Background

• Body Dysmorphic Disorder (BDD) is a psychiatric condition characterized by preoccupation with perceived flaws and defects in one’s physical appearance that are not noticeable to others or appear minor. Individuals with BDD excessively focus on specific body parts, leading to distress and impaired daily functioning.
• The condition can cause severe emotional distress, anxiety, and depression, affecting a person’s social and occupational life. BDD often emerges during adolescence or early adulthood, and its exact cause is not known, but genetic, neurobiological, and environmental factors may play a role.
• It is crucial to differentiate BDD from normal body dissatisfaction, as the disorder can lead to significant suffering and even suicidal ideation if left untreated. Treatment may involve cognitive-behavioral therapy, antidepressant medication, or a combination of both to help individuals manage their obsessive concerns and improve their overall well-being. 

Epidemiology

• Prevalence: BDD is estimated to affect approximately 1-2% of the general population. It is considered one of the more common obsessive-compulsive spectrum disorders. 
• Age of Onset: BDD often emerges during adolescence and early adulthood, typically between the ages of 12 and 18 years. However, it can also develop later in life. 
• Gender Differences: BDD affects both men and women, but some studies suggest a higher prevalence in women. 
• Comorbidity: BDD is frequently associated with other psychiatric disorders, particularly mood and anxiety disorders. Common comorbid conditions include major depressive disorder, social anxiety disorder, and obsessive-compulsive disorder. 
• Impact on Daily Life: BDD can significantly impair daily functioning and quality of life. Individuals with BDD often experience high levels of distress, avoidance of social situations, and difficulty in maintaining relationships or pursuing professional opportunities. 
• Suicidality: BDD is associated with a heightened risk of suicidal ideas & suicide attempts, particularly in those with severe and untreated symptoms. 
• Delay in Seeking Treatment: Many individuals with BDD may not seek help for their condition, often due to shame or embarrassment about their concerns regarding their appearance. 

Anatomy

Pathophysiology

• Neurobiological Factors: Studies using neuroimaging techniques have identified brain abnormalities in individuals with BDD. These abnormalities involve areas of the brain responsible for processing visual information and emotions. There may be altered connectivity and activity in these brain regions, leading to distorted perceptions of one’s appearance and increased emotional reactivity to perceived flaws. 
• Serotonin Dysregulation: Serotonin is a neurotransmitter that plays a crucial role in mood regulation and impulse control. Some research has suggested that BDD may be associated with dysregulation of serotonin pathways in the brain.  
• Genetic Factors: BDD appears to have a genetic component, as it can run in families. Specific genes related to neurotransmitter function and brain development may be involved in the development of the disorder. 
• Cognitive Factors: Cognitive factors are thought to contribute to the pathophysiology of BDD. Individuals with BDD tend to have distorted perceptions of their appearance and engage in negative thought patterns and beliefs about their flaws. These cognitive biases can perpetuate and worsen the symptoms of BDD. 
• Psychological Factors: BDD is often associated with co-occurring psychiatric conditions like depression, anxiety, & obsessive-compulsive disorder. These psychological factors may interact and exacerbate BDD symptoms. 
• Environmental Influences: Sociocultural factors, including media portrayals of beauty ideals, societal pressure on appearance, and experiences of teasing or bullying related to appearance, may contribute to the development or exacerbation of BDD. 

Etiology

• Genetic Factors: BDD has been found to run in families, suggesting a genetic component in its etiology. Individuals with a family history of BDD or other psychiatric disorders may have a higher risk of developing the condition. 
• Neurobiological Factors: Studies using brain imaging techniques have revealed the differences in brain structure & function in individuals with BDD. These brain abnormalities are often seen in areas responsible for processing visual information and emotions, which may contribute to the distorted perceptions of appearance and heightened emotional responses observed in BDD. 
• Psychological Factors: Certain psychological factors can play a role in the development of BDD. Negative body image, low self-esteem, perfectionism, and cognitive biases (e.g., selective attention to perceived flaws) may contribute to the fixation on perceived defects and flaws in one’s appearance. 
• Serotonin Dysregulation: Serotonin is a neurotransmitter that plays a role in mood regulation and impulse control. Dysregulation of serotonin pathways in the brain has been implicated in BDD, as evidenced by the effectiveness of serotonin-enhancing medications (e.g., SSRIs) in reducing BDD symptoms. 
• Environmental Influences: Sociocultural factors, such as societal pressure on appearance, media portrayals of beauty ideals, and experiences of teasing or bullying related to appearance, may contribute to the development or exacerbation of BDD, especially in vulnerable individuals. 
• Early Life Experiences: Traumatic experiences or adverse childhood events may be associated with the development of BDD in some individuals. 

Genetics

Prognostic Factors

• Severity of Symptoms: The severity of BDD symptoms at the time of diagnosis can impact the prognosis. Individuals with more severe and pervasive symptoms may have a more challenging recovery process. 
• Duration of Untreated BDD: Delay in seeking treatment for BDD may prolong symptom duration and increase the risk of chronicity. Early intervention is associated with better treatment outcomes. 
• Presence of Comorbid Conditions: BDD is often associated with psychiatric disorders, like depression, anxiety disorders, and obsessive-compulsive disorder (OCD). The presence of comorbidities can complicate treatment and affect prognosis. 
• Insight into the Disorder: The level of insight an individual has regarding their BDD symptoms can influence treatment engagement and response. Individuals with better insight may be more likely to participate in treatment and adhere to therapeutic recommendations. 
• Social Support: Strong social support from family, friends, or support groups can positively impact treatment outcomes by providing encouragement and understanding throughout the recovery process. 
• Access to Treatment: Availability and access to evidence-based treatments like cognitive-behavioral therapy and selective serotonin reuptake inhibitors, can influence the prognosis of BDD. 
• Personal Motivation: An individual’s willingness to engage actively in treatment and work on cognitive and behavioral changes can significantly affect prognosis. 
• Relapse Prevention: Learning and practicing relapse prevention strategies can help individuals manage potential setbacks and maintain progress made during treatment. 

Clinical History

Age of Onset: BDD often emerges during adolescence and early adulthood, typically between the ages of 12 and 18 years. However, it can also develop later in life. 

Physical Examination

• Clinical Interview: The healthcare provider conducts a comprehensive interview with the patient to gather information about their concerns, symptoms, and emotional experiences related to their appearance. The goal is to understand the patient’s beliefs about their perceived flaws and the impact these beliefs have on their daily life. 
• Diagnostic Criteria: The healthcare provider uses the criteria outlined in the DSM-5 or the ICD-10 to determine the criteria for a diagnosis of BDD. 
• Assessment of Appearance Concerns: The patient’s specific concerns about their appearance are explored in detail. Healthcare providers may ask the patient to describe the perceived flaws or defects they are fixated on. 
• Assessment of Insight: The healthcare provider evaluates the patient’s insight into their beliefs and whether they recognize that their appearance concerns are excessive or irrational. 
• Assessment of Functional Impairment: The impact of BDD on the patient’s daily functioning, relationships, and overall quality of life is assessed. 

• Differential Diagnosis: The healthcare provider may rule out other medical or psychiatric conditions that may present with similar symptoms, such as other body image disorders, delusional disorders, or anxiety disorders. 

Age group

Associated comorbidity

• Depression: BDD is commonly associated with major depressive disorder. Feelings of hopelessness, sadness, and low self-esteem may be prominent in individuals with BDD and comorbid depression. 
• Anxiety Disorders: BDD frequently co-occurs with anxiety disorders like generalized anxiety disorder or social anxiety disorder. Heightened anxiety may be related to concerns about perceived flaws being noticed or judged by others. 
• Obsessive-Compulsive Disorder (OCD): Some individuals with BDD may also have comorbid OCD, as they may engage in repetitive rituals (e.g., checking, reassurance-seeking) to cope with their appearance-related obsessions. 
• Eating Disorders: There is a notable association between BDD and eating disorders, especially in cases where body image concerns are centered around weight or body shape. 

Associated activity

Acuity of presentation

• Severe Distress and Impairment: Patients with BDD often present with significant emotional distress and impairment in daily functioning. Their preoccupation with perceived flaws can consume a substantial amount of time and interfere with work, school, or relationships. 
• Avoidance Behaviors: Individuals with BDD may avoid social situations or mirrors to prevent further distress about their appearance. 
• Excessive Grooming or Camouflaging: Some patients may engage in excessive grooming, makeup application, or attempts to camouflage perceived flaws to alleviate distress. 
• Repetitive Behaviors: BDD may manifest with repetitive behaviors like mirror checking, seeking reassurance, or comparing oneself with others. 

Differential Diagnoses

• Obsessive-Compulsive Disorder (OCD): Both BDD and OCD involve obsessions and compulsions. In BDD, the obsessions are centered around perceived flaws in appearance, while in OCD, the obsessions can be unrelated to appearance. However, some individuals may experience both BDD and OCD simultaneously. 
• Social Anxiety Disorder: It involves excessive fear & avoidance of social situations due to the concerns about being judged or embarrassed. Some individuals with BDD may avoid social situations because of their appearance-related anxieties, leading to a potential overlap in symptoms. 
• Delusional Disorder, Somatic Type: In delusional disorder, somatic type, individuals have fixed, false beliefs about their body or physical appearance. The key distinction from BDD is that in BDD, the beliefs are typically non-delusional, meaning the person recognizes that their beliefs may not be true. 
• Eating Disorders: Body image concerns are common in eating disorders like anorexia nervosa & bulimia nervosa. However, in BDD, the preoccupation is typically focused on specific body parts rather than overall body weight or shape. 
• Major Depressive Disorder (MDD): Depression can coexist with BDD, and both conditions may share symptoms of low mood, feelings of worthlessness, and changes in appetite or sleep. The distinction lies in the primary focus of the distress, which is on appearance in BDD and more generalized in MDD. 
• Dysmorphic Concerns in Medical Conditions: Some medical conditions, such as dermatological conditions or congenital abnormalities, can lead to concerns about appearance. It is essential to rule out these medical conditions that may cause similar symptoms. 
• Body Dysmorphic Symptoms in Body Dysmorphic Syndrome in Schizophrenia: Body dysmorphic symptoms can also be present in individuals with schizophrenia or schizoaffective disorder. The key difference from BDD is the context in which the symptoms occur and their relationship to other psychotic features. 
• Adjustment Disorder: During significant life changes or stressful events, individuals may experience body image concerns or changes in appearance perception. However, these symptoms are typically related to the specific stressor and resolve with time. 

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

Assessment and Diagnosis: Accurate diagnosis of BDD is the first step in the treatment paradigm. Mental health professionals conduct a thorough assessment, including clinical interviews and psychological evaluations, to determine if the individual meets the criteria for BDD and to identify any coexisting conditions. 

Psychotherapy: 

• Cognitive-Behavioral Therapy (CBT): CBT is considered the gold standard psychotherapy for BDD. It helps individuals to identify & challenge negative thought patterns and beliefs about their appearance. CBT also includes exposure and response prevention (ERP) techniques to reduce avoidance behaviors related to appearance concerns. 
• Other Psychotherapies: In some cases, other therapeutic modalities like Acceptance and Commitment Therapy, Mindfulness-Based Cognitive Therapy, or supportive therapy may be used, depending on the individual’s needs and preferences. 

Pharmacotherapy: 

• Selective Serotonin Reuptake Inhibitors (SSRIs): Certain SSRIs, such as fluoxetine, sertraline, or escitalopram, have shown efficacy in reducing BDD symptoms, particularly when there is comorbid depression or anxiety. 

• Other Medications: In some cases, other medications such as tricyclic antidepressants or atypical antipsychotics may be considered if SSRIs are not effective or well-tolerated. 

Environmental and Behavioral Modifications: 

• Mirror Avoidance: Limiting mirror use or using small, non-distorting mirrors can be helpful to reduce preoccupation with appearance. 
• Avoidance of Triggers: Minimizing exposure to media or social media that may exacerbate appearance concerns can be beneficial. 

Supportive Care: Offering support, understanding, and empathy to individuals with BDD is essential in creating a safe and non-judgmental environment. 

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

non-pharmacological-treatment-of-body-dysmorphic-disorder

Lifestyle modifications: 

• Seeking Professional Help: The first and most crucial lifestyle modification is to seek professional help.  
• Adhering to Treatment Plan: If diagnosed with BDD, it is crucial to include therapy, medication, or a combination of both. Consistent adherence to the treatment plan can help manage symptoms effectively. 
• Limiting Mirror Use: Reducing excessive mirror checking or avoidance behaviors can be beneficial in managing BDD. Limiting mirror use can help reduce self-focused attention and obsessive thoughts about perceived flaws. 
• Avoiding Comparisons: Avoid comparing oneself to others, especially based on appearance. Constant comparison can reinforce negative self-perceptions and exacerbate BDD symptoms. 
• Supportive Social Network: Surrounding oneself with supportive friends and family can be helpful. A strong support system can provide understanding, empathy, and encouragement throughout the recovery process. 
• Participating in Physical Activities: Engaging in regular physical activities, such as exercise or sports, can have positive effects on mood and body image perception. 
• Practicing Stress Reduction Techniques: Stress-reduction techniques like mindfulness, deep breathing exercises, meditation, yoga can help manage anxiety and reduce body-focused distress. 
• Improving Self-Compassion: Practicing self-compassion and self-acceptance can help challenge negative self-perceptions and promote a healthier self-image. 

Use of Antidepressants, SSRIs in the treatment of Body Dysmorphic Disorder

Escitalopram (Lexapro):  

• It is an SSRI that is commonly prescribed for BDD. It is effective in treating symptoms of anxiety and depression, which often co-occur with BDD. 

Citalopram (Celexa):  

• Citalopram is another SSRI that may be used in the treatment of BDD. Like other SSRIs, it helps in improving mood and reducing anxiety. 

Fluoxetine (Prozac):  

• Fluoxetine is one of the first SSRIs to be approved for use in the United States. It is often prescribed for BDD due to its effectiveness in managing symptoms of depression and anxiety. 

Fluvoxamine (Luvox):  

• Fluvoxamine is another SSRI that has shown to be beneficial in treating BDD symptoms, including obsessive-compulsive symptoms. 

Sertraline (Zoloft):  

• It is an SSRI that is commonly prescribed for various anxiety disorders, depression, and OCD. It may also be used in the treatment of BDD. 

Use of Antidepressants, TCAs in the treatment of Body Dysmorphic Disorder

Clomipramine (Anafranil):  

• Clomipramine is a TCA that is FDA-approved for the treatment of obsessive-compulsive disorder. BDD shares similarities with OCD in terms of intrusive thoughts and repetitive behaviors. Therefore, clomipramine may be considered when BDD symptoms have obsessive-compulsive features. 

Imipramine (Tofranil, Tofranil PM):  

• Imipramine is another TCA that has been used in the treatment of various anxiety disorders and depression. It may be prescribed off-label for BDD, particularly if there is comorbid anxiety or mood disorder. 

Amitriptyline:  

• Amitriptyline is a TCA with both antidepressant and analgesic properties. While it is not as commonly used in BDD as SSRIs or clomipramine, it may be considered in certain cases when other medications have not been effective. 

Use of Neuroleptic Agents in the treatment of Body Dysmorphic Disorder

Pimozide (Orap)  

• Pimozide (Orap) is a neuroleptic agent, specifically an antipsychotic medication, that has been used in the treatment of Body Dysmorphic Disorder (BDD), particularly when other treatments have not provided sufficient relief. However, it is essential to note that the use of pimozide for BDD is considered off-label, meaning it has not been specifically approved by regulatory authorities for this particular condition. The use of pimozide for BDD is based on some limited research and clinical experience suggesting its potential effectiveness in managing certain symptoms of BDD. 
• Pimozide is primarily used to treat certain psychotic disorders, such as schizophrenia and Tourette’s syndrome. It acts by blocking dopamine receptors, which can help reduce certain obsessive-compulsive symptoms. BDD shares some features with obsessive-compulsive disorder (OCD), and some research suggests that antipsychotic medications, including pimozide, may be helpful in managing BDD symptoms, particularly those with delusional or severe preoccupations with appearance. 

use-of-cognitive-behavioral-therapy-in-the-treatment-of-body-dysmorphic-disorder

Cognitive-Behavioral Therapy is one of the most effective and evidence-based treatments for Body Dysmorphic Disorder (BDD). In the context of BDD, CBT aims to address the cognitive distortions and body-focused behaviors that are central to the disorder. Here’s how CBT is used in the treatment of BDD: 

• Psychoeducation: The therapist provides education about BDD, its symptoms, and its impact on the individual’s life. Understanding the nature of the disorder helps the individual gain insight into their condition and reduces self-blame. 
• Identifying Cognitive Distortions: The therapist helps the individual recognize and challenge distorted thoughts and beliefs about their appearance. These thoughts often involve excessive focus on perceived flaws and unrealistic evaluations of one’s appearance. 
• Exposure and Response Prevention (ERP): ERP is a key component of CBT for BDD. It involves gradual exposure to anxiety-provoking situations related to body image, such as looking in a mirror or engaging in grooming behaviors. Through exposure, the individual learns to tolerate the associated distress without resorting to compulsive behaviors. 
• Behavioral Experiments: Behavioral experiments are conducted to test the accuracy of the individual’s negative beliefs about their appearance. This involves gathering evidence to challenge the validity of their negative thoughts. 
• Developing Coping Strategies: The therapist helps the individual develop healthier coping strategies for dealing with distress and anxiety related to appearance concerns. This may include mindfulness techniques, relaxation exercises, and problem-solving skills. 
• Body Image Distortion Work: The therapist helps the individual develop a more realistic and balanced perception of their appearance through a process of reevaluation and reassessment. 

use-of-mindfulness-based-cognitive-therapy-in-the-treatment-of-body-dysmorphic-disorder

Mindfulness-Based Cognitive Therapy (MBCT) for Body Dysmorphic Disorder (BDD), MBCT has shown effectiveness in treating other anxiety and mood disorders, which share some similarities with BDD. As a result, MBCT may be considered as a complementary or adjunctive therapy for individuals with BDD. Here’s how MBCT can be used in the treatment of BDD: 

• Mindfulness Techniques: MBCT incorporates various mindfulness practices, such as meditation and mindful breathing, to help individuals more aware of their thoughts & feelings without judgment. Mindfulness can enhance self-awareness and reduce the tendency to engage in excessive self-criticism or rumination, which are common features of BDD. 
• Cognitive Restructuring: MBCT incorporates cognitive restructuring techniques to helps to recognize and challenge negative thought patterns related to body image and appearance concerns. By challenging and reframing negative beliefs, individuals can develop a more balanced and realistic perspective of their appearance. 
• Emotion Regulation: MBCT aims to improve emotion regulation skills, enabling individuals to manage distressing emotions associated with BDD in a healthier way.  
• Mindful Exposure: MBCT may involve mindful exposure exercises, where individuals gradually confront their body image-related fears and anxieties in a non-judgmental and accepting manner. Mindful exposure can help individuals build tolerance to distressing thoughts and sensations. 

use-of-acceptance-and-commitment-therapy-in-the-treatment-of-body-dysmorphic-disorder

Acceptance and Commitment Therapy is a type of psychotherapy that focuses on promoting psychological flexibility. While there is limited research specifically examining ACT for Body Dysmorphic Disorder (BDD), ACT has shown effectiveness in treating other anxiety and mood disorders, which share some features with BDD. As a result, ACT may be considered as a complementary or adjunctive therapy for individuals with BDD. Here’s how ACT can be used in the treatment of BDD: 

• Acceptance of Thoughts and Feelings: In ACT, individuals learn to acknowledge and accept their distressing thoughts and feelings related to body image and appearance concerns without judgment. Rather than engaging in avoidance or suppression, they develop the ability to experience these thoughts and emotions with openness and willingness. 
• Cognitive Defusion: ACT incorporates cognitive defusion techniques to help individuals distance themselves from their negative thoughts and beliefs about their appearance. This allows individuals to see their thoughts as passing events rather than absolute truths, reducing their impact on their sense of self-worth. 
• Mindfulness Skills: ACT includes mindfulness practices to help individuals become more aware of the present moment and develop a non-judgmental attitude toward their experiences. Mindfulness can help individuals observe their thoughts & emotions without getting caught up in them, leading to greater psychological flexibility. 
• Values Clarification: ACT focuses on helping individuals clarify their core values and what is truly important to them in life. By aligning their actions and behaviors with their values, individuals can cultivate a sense of purpose and meaning beyond appearance concerns. 
• Committed Action: ACT encourages individuals to take meaningful and value-driven actions in their lives, even in the presence of distressing body image-related thoughts and emotions. This involves committing to behaviors that align with their values and long-term goals. 

use-of-cosmetic-surgery-in-the-treatment-of-body-dysmorphic-disorder

Cosmetic surgery involves elective procedures to alter or enhance a person’s physical appearance. While some individuals with BDD may seek cosmetic surgery as a way to address their appearance-related distress, it is essential to approach this option with caution. For individuals with BDD, cosmetic surgery is generally not recommended as a primary or sole treatment for several reasons: 

• Perception Distortion: Individuals with BDD have a distorted perception of their appearance, often focusing on minor or nonexistent flaws. Cosmetic surgery may not address the underlying psychological issues driving their dissatisfaction. 
• Unrealistic Expectations: Individuals with BDD may have unrealistic expectations about the outcomes of cosmetic surgery, leading to potential dissatisfaction with the results and exacerbating their distress. 
• Risk of Complications: Cosmetic surgery, like any medical procedure, carries inherent risks and potential complications. For individuals with BDD, the risk of dissatisfaction or fixation on perceived imperfections may be heightened. 
• Body Dysmorphic Disorder Worsening: In some cases, cosmetic surgery can worsen BDD symptoms, leading to further preoccupation with appearance and seeking more procedures. 
• Ethical Considerations: Ethical guidelines discourage performing cosmetic surgery on individuals with untreated BDD because it may not address the underlying psychological issues and could be considered exploitative. 

management-of-body-dysmorphic-disorder

Acute Phase: 

• Goal: The primary goal of the Acute Phase is to provide immediate relief from distressing BDD symptoms and reduce the intensity of obsessive thoughts and compulsive behaviors related to appearance concerns. 
• Treatment: During this phase, intensive interventions are employed to address the acute symptoms of BDD. This may include individual or group cognitive-behavioral therapy (CBT), Acceptance and Commitment Therapy (ACT), or psychopharmacological treatments such as SSRIs or other medications. 
• Duration: The Acute Phase typically lasts around 12 to 16 weeks, but the duration may vary based on individual response to treatment and symptom severity. 

Continuation Phase: 

• Goal: The Continuation Phase aims to maintain the gains achieved during the Acute Phase and prevent relapse of BDD symptoms. 
• Treatment: During this phase, the focus shifts from intensive intervention to ongoing support and monitoring. Therapeutic sessions may be less frequent but still provide essential support and reinforcement of learned coping skills. 
• Duration: The Continuation Phase generally lasts around 4 to 9 months, but the duration can be adjusted based on individual needs and progress. 

Maintenance Phase: 

• Goal: The Maintenance Phase is focused on maintaining the progress made in previous phases and preventing future relapses of BDD symptoms. 
• Treatment: The main emphasis during this phase is on relapse prevention strategies and fostering long-term coping skills. It may involve periodic check-ins with the mental health professional and continued use of learned strategies in daily life. 

• Duration: The Maintenance Phase can last several months to years, depending on the individual’s progress and needs. 

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References

• www.Body Dysmorphic Disorder.ncbi.nlm.nih.gov 
• www.Body dysmorphic disorder: recognizing and treating imagined ugliness.ncbi.nlm.nih.gov