Body Dysmorphic Disorder (BDD) – Fear of Imagined Ugliness
Body Dysmorphic Disorder (BDD) is characterised as an excessive preoccupation with an imagined or slight defect in appearance of a body part or parts. This preoccupation is distressing, the sufferer feels unattractive even though the defect is often non - existent. To alleviate the distress, time consuming rituals are performed that are without effect or paradoxically exacerbate the distress. Sufferers are convinced that their distress is warranted and the defects visible. Reassurance that there is indeed no visible defect is without effect in modifying their convictions.
BDD was first described as “dysmorphophobia” by the Italian Psychiatrist Enrique Morselli more than a century ago. At about the same time, it was recognised by the French psychiatrist Pierre Janet who stated that, "It was common if one looked for it". Today, BDD is categorised as a Somatoform disorder, the features of which are listed in Table 1.
TABLE 1 Features of BDD
- There is a preoccupation with an imagined defect in appearance. However, if there is a slight physical defect, excessive worry occurs.
- The Preoccupation causes significant distress or impairment in social, occupational, or other important areas of functioning.
- The preoccupation is not better accounted for by another mental disorder e.g., dissatisfaction with body shape and size in anorexia nervosa.
A slow onset is the norm, the illness increasingly restricting the life of the sufferer and compromising life chances. Onset may be at any age, however, the mean age is sixteen. The sex ratio is controversial, some studies suggesting a female prevalence, others a male. Tragically, for most, the illness is chronic, unremitting and often goes undiagnosed and unrecognised in clinical settings.
Any body part, parts or the whole body may become the focus of the preoccupation. The most common sites of preoccupation are listed in Table 2. Gender differences have shown that females focus more on hips and weight; males on hair thinning, genitalia and body build. Muscle dysmorphia, a preoccupation with being inadequately muscular, is far more common in men. Insight into the preoccupation varies; some recognise their concerns as unrealistic and exaggerated, others have overvalued ideas and 50% are delusional. The distress and preoccupation is over size, shape, texture, colouring markings and symmetry.
TABLE 2 The most common sites of ugliness in BDD
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BDD is a time consuming illness with preoccupation a daily concern. Thirty - five percent of sufferers spend up to eight hours each day consumed by their illness. The content of the preoccupation is about their ugliness, its visibility to others and the conviction that others will view their ugliness unfavourably, even though it may be non - existent. Common time consuming behaviours are listed in Table 3.
TABLE 3 Time consuming behaviours undertaken by the BDD sufferer
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Comparing is undertaken by 90% of BDD sufferers. This involves secretly comparing the unattractiveness of their body part with the same body parts of others, hoping to reinforce their own normality. Comparing rarely brings relief; most in fact feel worse, their perception of ugliness confirmed. Some compare using personal photos or photographs of others in magazines.
Checking is undertaken by 83% and is motivated by the desire to demonstrate that their ugliness is non - existent, has improved or is not visible to others. Checking occurs using mirrors and other reflective surfaces, the whereabouts of which are often well known. Some carry mirrors or have their favourite mirrors, which they may spend hours in front of, checking their appearance. Despite those with BDD being secretive as to their condition, they often persistently question others about their appearance.
Camouflaging and grooming the site of the perceived ugliness with clothing, hats, scarves, combs and make - up is common. Cosmetics are used by male and females with brands names often being important; hours are spent, daily, applying make - up. Touching or palpating the site or sites is undertaken by 33%; the purpose behind this behaviour is to determine if the site feels right or to manipulate the site so that it looks "just right".
Skin picking and other forms of self - surgery are undertaken by 27% of sufferers. These behaviours aim to improve the appearance of the body part or parts. Self - surgery is often detrimental, the remaining wound, lesions and scar tissue often exacerbating the feelings of unattractiveness. For some, the scarring becomes permanent.
BDD dominates the life of most sufferers. Up to 98% report restriction of their social lives, 76% never marry or experience a heterosexual relationship and many live alone or with family members. Up to 75%, report restriction of their educational choices, 42 to 50% are unemployed and one - third housebound, at sometime.
BDD DOES NOT OCCUR ALONE
Other concurrent psychiatric conditions are the norm in BDD with over 80% having a lifetime prevalence of major depression; onset of which occurs after the onset of BDD. The anxiety disorders are also common, 38% suffer social anxiety disorder and 30% have a lifetime prevalence of Obsessive Compulsive Disorder (OCD). Substance and alcohol abuse is high, the abuse is often an attempt to minimise the distress arising from the preoccupation.