Dysmorphophobia (Body Dysmorphic Disorder)

The patient with body dysmorphic disorder (BDD) (dysmorphophobia) is convinced that part of their body is too large, too small or deformed in some way. To the observer the appearance is normal or of a minor abnormality.

Initially described as an atypical somatoform disorder and then a distinct somatoform disorder in 1987, BDD now falls in the DSM-5-TR under the spectrum of obsessive-compulsive and related disorders. (1)

To meet the diagnostic criteria, patients must engage in repetitive behaviours, such as excessive mirror checking, camouflaging (such as covering up the defect with makeup or clothing), skin picking, excessive grooming, excessive weight lifting, or pervasive mental acts such as comparing one’s appearance to others. (2)

BDD has both psychotic and nonpsychotic variants, which are classified as separate disorders

• despite their separate classification, available evidence indicates that BDD's delusional and non-delusional forms have many similarities (although the delusional variant appears more severe), suggesting that they may actually be the same disorder, characterized by a spectrum of insight

Common parts of the body complained about include the nose, ears, mouth, breasts, buttocks and penis, but any part of the body may be involved.

Factors that may predispose persons to BDD include:

• low self-esteem
• critical parents and significant others
• early childhood trauma
• unconscious displacement of emotional conflict

About 75% of people with BDD experience past or current major depressive disorder. It is the most common comorbid disorder. (3) Patients with BDD also had an earlier onset of - and higher lifetime rates of - social phobia (16%), obsessive compulsive disorder (6%), and psychotic disorder diagnoses as well as higher rates of substance use disorders in first-degree relatives (3)

Patients typically have BDD for up to 15 years before receiving mental health treatment. (4)

Appropriate pharmacotherapy and cognitive behavioural therapy for BDD results in high response and remission rates. (5) Selective serotonin-reuptake inhibitors (SSRIs) and the tricyclic antidepressant clomipramine are the first-line medications for BDD. (6) SSRIs are usually tried before clomipramine because they are usually better tolerated (7) but high doses of SSRIs or clomipramine are usually needed, typically in the range used for obsessive-compulsive disorder and higher than those often used for other disorders (e.g., depression) (8)

Reference:

1. França K, Roccia MG, Castillo D, ALHarbi M, Tchernev G, Chokoeva A, Lotti T, Fioranelli M. Body dysmorphic disorder: history and curiosities. Wien Med Wochenschr. 2017 Oct;167(Suppl 1):5-7
2. Phillips KA, Wilhelm S, Koran LM, Didie ER, Fallon BA, Feusner J, Stein DJ. Body dysmorphic disorder: some key issues for DSM-V. Depress Anxiety. 2010 Jun;27(6):573-91.
3. Gunstad J, Phillips KA. Axis I comorbidity in body dysmorphic disorder. Compr Psychiatry. 2003 Jul-Aug;44(4):270-6.
4. Neziroglu, F, Lippman, N. A review of body dysmorphic disorder after 20 years of research. Aus Clin Psych. 2015;1(1):22-9.
5. Phillips KA, Keshaviah A, Dougherty DD, et al. Pharmacotherapy relapse prevention in body dysmorphic disorder: a double-blind, placebo-controlled trial. Am J Psychiatry. 2016 Sep 1;173(9):887-95.
6. Castle D, Beilharz F, Phillips KA, et al. Body dysmorphic disorder: a treatment synthesis and consensus on behalf of the International College of Obsessive-Compulsive Spectrum Disorders and the Obsessive Compulsive and Related Disorders Network of the European College of Neuropsychopharmacology. Int Clin Psychopharmacol. 2021 Mar 1;36(2):61-75.
7. Koran LM, Hanna GL, Hollander E, et al. Practice guideline for the treatment of patients with obsessive-compulsive disorder. Am J Psychiatry. 2007 Jul;164(suppl 7):5-53.
8. Phillips KA, Kelly MM. Body dysmorphic disorder: clinical overview and relationship to obsessive-compulsive disorder. Focus (Am Psychiatr Publ). 2021 Oct;19(4):413-9.