=1130–1139|issn=0893-133X|doi=10.1038/npp.2013.18}}</ref> <ref name="FeusnerArienzo2013">{{cite journal|last1=Feusner|first1=Jamie D.|last2=Arienzo|first2=Donatello|last3=Li|first3=Wei|last4=Zhan|first4=Liang|last5=GadElkarim|first5=Johnson|last6=Thompson|first6=Paul M.|last7=Leow|first7=Alex D.|title=White matter microstructure in body dysmorphic disorder and its clinicalcorrelates|journal=Psychiatry Research: Neuroimaging|volume=211|issue=2|year=2013|pages=132–140|issn=09254927|doi=10.1016/j.pscychresns.2012.11.001}}</ref> <ref name="LeowZhan2012">{{cite journal|last1=Leow|first1=Alex D.|last2=Zhan|first2=Liang|last3=Arienzo|first3=Donatello|last4=GadElkarim|first4=Johnson J.|last5=Zhang|first5=Aifeng F.|last6=Ajilore|first6=Olusola|last7=Kumar|first7=Anand|last8=Thompson|first8=Paul M.|last9=Feusner|first9=Jamie D.|title=Hierarchical Structural Mapping for Globally Optimized Estimation of Functional Networks|volume=7511|year=2012|pages=228–236|issn=0302-9743|doi=10.1007/978-3-642-33418-4_29}}</ref> <ref name="LiArienzo2013">{{cite journal|last1=Li|first1=Wei|last2=Arienzo|first2=Donatello|last3=Feusner|first3=Jamie D.|title=Body Dysmorphic Disorder: Neurobiological Features and an Updated Model|journal=Zeitschrift für Klinische Psychologie und Psychotherapie|volume=42|issue=3|year=2013|pages=184–191|issn=1616-3443|doi=10.1026/1616-3443/a000213}}</ref>
A dysfunction in [[visual processing systems]] accounts for the heightened detail processing in BDD patients. This is due to the observed early travel of [[first-order visual information]] from V1 and V2 areas to [[temporal]] regions in the left hemisphere, where detail and structure are encoded. In addition, there is the faulty formation of holistic elements of visual information due to decreased use of the processing of [[second-order visual information]], as evidenced by decreased activity in the lateral [[occipital]] [[cortex]] and [[precuneus]]. These findings explain the enhanced awareness of perceived imperfections in BDD patients.<ref name="ArienzoLeow2013">{{cite journal|last1=Arienzo|first1=Donatello|last2=Leow|first2=Alex|last3=Brown|first3=Jesse A|last4=Zhan|first4=Liang|last5=GadElkarim|first5=Johnson|last6=Hovav|first6=Sarit|last7=Feusner|first7=Jamie D|title=Abnormal Brain Network Organization in Body Dysmorphic Disorder|journal=Neuropsychopharmacology|volume=38|issue=6|year=2013|pages=1130–1139|issn=0893-133X|doi=10.1038/npp.2013.18}}</ref> <ref name="FeusnerArienzo2013">{{cite journal|last1=Feusner|first1=Jamie D.|last2=Arienzo|first2=Donatello|last3=Li|first3=Wei|last4=Zhan|first4=Liang|last5=GadElkarim|first5=Johnson|last6=Thompson|first6=Paul M.|last7=Leow|first7=Alex D.|title=White matter microstructure in body dysmorphic disorder and its clinicalcorrelates|journal=Psychiatry Research: Neuroimaging|volume=211|issue=2|year=2013|pages=132–140|issn=09254927|doi=10.1016/j.pscychresns.2012.11.001}}</ref> <ref name="LeowZhan2012">{{cite journal|last1=Leow|first1=Alex D.|last2=Zhan|first2=Liang|last3=Arienzo|first3=Donatello|last4=GadElkarim|first4=Johnson J.|last5=Zhang|first5=Aifeng F.|last6=Ajilore|first6=Olusola|last7=Kumar|first7=Anand|last8=Thompson|first8=Paul M.|last9=Feusner|first9=Jamie D.|title=Hierarchical Structural Mapping for Globally Optimized Estimation of Functional Networks|volume=7511|year=2012|pages=228–236|issn=0302-9743|doi=10.1007/978-3-642-33418-4_29}}</ref> <ref name="LiArienzo2013">{{cite journal|last1=Li|first1=Wei|last2=Arienzo|first2=Donatello|last3=Feusner|first3=Jamie D.|title=Body Dysmorphic Disorder: Neurobiological Features and an Updated Model|journal=Zeitschrift für Klinische Psychologie und Psychotherapie|volume=42|issue=3|year=2013|pages=184–191|issn=1616-3443|doi=10.1026/1616-3443/a000213}}</ref> <ref name="GraceLabuschagne2017">{{cite journal|last1=Grace|first1=Sally A.|last2=Labuschagne|first2=Izelle|last3=Kaplan|first3=Ryan A.|last4=Rossell|first4=Susan L.|title=The neurobiology of body dysmorphic disorder: A systematic review and theoretical model|journal=Neuroscience & Biobehavioral Reviews|volume=83|year=2017|pages=83–96|issn=01497634|doi=10.1016/j.neubiorev.2017.10.003}}</ref>
In addition, there is the faulty formation of holistic elements of visual information due to decreased use of the processing of second-order visual information, as evidenced by decreased activity in the lateral occipital cortex and precuneus. These findings explain the enhanced awareness of perceived imperfections in BDD patients. <ref name="GraceLabuschagne2017">{{cite journal|last1=Grace|first1=Sally A.|last2=Labuschagne|first2=Izelle|last3=Kaplan|first3=Ryan A.|last4=Rossell|first4=Susan L.|title=The neurobiology of body dysmorphic disorder: A systematic review and theoretical model|journal=Neuroscience & Biobehavioral Reviews|volume=83|year=2017|pages=83–96|issn=01497634|doi=10.1016/j.neubiorev.2017.10.003}}</ref>


====Frontostriatal systems====
====Frontostriatal systems====
Increased activity and reduced grey matter volumes in the frontostriatal and subcortical regions are linked to BDD patients' repetitive and compulsive behaviors, which is similarly observed in OCD patients.<ref name="SaxenaRauch2000">{{cite journal|last1=Saxena|first1=Sanjaya|last2=Rauch|first2=Scott L.|title=FUNCTIONAL NEUROIMAGING AND THE NEUROANATOMY OF OBSESSIVE-COMPULSIVE DISORDER|journal=Psychiatric Clinics of North America|volume=23|issue=3|year=2000|pages=563–586|issn=0193953X|doi=10.1016/S0193-953X(05)70181-7}}</ref> The caudate nucleus seems to play an essential role in inappropriately mediating motor inhibition. This is supported by abnormal circuitry seen in the inferior occipitofrontal fasciculus, a pathway that connects the frontal and occipital lobes via the caudate. <ref name="BuchananRossell2013">{{cite journal|last1=Buchanan|first1=B. G.|last2=Rossell|first2=S. L.|last3=Maller|first3=J. J.|last4=Toh|first4=W. L.|last5=Brennan|first5=S.|last6=Castle|first6=D. J.|title=Brain connectivity in body dysmorphic disorder compared with controls: a diffusion tensor imaging study|journal=Psychological Medicine|volume=43|issue=12|year=2013|pages=2513–2521|issn=0033-2917|doi=10.1017/S0033291713000421}}</ref>
Increased activity and reduced [[grey matter]] volumes in the [[frontostriatal]] and [[subcortical]] regions are linked to BDD patients' [[repetitive]] and [[compulsive]] behaviors, which is similarly observed in OCD patients.This is supported by abnormal [[circuitry]] seen in the inferior [[occipitofrontal fasciculus]], a pathway that connects the [[frontal]] and [[occipital]] lobes via the [[caudate]]. The caudate nucleus seems to play an essential role in inappropriately mediating motor inhibition. <ref name="SaxenaRauch2000">{{cite journal|last1=Saxena|first1=Sanjaya|last2=Rauch|first2=Scott L.|title=FUNCTIONAL NEUROIMAGING AND THE NEUROANATOMY OF OBSESSIVE-COMPULSIVE DISORDER|journal=Psychiatric Clinics of North America|volume=23|issue=3|year=2000|pages=563–586|issn=0193953X|doi=10.1016/S0193-953X(05)70181-7}}</ref> <ref name="BuchananRossell2013">{{cite journal|last1=Buchanan|first1=B. G.|last2=Rossell|first2=S. L.|last3=Maller|first3=J. J.|last4=Toh|first4=W. L.|last5=Brennan|first5=S.|last6=Castle|first6=D. J.|title=Brain connectivity in body dysmorphic disorder compared with controls: a diffusion tensor imaging study|journal=Psychological Medicine|volume=43|issue=12|year=2013|pages=2513–2521|issn=0033-2917|doi=10.1017/S0033291713000421}}</ref>
            
            
====Temporolimbic systems====
====Temporolimbic systems====
The limbic system is also involved in BDD. In particular, the right amygdala demonstrates hyperactivity during visual tasks and mediates the relationship between anxiety and ventral visual system activation. This results in heightened emotions to visual information.<ref name="BuhlmannWinter2013">{{cite journal|last1=Buhlmann|first1=Ulrike|last2=Winter|first2=Anna|last3=Kathmann|first3=Norbert|title=Emotion recognition in body dysmorphic disorder: Application of the Reading the Mind in the Eyes Task|journal=Body Image|volume=10|issue=2|year=2013|pages=247–250|issn=17401445|doi=10.1016/j.bodyim.2012.12.001}}</ref> <ref name="MonzaniRijsdijk2012">{{cite journal|last1=Monzani|first1=Benedetta|last2=Rijsdijk|first2=Fruhling|last3=Iervolino|first3=Alessandra C.|last4=Anson|first4=Martin|last5=Cherkas|first5=Lynn|last6=Mataix-Cols|first6=David|title=Evidence for a genetic overlap between body dysmorphic concerns and obsessive-compulsive symptoms in an adult female community twin sample|journal=American Journal of Medical Genetics Part B: Neuropsychiatric Genetics|volume=159B|issue=4|year=2012|pages=376–382|issn=15524841|doi=10.1002/ajmg.b.32040}}</ref>
The [[limbic system]] is also involved in BDD. In particular, the right [[amygdala]] demonstrates [[hyperactivity]] during [[visual]] tasks and mediates the relationship between [[anxiety]] and ventral [[visual system]] activation. This results in heightened [[emotions]] to [[visual]] information.<ref name="BuhlmannWinter2013">{{cite journal|last1=Buhlmann|first1=Ulrike|last2=Winter|first2=Anna|last3=Kathmann|first3=Norbert|title=Emotion recognition in body dysmorphic disorder: Application of the Reading the Mind in the Eyes Task|journal=Body Image|volume=10|issue=2|year=2013|pages=247–250|issn=17401445|doi=10.1016/j.bodyim.2012.12.001}}</ref> <ref name="MonzaniRijsdijk2012">{{cite journal|last1=Monzani|first1=Benedetta|last2=Rijsdijk|first2=Fruhling|last3=Iervolino|first3=Alessandra C.|last4=Anson|first4=Martin|last5=Cherkas|first5=Lynn|last6=Mataix-Cols|first6=David|title=Evidence for a genetic overlap between body dysmorphic concerns and obsessive-compulsive symptoms in an adult female community twin sample|journal=American Journal of Medical Genetics Part B: Neuropsychiatric Genetics|volume=159B|issue=4|year=2012|pages=376–382|issn=15524841|doi=10.1002/ajmg.b.32040}}</ref>


===Genetic Factors===
===Genetic Factors===
A genetic component may also be involved in BBD. Patients with BDD have a family member with a similar condition in 8% of patients, while 7% of BDD patients have first-degree family members with OCD. <ref name="BjornssonDidie2013">{{cite journal|last1=Bjornsson|first1=Andri S.|last2=Didie|first2=Elizabeth R.|last3=Grant|first3=Jon E.|last4=Menard|first4=William|last5=Stalker|first5=Emily|last6=Phillips|first6=Katharine A.|title=Age at onset and clinical correlates in body dysmorphic disorder|journal=Comprehensive Psychiatry|volume=54|issue=7|year=2013|pages=893–903|issn=0010440X|doi=10.1016/j.comppsych.2013.03.019}}</ref>
A [[genetic]] component may also be involved in BBD. Patients with BDD have a family member with a similar condition in 8% of patients, while 7% of BDD patients have first-degree family members with [[OCD]]. <ref name="BjornssonDidie2013">{{cite journal|last1=Bjornsson|first1=Andri S.|last2=Didie|first2=Elizabeth R.|last3=Grant|first3=Jon E.|last4=Menard|first4=William|last5=Stalker|first5=Emily|last6=Phillips|first6=Katharine A.|title=Age at onset and clinical correlates in body dysmorphic disorder|journal=Comprehensive Psychiatry|volume=54|issue=7|year=2013|pages=893–903|issn=0010440X|doi=10.1016/j.comppsych.2013.03.019}}</ref>


==Differential Diagnosis==
==Differential Diagnosis==
Body dysmorphic disorder must be differentiated from: <ref name="DSMV">{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>
*[[Anxiety disorder]]
*[[Anxiety disorder]]
*[[Eating disorders]]
*[[Eating disorders]]
*Illness [[anxiety disorder]]
 
*[[Illness anxiety disorder]]
 
*[[Major depressive disorder]]
*[[Major depressive disorder]]
*Other [[OCD|obsessive-compulsive disorders]]
*Other [[OCD|obsessive-compulsive disorders]]
*[[Psychotic disorders]]
*[[Psychotic disorders]]


==Epidemiology and Demographics==
==Epidemiology and Demographics==
===Prevalence===
===Prevalence===
The prevalence of BDD is at 0.7-2.4% in the general population making it more common than other psychiatric disorders such as anorexia nervosa or schizophrenia. In clinical settings, BDD seems to have a prevalence of 9-13% in dermatology settings, 3-53% in cosmetic surgery settings and it coexists with OCD in 8-37% of patients.  
The prevalence of BDD is at 0.7-2.4% in the general population making it more common than other psychiatric disorders such as [[anorexia nervosa]] or [[schizophrenia]]. In clinical settings, BDD seems to have a prevalence of 9-13% in [[dermatology]] settings, 3-53% in [[cosmetic surgery]] settings and it coexists with [[OCD]] in 8-37% of patients.  
Considering how common this condition is, many individuals don’t report their symptoms due to embarrassment. <ref name="pmid20623926">{{cite journal| author=Bjornsson AS, Didie ER, Phillips KA| title=Body dysmorphic disorder. | journal=Dialogues Clin Neurosci | year= 2010 | volume= 12 | issue= 2 | pages= 221-32 | pmid=20623926 | doi= | pmc=3181960 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20623926  }} </ref>
Considering how common this condition is, many individuals don’t report their symptoms due to embarrassment. <ref name="pmid20623926">{{cite journal| author=Bjornsson AS, Didie ER, Phillips KA| title=Body dysmorphic disorder. | journal=Dialogues Clin Neurosci | year= 2010 | volume= 12 | issue= 2 | pages= 221-32 | pmid=20623926 | doi= | pmc=3181960 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20623926  }} </ref>


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==Risk Factors==
==Risk Factors==
*First-degree relatives of patients with [[obsessive compulsive disorder]] ([[OCD]])<ref name=DSMV>{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>
 
*History of childhood abuse<ref name=DSMV>{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>
Some of risk factors include: <ref name="DSMV">{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>
 
*First-degree relatives of patients with [[obsessive compulsive disorder]] ([[OCD]])
*History of childhood abuse


==Natural History, Complications, and Prognosis==
==Natural History, Complications, and Prognosis==
===Natural History===
===Natural History===
BDD usually develops in adolescence, a time when people are generally most sensitive about their appearance. However, many patients suffer for years before seeking help. When they do seek help through mental health professionals, patients often complain of other symptoms such as depression, social anxiety or obsessive compulsive disorder, but do not reveal their real concern over body image. Most patients cannot be convinced that they have a distorted view of their body image, due to the very limited knowledge of the disorder as compared to OCD or others.   
BDD usually develops in [[adolescence]], a time when people are generally most sensitive about their appearance. However, many patients suffer for years before seeking help. When they do seek help through mental health professionals, patients often complain of other symptoms such as [[depression]], [[social anxiety]] or [[obsessive-compulsive disorder]], but do not reveal their real concern over body image. Most patients cannot be convinced that they have a distorted view of their [[body image]], due to the very limited knowledge of the disorder as compared to OCD or others.   
Male patients have more risk of developing the obsession around the genitalia and females have higher risk of developing eating disorders associated with the BDD.
Male patients have more risk of developing the obsession around the genitalia and females have higher risk of developing [[eating disorders]] associated with the BDD.<ref name="pmid17183412">{{cite journal| author=Phillips KA| title=The Presentation of Body Dysmorphic Disorder in Medical Settings. | journal=Prim psychiatry | year= 2006 | volume= 13 | issue= 7 | pages= 51-59 | pmid=17183412 | doi= | pmc=1712667 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17183412  }} </ref>


===Complications===
===Complications===
====Suicide Risk====
====Suicide Risk====
* The suicide rates in patients with BDD are high in at all ages, with a higher incidence in adolescent patients.
 
* Risk factors associated with a completed suicide in patients with BDD are suicide thoughts and previous attempts, association with major depressive syndrome and demographic locations associated with high rates of suicide.
*The [[suicide]] rates in patients with BDD are high at all ages, with a higher incidence in adolescent patients.
* Phillips & Menard (2006) found the completed suicide rate in patients with BDD to be 45 times higher than in the general US population. This rate is more than double that of those with [[Clinical depression]] and three times as high as those with [[bipolar disorder]]<ref>http://ajp.psychiatryonline.org/cgi/content/full/163/7/1280</ref>. There has also been a suggested link between undiagnosed BDD and a higher than average suicide rate among people who have undergone cosmetic surgery<ref>http://www.newscientist.com/channel/health/mg19225745.200-cosmetic-surgery-special-when-looks-can-kill.html</ref>.
*Risk factors associated with completed [[suicide]] in patients with BDD are [[suicide]] thoughts and previous attempts, association with [[major depressive syndrome]] and demographic locations associated with high rates of suicide.
*Phillips & Menard (2006) found the completed [[suicide]] rate in patients with BDD to be 45 times higher than in the general US population. This rate is more than double that of those with [[Clinical depression]] and three times as high as those with [[bipolar disorder]]. There has also been a suggested link between undiagnosed BDD and a higher than average [[suicide]] rate among people who have undergone [[cosmetic surgery]]<ref>http://ajp.psychiatryonline.org/cgi/content/full/163/7/1280</ref><ref>http://www.newscientist.com/channel/health/mg19225745.200-cosmetic-surgery-special-when-looks-can-kill.html</ref>.


====Functional Consequences of BDD====
====Functional Consequences of BDD====
*Impaired psychosocial development which can range from mild (the patient avoid social situations) to severe (the patient doesn't leave the house).
 
*The severity of the disorder is usually directly associated with the degree of psychosocial impairment.
*Impaired [[psychosocial]] development which can range from mild (the patient avoids [[social situations]]) to severe (the patient doesn't leave the house).
*Chronically low self-esteem is characteristic of those with BDD due to the value of oneself being so closely linked with their perceived appearance. BDD causes chronic social [[anxiety]] for those suffering from the disorder[http://www.lipo.com/Health_Articles/Lifestyle_Articles/When_the_mirror_lies_-_Body_dysmorphic_disorder_(dysmorphophobia)_on_the_rise_and_taking_lives./].
*The severity of the disorder is usually directly associated with the degree of [[psychosocial impairment]].
*Chronically low [[self-esteem]] is characteristic of those with BDD due to the value of oneself being so closely linked with their perceived appearance. BDD causes chronic social [[anxiety]] for those suffering from the disorder[http://www.lipo.com/Health_Articles/Lifestyle_Articles/When_the_mirror_lies_-_Body_dysmorphic_disorder_(dysmorphophobia)_on_the_rise_and_taking_lives./]


===Prognosis===
===Prognosis===
Many individuals with BDD have repeatedly sought treatment from dermatologists or cosmetic surgeons with little satisfaction before finally accepting psychiatric or psychological help. Treatment can improve the outcome of the illness for most people. Other patients may function reasonably well for a time and then relapse, while others may remain chronically ill. Research on outcome without therapy is not known but it is thought the symptoms persist unless treated.  
Many individuals with BDD have repeatedly sought treatment from [[dermatologists]] or [[cosmetic surgeons]] with little satisfaction before finally accepting [[psychiatric]] or [[psychological]] help. Treatment can improve the outcome of the illness for most people. Other patients may function reasonably well for a time and then [[relapse]], while others may remain chronically ill. Research on outcomes without therapy is not known but it is thought the symptoms persist unless treated. <ref name="pmid29872676">{{cite journal| author=Higgins S, Wysong A| title=Cosmetic Surgery and Body Dysmorphic Disorder - An Update. | journal=Int J Womens Dermatol | year= 2018 | volume= 4 | issue= 1 | pages= 43-48 | pmid=29872676 | doi=10.1016/j.ijwd.2017.09.007 | pmc=5986110 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29872676  }} </ref>


==Diagnosis==
==Diagnosis==
===Diagnostic Criteria===
===Diagnostic Criteria===
====DSM-V Diagnostic Criteria for Body Dysmorphic Disorder Body Dysmorphic Disorder<ref name=DSMV>{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>====
====DSM-V Diagnostic Criteria for Body Dysmorphic Disorder Body Dysmorphic Disorder====
{{cquote|
{{cquote|
*The patient is preoccupied with an imagined defect of appearance or is excessively concerned about a slight physical anomaly.
*The patient is preoccupied with an imagined defect of appearance or is excessively concerned about a slight physical anomaly.
Line 83: Line 93:
'''AND'''
'''AND'''


*During the course of the disease the patient develops behaviors such as excessive mirror checking, grooming, seek for reassurance or compare his/her appearance with others.
*During the course of the disease the patient develops behaviors such as excessive mirror checking, grooming, seek for [[reassurance]] or compare his/her appearance with others.


'''AND'''
'''AND'''


*This preoccupation causes clinically important distress or impairs work, social or personal functioning.
*This preoccupation causes clinically important distress or impairs [[work]], [[social]] or [[personal]] functioning.


'''AND'''
'''AND'''
Line 94: Line 104:
}}
}}


* One must also specify if a patient with BDD has muscle dysmorphia where one seems to be preoccupied in a too small or insufficiently muscular physique even though they have a normal-looking build.
*One must also specify if a patient with BDD has [[muscle dysmorphia]] where one seems to be preoccupied in a too small or insufficiently muscular physique even though they have a normal-looking build.


*In addition, the degree of insight must also be evaluated.
*In addition, the degree of insight must also be evaluated <ref name="DSMV">{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>.


===Symptoms===
===Symptoms===
*Compulsive mirror checking, glancing in reflective doors, windows and other reflective surfaces.
[[Symptoms]] of body dysmorphic disorder include:<ref name="DSMV">{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>
*Alternatively, an inability to look at one's own reflection or photographs of oneself; often the removal of mirrors from the home.
 
*Compulsive skin-touching, especially to measure or feel the perceived defect.
*[[Compulsive]] mirror checking, glancing in reflective doors, windows, and other reflective surfaces
*Reassurance-seeking from loved ones.
*Alternatively, an inability to look at one's own reflection or photographs of oneself; often the removal of mirrors from the home
*Social withdrawal and co-morbid depression.
*[[Compulsive]] [[skin]]-touching, especially to measure or feel the perceived defect
*Obsessive viewing of favorite celebrities or models the person suffering from BDD may wish to resemble.
*[[Reassurance]]-seeking from loved ones
*Excessive grooming behaviors: combing hair, plucking eyebrows, shaving, etc.
*[[Social withdrawal]] and co-[[Morbidity|morbid]] [[depression]].
*Obsession with [[plastic surgery]] or multiple plastic surgeries with little satisfactory results for the patient.
*[[Obsessive viewing]] of favorite celebrities or models the person suffering from BDD may wish to resemble
*In obscure cases patients have performed plastic surgery on themselves, including [[liposuction]] and various implants with disastrous results.
*Excessive grooming behaviors: combing [[hair]], plucking [[eyebrows]], shaving, etc
*Obsession with [[plastic surgery]] or multiple [[plastic surgeries]] with few satisfactory results for the patient
*In obscure cases patients have performed [[plastic surgery]] on themselves, including [[liposuction]] and various [[implants]] with disastrous results


===Common Locations of imagined Defects===
===Common Locations of imagined Defects===
In research carried out by Dr. Katharine Philips, involving over 500 patients, the percentage of patients concerned with the most common locations were as follows:
In research carried out by Dr. Katharine Philips, involving over 500 patients, the percentage of patients concerned with the most common locations were as follows:
{{col-begin|width=80%}}
{{col-begin|width=80%}}
*Skin (73%)
*[[Skin]] (73%)
*Hair (56%)
*[[Hair]] (56%)
*Nose (37%)
*[[Nose]] (37%)
*Weight (22%)  
*[[Weight]] (22%)  
*Stomach (22%)
*[[Stomach]] (22%)
*Breasts/ Chest/ Nipples (21%)
*[[Breasts]]/ [[Chest]]/ [[Nipples]] (21%)
*Eyes (20%)
*[[Eyes]] (20%)
*Thighs (20%)
*[[Thighs]] (20%)
*Teeth (20%)
*[[Teeth]] (20%)
*Legs (Overall) (18%)
*[[Legs]] (Overall) (18%)
*Body Build/ Bone Structure (16%)
*Body Build/ [[Bone]] Structure (16%)
*Ugly Face (General) (14%)
*Ugly [[Face]] (General) (14%)
*Lips (12%)
*[[Lips]] (12%)
*Buttocks (12%)
*[[Buttocks]] (12%)
*Chin (11%)
*[[Chin]] (11%)
*Fingers  
*[[Fingers]]
*Eyebrows (11%)
*[[Eyebrows]] (11%)
{{col-end}}
{{col-end}}
''Source: '''The Broken Mirror''', Katharine A Philips, Oxford University Press, 2005 ed, p56 ''
People with BDD often have more than one area of concern.
People with BDD often have more than one area of concern.
''Source: ''' The Broken Mirror''', Katharine A Philips, Oxford University Press, 2005 ed, p56 ''


==Treatment==
The combination of Cognitive Behavioral Therapy (CBT) and Selective Serotonin Reuptake Inhibitors (SSRIs) are the mainstay treatments for BDD.
CBT involves psychotherapy centered on developing coping mechanisms by altering repetitive behavior patterns and thoughts. Strategies involve gradual sensitization of fear-inducing circumstances and retraining of thoughts. They are administered for 12-22 weeks of weekly sessions.<ref name="HofmannAsmundson2013">{{cite journal|last1=Hofmann|first1=Stefan G.|last2=Asmundson|first2=Gordon J.G.|last3=Beck|first3=Aaron T.|title=The Science of Cognitive Therapy|journal=Behavior Therapy|volume=44|issue=2|year=2013|pages=199–212|issn=00057894|doi=10.1016/j.beth.2009.01.007}}</ref> <ref name="WilhelmPhillips2014">{{cite journal|last1=Wilhelm|first1=Sabine|last2=Phillips|first2=Katharine A.|last3=Didie|first3=Elizabeth|last4=Buhlmann|first4=Ulrike|last5=Greenberg|first5=Jennifer L.|last6=Fama|first6=Jeanne M.|last7=Keshaviah|first7=Aparna|last8=Steketee|first8=Gail|title=Modular Cognitive-Behavioral Therapy for Body Dysmorphic Disorder: A Randomized Controlled Trial|journal=Behavior Therapy|volume=45|issue=3|year=2014|pages=314–327|issn=00057894|doi=10.1016/j.beth.2013.12.007}}</ref>
SSRIs, more commonly fluoxetine and escitalopram, are used to treat BDD and its accompanying comorbidities such as major depressive disorder, social anxiety disorder, and OCD. The incorporation of clomipramine is also initiated in some cases where SSRIs may not be of benefit. What should be noted with the use of SSRIs in the treatment of BDD is that they require higher doses compared to doses used to treat other psychiatric conditions. Typically, observed response to SSRI requires 12-16 weeks to determine response.<ref name="pmid29701157">{{cite journal| author=Hong K, Nezgovorova V, Uzunova G, Schlussel D, Hollander E| title=Pharmacological Treatment of Body Dysmorphic Disorder. | journal=Curr Neuropharmacol | year= 2019 | volume= 17 | issue= 8 | pages= 697-702 | pmid=29701157 | doi=10.2174/1570159X16666180426153940 | pmc=7059151 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29701157  }} </ref>
==Overview==
==Historical Perspective==
[Disease name] was first discovered by [name of scientist], a [nationality + occupation], in [year]/during/following [event].
The association between [important risk factor/cause] and [disease name] was made in/during [year/event].
In [year], [scientist] was the first to discover the association between [risk factor] and the development of [disease name].
In [year], [gene] mutations were first implicated in the pathogenesis of [disease name].
There have been several outbreaks of [disease name], including -----.
In [year], [diagnostic test/therapy] was developed by [scientist] to treat/diagnose [disease name].
==Classification==
There is no established system for the classification of [disease name].
OR
[Disease name] may be classified according to [classification method] into [number] subtypes/groups: [group1], [group2], [group3], and [group4].
OR
[Disease name] may be classified into [large number > 6] subtypes based on [classification method 1], [classification method 2], and [classification method 3].
[Disease name] may be classified into several subtypes based on [classification method 1], [classification method 2], and [classification method 3].
OR
Based on the duration of symptoms, [disease name] may be classified as either acute or chronic.
OR
If the staging system involves specific and characteristic findings and features:
According to the [staging system + reference], there are [number] stages of [malignancy name] based on the [finding1], [finding2], and [finding3]. Each stage is assigned a [letter/number1] and a [letter/number2] that designate the [feature1] and [feature2].
OR
The staging of [malignancy name] is based on the [staging system].
OR
There is no established system for the staging of [malignancy name].
==Pathophysiology==
The exact pathogenesis of [disease name] is not fully understood.
OR
It is thought that [disease name] is the result of / is mediated by / is produced by / is caused by either [hypothesis 1], [hypothesis 2], or [hypothesis 3].
OR
[Pathogen name] is usually transmitted via the [transmission route] route to the human host.
OR
Following transmission/ingestion, the [pathogen] uses the [entry site] to invade the [cell name] cell.
OR
[Disease or malignancy name] arises from [cell name]s, which are [cell type] cells that are normally involved in [function of cells].
OR
The progression to [disease name] usually involves the [molecular pathway].
OR
The pathophysiology of [disease/malignancy] depends on the histological subtype.
==Causes==
Disease name] may be caused by [cause1], [cause2], or [cause3].
OR
Common causes of [disease] include [cause1], [cause2], and [cause3].
OR
The most common cause of [disease name] is [cause 1]. Less common causes of [disease name] include [cause 2], [cause 3], and [cause 4].
OR
The cause of [disease name] has not been identified. To review risk factors for the development of [disease name], click [[Pericarditis causes#Overview|here]].
==Differentiating ((Page name)) from other Diseases==
[Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as [differential dx1], [differential dx2], and [differential dx3].
OR
[Disease name] must be differentiated from [[differential dx1], [differential dx2], and [differential dx3].
==Epidemiology and Demographics==
The incidence/prevalence of [disease name] is approximately [number range] per 100,000 individuals worldwide.
OR
In [year], the incidence/prevalence of [disease name] was estimated to be [number range] cases per 100,000 individuals worldwide.
OR
In [year], the incidence of [disease name] is approximately [number range] per 100,000 individuals with a case-fatality rate of [number range]%.
Patients of all age groups may develop [disease name].
OR
The incidence of [disease name] increases with age; the median age at diagnosis is [#] years.
OR
[Disease name] commonly affects individuals younger than/older than [number of years] years of age.
OR
[Chronic disease name] is usually first diagnosed among [age group].
OR
[Acute disease name] commonly affects [age group].
There is no racial predilection to [disease name].
OR
[Disease name] usually affects individuals of the [race 1] race. [Race 2] individuals are less likely to develop [disease name].
[Disease name] affects men and women equally.
OR
[Gender 1] are more commonly affected by [disease name] than [gender 2]. The [gender 1] to [gender 2] ratio is approximately [number > 1] to 1.
The majority of [disease name] cases are reported in [geographical region].
OR
[Disease name] is a common/rare disease that tends to affect [patient population 1] and [patient population 2].
==Risk Factors==
There are no established risk factors for [disease name].
OR
The most potent risk factor in the development of [disease name] is [risk factor 1]. Other risk factors include [risk factor 2], [risk factor 3], and [risk factor 4].
OR
Common risk factors in the development of [disease name] include [risk factor 1], [risk factor 2], [risk factor 3], and [risk factor 4].
OR
Common risk factors in the development of [disease name] may be occupational, environmental, genetic, and viral.
==Screening==
There is insufficient evidence to recommend routine screening for [disease/malignancy].
OR
According to the [guideline name], screening for [disease name] is not recommended.
OR
According to the [guideline name], screening for [disease name] by [test 1] is recommended every [duration] among patients with [condition 1], [condition 2], and [condition 3].
==Natural History, Complications, and Prognosis==
If left untreated, [#]% of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
OR
Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
OR
Prognosis is generally excellent/good/poor, and the 1/5/10-year mortality/survival rate of patients with [disease name] is approximately [#]%.
==Diagnosis==
===Diagnostic Study of Choice===
The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met: [criterion 1], [criterion 2], [criterion 3], and [criterion 4].
OR
The diagnosis of [disease name] is based on the [criteria name] criteria, which include [criterion 1], [criterion 2], and [criterion 3].
OR
The diagnosis of [disease name] is based on the [definition name] definition, which includes [criterion 1], [criterion 2], and [criterion 3].
OR
There are no established criteria for the diagnosis of [disease name].
===History and Symptoms===
The majority of patients with [disease name] are asymptomatic.
OR
The hallmark of [disease name] is [finding]. A positive history of [finding 1] and [finding 2] is suggestive of [disease name]. The most common symptoms of [disease name] include [symptom 1], [symptom 2], and [symptom 3]. Common symptoms of [disease] include [symptom 1], [symptom 2], and [symptom 3]. Less common symptoms of [disease name] include [symptom 1], [symptom 2], and [symptom 3].
===Physical Examination===
Patients with [disease name] usually appear [general appearance]. Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].
OR
Common physical examination findings of [disease name] include [finding 1], [finding 2], and [finding 3].
OR
The presence of [finding(s)] on physical examination is diagnostic of [disease name].
OR
The presence of [finding(s)] on physical examination is highly suggestive of [disease name].
===Laboratory Findings===
An elevated/reduced concentration of serum/blood/urinary/CSF/other [lab test] is diagnostic of [disease name].
OR
Laboratory findings consistent with the diagnosis of [disease name] include [abnormal test 1], [abnormal test 2], and [abnormal test 3].
OR
[Test] is usually normal among patients with [disease name].
OR
Some patients with [disease name] may have elevated/reduced concentration of [test], which is usually suggestive of [progression/complication].
OR
There are no diagnostic laboratory findings associated with [disease name].
===Electrocardiogram===
There are no ECG findings associated with [disease name].
OR
An ECG may be helpful in the diagnosis of [disease name]. Findings on an ECG suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
===X-ray===
There are no x-ray findings associated with [disease name].
OR
An x-ray may be helpful in the diagnosis of [disease name]. Findings on an x-ray suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
OR
There are no x-ray findings associated with [disease name]. However, an x-ray may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].
===Echocardiography or Ultrasound===
There are no echocardiography/ultrasound  findings associated with [disease name].
OR
Echocardiography/ultrasound  may be helpful in the diagnosis of [disease name]. Findings on an echocardiography/ultrasound suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
OR
There are no echocardiography/ultrasound  findings associated with [disease name]. However, an echocardiography/ultrasound  may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].
===CT scan===
There are no CT scan findings associated with [disease name].
OR
[Location] CT scan may be helpful in the diagnosis of [disease name]. Findings on CT scan suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
OR
There are no CT scan findings associated with [disease name]. However, a CT scan may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].
===MRI===
There are no MRI findings associated with [disease name].
OR
[Location] MRI may be helpful in the diagnosis of [disease name]. Findings on MRI suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
OR
There are no MRI findings associated with [disease name]. However, a MRI may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].
===Other Imaging Findings===
There are no other imaging findings associated with [disease name].
OR
[Imaging modality] may be helpful in the diagnosis of [disease name]. Findings on an [imaging modality] suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
===Other Diagnostic Studies===
There are no other diagnostic studies associated with [disease name].
OR
[Diagnostic study] may be helpful in the diagnosis of [disease name]. Findings suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
OR
Other diagnostic studies for [disease name] include [diagnostic study 1], which demonstrates [finding 1], [finding 2], and [finding 3], and [diagnostic study 2], which demonstrates [finding 1], [finding 2], and [finding 3].


==Treatment==
==Treatment==
===Medical Therapy===
*The combination of [[Cognitive Behavioral Therapy]] [[(CBT)]] and [[Selective Serotonin Reuptake Inhibitors]] [[(SSRIs)]] are the mainstay treatments for BDD.
There is no treatment for [disease name]; the mainstay of therapy is supportive care.
 
*[[CBT]] involves [[psychotherapy]] centered on developing [[coping mechanisms]] by altering [[repetitive]] [[behavior]] patterns and [[thoughts]]. Strategies involve gradual [[sensitization]] of fear-inducing circumstances and [[retraining]] of thoughts. They are administered for 12-22 weeks of weekly sessions.<ref name="HofmannAsmundson2013">{{cite journal|last1=Hofmann|first1=Stefan G.|last2=Asmundson|first2=Gordon J.G.|last3=Beck|first3=Aaron T.|title=The Science of Cognitive Therapy|journal=Behavior Therapy|volume=44|issue=2|year=2013|pages=199–212|issn=00057894|doi=10.1016/j.beth.2009.01.007}}</ref> <ref name="WilhelmPhillips2014">{{cite journal|last1=Wilhelm|first1=Sabine|last2=Phillips|first2=Katharine A.|last3=Didie|first3=Elizabeth|last4=Buhlmann|first4=Ulrike|last5=Greenberg|first5=Jennifer L.|last6=Fama|first6=Jeanne M.|last7=Keshaviah|first7=Aparna|last8=Steketee|first8=Gail|title=Modular Cognitive-Behavioral Therapy for Body Dysmorphic Disorder: A Randomized Controlled Trial|journal=Behavior Therapy|volume=45|issue=3|year=2014|pages=314–327|issn=00057894|doi=10.1016/j.beth.2013.12.007}}</ref>
OR
 
Supportive therapy for [disease name] includes [therapy 1], [therapy 2], and [therapy 3].
 
OR
 
The majority of cases of [disease name] are self-limited and require only supportive care.
 
OR
 
[Disease name] is a medical emergency and requires prompt treatment.
 
OR
 
The mainstay of treatment for [disease name] is [therapy].
 
OR
 
The optimal therapy for [malignancy name] depends on the stage at diagnosis.
 
OR
 
[Therapy] is recommended among all patients who develop [disease name].
 
OR
 
Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].
 
OR
 
Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].
 
OR
 
Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].
 
OR
 
Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].
 
===Surgery===
Surgical intervention is not recommended for the management of [disease name].
 
OR
 
Surgery is not the first-line treatment option for patients with [disease name]. Surgery is usually reserved for patients with either [indication 1], [indication 2], and [indication 3]
 
OR
 
The mainstay of treatment for [disease name] is medical therapy. Surgery is usually reserved for patients with either [indication 1], [indication 2], and/or [indication 3].
 
OR
 
The feasibility of surgery depends on the stage of [malignancy] at diagnosis.
 
OR
 
Surgery is the mainstay of treatment for [disease or malignancy].
 
===Primary Prevention===
There are no established measures for the primary prevention of [disease name].
 
OR
 
There are no available vaccines against [disease name].
 
OR
 
Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].
 
OR
 
[Vaccine name] vaccine is recommended for [patient population] to prevent [disease name]. Other primary prevention strategies include [strategy 1], [strategy 2], and [strategy 3].
 
===Secondary Prevention===
There are no established measures for the secondary prevention of [disease name].
 
OR
 
Effective measures for the secondary prevention of [disease name] include [strategy 1], [strategy 2], and [strategy 3].


*[[SSRIs]], more commonly [[fluoxetine]] and [[escitalopram]], are used to treat BDD and its accompanying comorbidities such as [[major depressive disorder]], (social [[anxiety disorder]], and [[OCD]]. The incorporation of [[clomipramine]] is also initiated in some cases where [[SSRIs]] may not be of benefit. What should be noted with the use of [[SSRIs]] in the treatment of BDD is that they require higher doses compared to doses used to treat other psychiatric conditions. Typically, observed response to [[SSRI]] requires 12-16 weeks to determine response.<ref name="pmid29701157">{{cite journal| author=Hong K, Nezgovorova V, Uzunova G, Schlussel D, Hollander E| title=Pharmacological Treatment of Body Dysmorphic Disorder. | journal=Curr Neuropharmacol | year= 2019 | volume= 17 | issue= 8 | pages= 697-702 | pmid=29701157 | doi=10.2174/1570159X16666180426153940 | pmc=7059151 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29701157  }} </ref>


==References==
==References==

Latest revision as of 03:44, 8 July 2021


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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Chelsea Mae Nobleza, M.D.[2] Alonso Alvarado, M.D. [3]

Synonyms and keywords: BDD

Overview

Body dysmorphic disorder (BDD) is a mental disorder that involves a disturbed body image where there is an excessive preoccupation with the physical appearance despite the fact there may be no noticeable disfigurement or defect. Common areas of concern in most people suffering from BDD include perceived flaws relating to the face, nose, eyes, skin, and hair. BDD combines obsessive and compulsive aspects, which links it to the OCD spectrum disorders. People with BDD may engage in compulsive mirror checking behaviors or mirror avoidance, typically think about their appearance for more than one hour a day, and in severe cases may drop all social contact and responsibilities as they become homebound. The disorder is linked to an unusually high suicide rate among all mental disorders.

Historical Perspective

BDD was first documented in 1886 by the researcher Morselli, who called the condition simply "Dysmorphophobia". BDD was first recorded/formally recognized in 1997 as a disorder in the DSM; however, in 1987 it was first truly recognized by the American Psychiatric Association.

In his practice, Freud eventually had a patient who would today be diagnosed with the disorder; Russian aristocrat Sergei Pankejeff, nicknamed "The Wolf Man" by Freud himself in order to protect Pankejeff's identity, had a preoccupation with his nose to an extent that greatly limited his functioning.

Causes

The exact etiology of BDD is unclear, but it is likely an interplay in social, psychological, and biological factors. [1]

Social Factors

Individuals with BDD have suffered from some form of abuse in the past. These experiences comprised emotional neglect in 68%, emotional abuse in 56 %, physical abuse in 34.7%, and sexual abuse in 28% of patients. [1] [2]

Neurobiological Model for BDD

Detailed processing and visual processing streams

A dysfunction in visual processing systems accounts for the heightened detail processing in BDD patients. This is due to the observed early travel of first-order visual information from V1 and V2 areas to temporal regions in the left hemisphere, where detail and structure are encoded. In addition, there is the faulty formation of holistic elements of visual information due to decreased use of the processing of second-order visual information, as evidenced by decreased activity in the lateral occipital cortex and precuneus. These findings explain the enhanced awareness of perceived imperfections in BDD patients.[3] [4] [5] [6] [7]

Frontostriatal systems

Increased activity and reduced grey matter volumes in the frontostriatal and subcortical regions are linked to BDD patients' repetitive and compulsive behaviors, which is similarly observed in OCD patients.This is supported by abnormal circuitry seen in the inferior occipitofrontal fasciculus, a pathway that connects the frontal and occipital lobes via the caudate. The caudate nucleus seems to play an essential role in inappropriately mediating motor inhibition. [8] [9]

Temporolimbic systems

The limbic system is also involved in BDD. In particular, the right amygdala demonstrates hyperactivity during visual tasks and mediates the relationship between anxiety and ventral visual system activation. This results in heightened emotions to visual information.[10] [11]

Genetic Factors

A genetic component may also be involved in BBD. Patients with BDD have a family member with a similar condition in 8% of patients, while 7% of BDD patients have first-degree family members with OCD. [12]

Differential Diagnosis

Body dysmorphic disorder must be differentiated from: [13]

Epidemiology and Demographics

Prevalence

The prevalence of BDD is at 0.7-2.4% in the general population making it more common than other psychiatric disorders such as anorexia nervosa or schizophrenia. In clinical settings, BDD seems to have a prevalence of 9-13% in dermatology settings, 3-53% in cosmetic surgery settings and it coexists with OCD in 8-37% of patients. Considering how common this condition is, many individuals don’t report their symptoms due to embarrassment. [14]

Gender

BDD affects more women than men (2.5% vs 2.2%) and the average onset is at 17 years old.[15]

Risk Factors

Some of risk factors include: [13]

Natural History, Complications, and Prognosis

Natural History

BDD usually develops in adolescence, a time when people are generally most sensitive about their appearance. However, many patients suffer for years before seeking help. When they do seek help through mental health professionals, patients often complain of other symptoms such as depression, social anxiety or obsessive-compulsive disorder, but do not reveal their real concern over body image. Most patients cannot be convinced that they have a distorted view of their body image, due to the very limited knowledge of the disorder as compared to OCD or others. Male patients have more risk of developing the obsession around the genitalia and females have higher risk of developing eating disorders associated with the BDD.[16]

Complications

Suicide Risk

  • The suicide rates in patients with BDD are high at all ages, with a higher incidence in adolescent patients.
  • Risk factors associated with completed suicide in patients with BDD are suicide thoughts and previous attempts, association with major depressive syndrome and demographic locations associated with high rates of suicide.
  • Phillips & Menard (2006) found the completed suicide rate in patients with BDD to be 45 times higher than in the general US population. This rate is more than double that of those with Clinical depression and three times as high as those with bipolar disorder. There has also been a suggested link between undiagnosed BDD and a higher than average suicide rate among people who have undergone cosmetic surgery[17][18].

Functional Consequences of BDD

  • Impaired psychosocial development which can range from mild (the patient avoids social situations) to severe (the patient doesn't leave the house).
  • The severity of the disorder is usually directly associated with the degree of psychosocial impairment.
  • Chronically low self-esteem is characteristic of those with BDD due to the value of oneself being so closely linked with their perceived appearance. BDD causes chronic social anxiety for those suffering from the disorder[4]

Prognosis

Many individuals with BDD have repeatedly sought treatment from dermatologists or cosmetic surgeons with little satisfaction before finally accepting psychiatric or psychological help. Treatment can improve the outcome of the illness for most people. Other patients may function reasonably well for a time and then relapse, while others may remain chronically ill. Research on outcomes without therapy is not known but it is thought the symptoms persist unless treated. [19]

Diagnosis

Diagnostic Criteria

DSM-V Diagnostic Criteria for Body Dysmorphic Disorder Body Dysmorphic Disorder

“
  • The patient is preoccupied with an imagined defect of appearance or is excessively concerned about a slight physical anomaly.

AND

  • During the course of the disease the patient develops behaviors such as excessive mirror checking, grooming, seek for reassurance or compare his/her appearance with others.

AND

  • This preoccupation causes clinically important distress or impairs work, social or personal functioning.

AND

  • Another mental disorder (such as Anorexia Nervosa) does not better explain the preoccupation.
 ”
  • One must also specify if a patient with BDD has muscle dysmorphia where one seems to be preoccupied in a too small or insufficiently muscular physique even though they have a normal-looking build.
  • In addition, the degree of insight must also be evaluated [13].

Symptoms

Symptoms of body dysmorphic disorder include:[13]

Common Locations of imagined Defects

In research carried out by Dr. Katharine Philips, involving over 500 patients, the percentage of patients concerned with the most common locations were as follows:

People with BDD often have more than one area of concern. Source: The Broken Mirror, Katharine A Philips, Oxford University Press, 2005 ed, p56


Treatment

  • SSRIs, more commonly fluoxetine and escitalopram, are used to treat BDD and its accompanying comorbidities such as major depressive disorder, (social anxiety disorder, and OCD. The incorporation of clomipramine is also initiated in some cases where SSRIs may not be of benefit. What should be noted with the use of SSRIs in the treatment of BDD is that they require higher doses compared to doses used to treat other psychiatric conditions. Typically, observed response to SSRI requires 12-16 weeks to determine response.[22]

References

  1. ↑ 1.0 1.1 Buhlmann, Ulrike; Marques, Luana M.; Wilhelm, Sabine (2012). "Traumatic Experiences in Individuals With Body Dysmorphic Disorder". Journal of Nervous & Mental Disease. 200 (1): 95–98. doi:10.1097/NMD.0b013e31823f6775. ISSN 0022-3018.
  2. ↑ Didie, Elizabeth R.; Tortolani, Christina C.; Pope, Courtney G.; Menard, William; Fay, Christina; Phillips, Katharine A. (2006). "Childhood abuse and neglect in body dysmorphic disorder". Child Abuse & Neglect. 30 (10): 1105–1115. doi:10.1016/j.chiabu.2006.03.007. ISSN 0145-2134.
  3. ↑ Arienzo, Donatello; Leow, Alex; Brown, Jesse A; Zhan, Liang; GadElkarim, Johnson; Hovav, Sarit; Feusner, Jamie D (2013). "Abnormal Brain Network Organization in Body Dysmorphic Disorder". Neuropsychopharmacology. 38 (6): 1130–1139. doi:10.1038/npp.2013.18. ISSN 0893-133X.
  4. ↑ Feusner, Jamie D.; Arienzo, Donatello; Li, Wei; Zhan, Liang; GadElkarim, Johnson; Thompson, Paul M.; Leow, Alex D. (2013). "White matter microstructure in body dysmorphic disorder and its clinicalcorrelates". Psychiatry Research: Neuroimaging. 211 (2): 132–140. doi:10.1016/j.pscychresns.2012.11.001. ISSN 0925-4927.
  5. ↑ Leow, Alex D.; Zhan, Liang; Arienzo, Donatello; GadElkarim, Johnson J.; Zhang, Aifeng F.; Ajilore, Olusola; Kumar, Anand; Thompson, Paul M.; Feusner, Jamie D. (2012). "Hierarchical Structural Mapping for Globally Optimized Estimation of Functional Networks". 7511: 228–236. doi:10.1007/978-3-642-33418-4_29. ISSN 0302-9743.
  6. ↑ Li, Wei; Arienzo, Donatello; Feusner, Jamie D. (2013). "Body Dysmorphic Disorder: Neurobiological Features and an Updated Model". Zeitschrift für Klinische Psychologie und Psychotherapie. 42 (3): 184–191. doi:10.1026/1616-3443/a000213. ISSN 1616-3443.
  7. ↑ Grace, Sally A.; Labuschagne, Izelle; Kaplan, Ryan A.; Rossell, Susan L. (2017). "The neurobiology of body dysmorphic disorder: A systematic review and theoretical model". Neuroscience & Biobehavioral Reviews. 83: 83–96. doi:10.1016/j.neubiorev.2017.10.003. ISSN 0149-7634.
  8. ↑ Saxena, Sanjaya; Rauch, Scott L. (2000). "FUNCTIONAL NEUROIMAGING AND THE NEUROANATOMY OF OBSESSIVE-COMPULSIVE DISORDER". Psychiatric Clinics of North America. 23 (3): 563–586. doi:10.1016/S0193-953X(05)70181-7. ISSN 0193-953X.
  9. ↑ Buchanan, B. G.; Rossell, S. L.; Maller, J. J.; Toh, W. L.; Brennan, S.; Castle, D. J. (2013). "Brain connectivity in body dysmorphic disorder compared with controls: a diffusion tensor imaging study". Psychological Medicine. 43 (12): 2513–2521. doi:10.1017/S0033291713000421. ISSN 0033-2917.
  10. ↑ Buhlmann, Ulrike; Winter, Anna; Kathmann, Norbert (2013). "Emotion recognition in body dysmorphic disorder: Application of the Reading the Mind in the Eyes Task". Body Image. 10 (2): 247–250. doi:10.1016/j.bodyim.2012.12.001. ISSN 1740-1445.
  11. ↑ Monzani, Benedetta; Rijsdijk, Fruhling; Iervolino, Alessandra C.; Anson, Martin; Cherkas, Lynn; Mataix-Cols, David (2012). "Evidence for a genetic overlap between body dysmorphic concerns and obsessive-compulsive symptoms in an adult female community twin sample". American Journal of Medical Genetics Part B: Neuropsychiatric Genetics. 159B (4): 376–382. doi:10.1002/ajmg.b.32040. ISSN 1552-4841.
  12. ↑ Bjornsson, Andri S.; Didie, Elizabeth R.; Grant, Jon E.; Menard, William; Stalker, Emily; Phillips, Katharine A. (2013). "Age at onset and clinical correlates in body dysmorphic disorder". Comprehensive Psychiatry. 54 (7): 893–903. doi:10.1016/j.comppsych.2013.03.019. ISSN 0010-440X.
  13. ↑ 13.0 13.1 13.2 13.3 Diagnostic and statistical manual of mental disorders : DSM-5. Washington, D.C: American Psychiatric Association. 2013. ISBN 0890425558.
  14. ↑ Bjornsson AS, Didie ER, Phillips KA (2010). "Body dysmorphic disorder". Dialogues Clin Neurosci. 12 (2): 221–32. PMC 3181960. PMID 20623926.
  15. ↑ Hong, Kevin; Nezgovorova, Vera; Uzunova, Genoveva; Schlussel, Danya; Hollander, Eric (2019). "Pharmacological Treatment of Body Dysmorphic Disorder". Current Neuropharmacology. 17 (8): 697–702. doi:10.2174/1570159X16666180426153940. ISSN 1570-159X.
  16. ↑ Phillips KA (2006). "The Presentation of Body Dysmorphic Disorder in Medical Settings". Prim psychiatry. 13 (7): 51–59. PMC 1712667. PMID 17183412.
  17. ↑ http://ajp.psychiatryonline.org/cgi/content/full/163/7/1280
  18. ↑ http://www.newscientist.com/channel/health/mg19225745.200-cosmetic-surgery-special-when-looks-can-kill.html
  19. ↑ Higgins S, Wysong A (2018). "Cosmetic Surgery and Body Dysmorphic Disorder - An Update". Int J Womens Dermatol. 4 (1): 43–48. doi:10.1016/j.ijwd.2017.09.007. PMC 5986110. PMID 29872676.
  20. ↑ Hofmann, Stefan G.; Asmundson, Gordon J.G.; Beck, Aaron T. (2013). "The Science of Cognitive Therapy". Behavior Therapy. 44 (2): 199–212. doi:10.1016/j.beth.2009.01.007. ISSN 0005-7894.
  21. ↑ Wilhelm, Sabine; Phillips, Katharine A.; Didie, Elizabeth; Buhlmann, Ulrike; Greenberg, Jennifer L.; Fama, Jeanne M.; Keshaviah, Aparna; Steketee, Gail (2014). "Modular Cognitive-Behavioral Therapy for Body Dysmorphic Disorder: A Randomized Controlled Trial". Behavior Therapy. 45 (3): 314–327. doi:10.1016/j.beth.2013.12.007. ISSN 0005-7894.
  22. ↑ Hong K, Nezgovorova V, Uzunova G, Schlussel D, Hollander E (2019). "Pharmacological Treatment of Body Dysmorphic Disorder". Curr Neuropharmacol. 17 (8): 697–702. doi:10.2174/1570159X16666180426153940. PMC 7059151 Check |pmc= value (help). PMID 29701157.
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