Body Dysmorphic Disorder part 1

8/20/2019 Body Dysmorphic Disorder part 1

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Body Dysmorphic Disorder

Diagnostic Criteria 300.7 (F45.22)

A. Preoccupation with one or more perceived defects or flaws in physical appearance that

are not observable or appear slight to others.

B. At some point during the course of the disorder, the individual has performed repetitive

behaviors (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking ormental acts (e.g., comparing his or her appearance with that of others in response to the

appearance concerns.

!. "he preoccupation causes clinically significant distress or impairment in social,

occupational, or other important areas of functioning.

D. "he appearance preoccupation is not better explained by concerns with body fat

or Specify if# $ith muscle dysmorphia# "he individual is preoccupied with the idea that his

or her body build is too small or insufficiently muscular. "his specifier is used even if the

individual is preoccupied with other body areas, which is often the case. Specify if# %ndicate

degree of insight regarding body dysmorphic disorder beliefs (e.g., &% look ugly' or &% lool

deformed'. $ith good or fair insight# "he individual recogni)es that the body dysmorphic

disorder beliefs are definitely or probably not true or that they may or may not be true.$ith poor insight# "he individual thinks that the body dysmorphic disorder beliefs are

probably true. $ith absent insight*delusionai beliefs# "he individual is completely

convinced that the body dysmorphic disorder beliefs are true.

Diagnostic +eatures

Individuals with bod ds!or"hic disorder (#or!erl $nown as dysmorphophobia) are

"reoccu"ied with one or !ore "erceived de#ects or #laws in their "hsical a""earance% which

the believe loo$ ugl% unattractive% abnor!al% or de#or!ed (Criterion &). 'he "erceived #laws

are not observable or a""ear onl slight to other individuals. Concerns range #ro! loo$ingunattractive or not right to loo$ing hideous or li$e a !onster. reoccu"ations can #ocus

on one or !an bod areas% !ost co!!onl the s$in (e.g.% "erceived acne% scars% lines% wrin$les% "aleness)% hair (e.g.% thinning hair or e*cessive bod or #acial hair)% or nose (e.g.% si+e or sha"e). ,owever% an bod area can be the #ocus o# concern (e.g.% ees% teeth% weight% sto!ach%

breasts% legs% #ace si+e or sha"e% li"s% chin% eebrows% genitals). -o!e individuals are concerned

about "erceived as!!etr o# bod areas. 'he "reoccu"ations are intrusive% unwanted% ti!econsu!ing (occurring% on average% 3/ hours "er da)% and usuall di##icult to resist or control.

*cessive re"etitive behaviors or !ental acts (e.g.% co!"aring) are "er#or!ed in res"onse

to the "reoccu"ation (Criterion 1). 'he individual #eels driven to "er#or! these behaviors% which

are not "leasurable and !a increase an*iet and ds"horia. 'he are t"icall ti!econsu!ingand di##icult to resist or control. Co!!on behaviors are co!"aring ones a""earance with that o#

other individuals re"eatedl chec$ing "erceived de#ects in !irrors or other re#lecting sur#aces or

e*a!ining the! directl e*cessivel groo!ing (e.g.% co!bing% stling% shaving% "luc$ing% or "ulling hair) ca!ou#laging (e.g.% re"eatedl a""ling !a$eu" or covering disli$ed areas with

such things as a hat% clothing% !a$eu"% or hair) see$ing reassurance about how the "erceived

#laws loo$ touching disli$ed areas to chec$ the! e*cessivel e*ercising or weight li#ting andsee$ing cos!etic "rocedures. -o!e individuals e*cessivel tan (e.g.% to dar$en "ale s$in or

di!inish "erceived acne)% re"eatedl change their clothes (e.g.% to ca!ou#lage "erceived de#ects)%

or co!"ulsivel sho" (e.g.% #or beaut "roducts). Co!"ulsive s$in "ic$ing intended to i!"rove

"erceived s$in de#ects is co!!on and can cause s$in da!age% in#ections% or ru"tured blood



vessels. 'he "reoccu"ation !ust cause clinicall signi#icant distress or i!"air!ent in social%

occu"ational% or other i!"ortant areas o# #unctioning (Criterion C) usuall both are "resent.

1od ds!ohic disorder !ust be di##erentiated #ro! an eating disorder. Muscle dysmorphia, a #or! o# bod ds!ohic disorder occurring al!ost e*clusivel in

!ales% consists o# "reoccu"ation with the idea that ones bod is too s!all or insu##icientl lean

or !uscular. Individuals with this #or! o# the disorder actuall have a nor!alloo$ing bod or are even ver !uscular. 'he !a also be "reoccu"ied with other bod areas% such as s$in or

hair. & !aorit (but not all) diet% e*ercise% and6or li#t weights e*cessivel% so!eti!es causing

bodil da!age. -o!e use "otentiall dangerous anabolicandrogenic steroids and other substances to tr to !a$e their bod bigger and !ore !uscular.

1od ds!or"hic disorder b "ro* is a #or! o# bod ds!or"hic disorder in which

individuals are "reoccu"ied with de#ects the "erceive in another "ersons a""earance. Insight

regarding bod ds!or"hic disorder belie#s can range #ro! good to absent6 delusional (i.e.%delusional belie#s consisting o# co!"lete conviction that the individuals view o# their a""earance

is accurate and undistorted). n average% insight is "oor onethird or !ore o# individuals

currentl have delusional bod ds!or"hic disorder belie#s. Individuals with delusional bod

ds!or"hic disorder tend to have greater !orbidit in so!e areas (e.g.% suicidalit)% but thisa""ears accounted #or b their tendenc to have !ore severe bod ds!or"hic disorder

s!"to!s.

Associated +eatures upporting Diagnosis

8an individuals with bod ds!or"hic disorder have ideas or delusions o# re#erence% believing that other "eo"le ta$e s"ecial notice o# the! or !oc$ the! because o# how the loo$.

1od ds!or"hic disorder is associated with high levels o# an*iet% social an*iet% social

avoidance% de"ressed !ood% neuroticis!% and "er#ectionis! as well as low e*troversion and low

sel#estee!. 8an individuals are asha!ed o# their a""earance and their e*cessive #ocus on howthe loo$% and are reluctant to reveal their concerns to others. & !aorit o# individuals receive

cos!etic treat!ent to tr to i!"rove their "erceived de#ects.

Der!atological treat!ent and surger are !ost co!!on% but an t"e (e.g.% dental%electrolsis) !a be received. ccasionall% individuals !a "er#or! surger on the!selves.

1od ds!or"hic disorder a""ears to res"ond "oorl to such treat!ents and so!eti!es beco!es

worse. -o!e individuals ta$e legal action or are violent toward the clinician because the aredissatis#ied with the cos!etic outco!e.

1od ds!or"hic disorder has been associated with e*ecutive ds#unction and visual

"rocessing abnor!alities% with a bias #or anal+ing and encoding details rather than holistic or

con#igurai as"ects o# visual sti!uli. Individuals with this disorder tend to have a bias #or negativeand threatening inter"retations o# #acial e*"ressions and a!biguous scenarios.

Prevalence

'he "oint "revalence a!ong 9.-. adults is 2.4: (2.5: in #e!ales and 2.2: in !ales). utside

the 9nited -tates (i.e.% ;er!an)% current "revalence is a""ro*i!atel <.7:<%/:% with a gender

distribution si!ilar to that in the 9nited -tates. 'he current "revalence is =:<5: a!ongder!atolog "atients% 7:/: a!ong 9.-. cos!etic surger "atients% 3: <>: a!ong

international cos!etic surger "atients (!ost studies)% /: a!ong adult orthodontia "atients% and

<0: a!ong "atients "resenting #or oral or !a*illo#acial surger.



Deveiopment and !ourse

'he !ean age at disorder onset is <><7 ears% the !edian age at onset is <5 ears% and the !ost

co!!on age at onset is <2<3 ears. 'wothirds o# individuals have disorder onset be#ore age </.-ubclinical bod ds!or"hic disorder s!"to!s begin% on average% at age <2 or <3 ears.

-ubclinical concerns usuall evolve graduall to the #ull disorder% although so!e individuals

e*"erience abru"t onset o# bod ds!or"hic disorder. 'he disorder a""ears to usuall be chronic%although i!"rove!ent is li$el when evidencebased treat!ent is received. 'he disorders

clinical #eatures a""ear largel si!ilar in children6 adolescents and adults. 1od ds!ohic

disorder occurs in the elderl% but little is $nown about the disorder in this age grou". Individualswith disorder onset be#ore age </ ears are !ore li$el to atte!"t suicide% have !ore

co!orbidit% and have gradual (rather than acute) disorder onset than those with adultonset bod

ds!or"hic disorder.

-isk and Prognostic +actors

nvironmental. 1od ds!or"hic disorder has been associated with high rates o# childhood

neglect and abuse.

/enetic and physiological. 'he "revalence o# bod ds!or"hic disorder is elevated in #irst

degree relatives o# individuals with obsessiveco!"ulsive disorder (CD).

!ulture0-eiated Diagnostic issues

1od ds!or"hic disorder has been re"orted internationall. It a""ears that the disorder !a have !ore si!ilarities than di##erences across races and cultures but that cultural values and

"re#erences !a in#luence s!"to! content to so!e degree. Taijin kyofusho, included in the

traditional ?a"anese diagnostic sste!% has a subt"e si!ilar to bod ds!or"hic disorder@

shubo-kyofu (the "hobia o# a de#or!ed bod).

/ender0-eiated Diagnostic issues

Fe!ales and !ales a""ear to have !ore si!ilarities than di##erences in ter!s o# !ost clinical#eaturesA #or e*a!"le% disli$ed bod areas% t"es o# re"ehtive behaviors% s!"to! severit%

suicidalit% co!orbidit% illness course% and recei"t o# cos!etic "rocedures #or bod ds!or"hic

disorder. ,owever% !ales are !ore li$el to have genital "reoccu"ations% and #e!ales are !oreli$el to have a co!orbid eating disorder. 8uscle ds!or"hia occurs al!ost e*clusivel in

!ales.

uicide -isic

Bates o# suicidal ideation and suicide atte!"ts are high in both adults and children6adolescents

with bod ds!or"hic disorder. Further!ore% ris$ #or suicide a""ears high in adolescents. &

substantial "ro"ortion o# individuals attribute suicidal ideation or suicide atte!"ts "ri!aril totheir a""earance concerns. Individuals with bod ds!or"hic disorder have !an ris$ #actors #or

co!"leted suicide% such as high rates o# suicidal ideation and suicide atte!"ts% de!ogra"hic

characteristics associated with suicide% and high rates o# co!orbid !aor de"ressive disorder.

+unctional !onse1uences of Body Dysmorphic Disorder

earl all individuals with bod ds!or"hic disorder e*"erience i!"aired "schosocial

#unctioning because o# their a""earance concerns. I!"air!ent can range #ro! !oderate (e.g.%



avoidance o# so!e social situations) to e*tre!e and inca"acitating (e.g.% being co!"letel

housebound). n average% "schosocial #unctioning and ualit o# li#e are !ar$edl "oor. 8ore

severe bod ds!or"hic disorder s!"to!s are associated with "oorer #unctioning and ualito# li#e. 8ost individuals e*"erience i!"air!ent in their ob% acade!ic% or role #unctioning (e.g.%

as a "arent or caregiver)% which is o#ten severe (e.g.% "er#or!ing "oorl% !issing school or wor$%

not wor$ing). &bout 20: o# ouths with bod ds!or"hic disorder re"ort dro""ing out o# school "ri!aril because o# their bod ds!or"hic disorder s!"to!s. I!"air!ent in social

#unctioning (e.g.% social activities% relationshi"s% inti!ac)% including avoidance% is co!!on.

Individuals !a be housebound because o# their bod ds!or"hic disorder s!"to!s%so!eti!es #or ears. & high "ro"ortion o# adults and adolescents have been "schiatricall

hos"itali+ed.

Differential Diagnosis

2ormal appearance concerns and clearly noticeable physical defects.

1od ds!or"hic disorder di##ers #ro! nor!al a""earance concerns in being characteri+ed b

e*cessive a""earancerelated "reoccu"ations and re"etitive behaviors that are ti!econsu!ing%

are usuall di##icult to resist or control% and cause clinicall signi#icant distress or i!"air!ent in#unctioning. hsical de#ects that are clearl noticeable (i.e.% not slight) are not diagnosed as

bod ds!or"hic disorder. ,owever% s$in "ic$ing as a s!"to! o# bod ds!ohic disorder cancause noticeable s$in lesions and scarring in such cases% bod ds!or"hic disorder should be

diagnosed.

ating disorders. In an individual with an eating disorder% concerns about being #at are

considered a s!"to! o# the eating disorder rather than bod ds!or"hic disorder. ,owever%

weight concerns !a occur in bod ds!or"hic disorder. ating disorders and bod ds!or"hic

disorder can be co!orbid% in which case both should be diagnosed.

3ther obsessive0compulsive and related disorders.

'he "reoccu"ations and re"etitive behaviors o# bod ds!or"hic disorder di##er #ro! obsessionsand co!"ulsions in CD in that the #or!er #ocus onl on a""earance. 'hese disorders have

other di##erences% such as "oorer insight in bod ds!ohic disorder. Ehen s$in "ic$ing is

intended to i!"rove the a""earance o# "erceived s$in de#ects% bod ds!or"hic disorder% rather than e*coriation (s$in"ic$ing) disorder% is diagnosed. Ehen hair re!oval ("luc$ing% "ulling% or

other t"es o# re!oval) is intended to i!"rove "erceived de#ects in the a""earance o# #acial or

bod hair% bod ds!ohic disorder is diagnosed rather than trichotillo!ania (hair"ulling

disorder).

%llness anxiety disorder. Individuals with bod ds!or"hic disorder are not "reoccu"ied with

having or acuiring a serious illness and do not have "articularl elevated levels o# so!ati+ation.

4a5or depressive disorder. 'he "ro!inent "reoccu"ation with a""earance and e*cessive

re"etitive behaviors in bod ds!or"hic disorder di##erentiate it #ro! !aor de"ressive disorder.,owever% !aor de"ressive disorder and de"ressive s!"to!s are co!!on in individuals with

bod ds!ohic disorder% o#ten a""earing to be secondar to the distress and i!"air!ent that

bod ds!or"hic disorder causes. 1od ds!ohic disorder should be diagnosed in de"ressed

individuals i# diagnostic criteria #or bod ds!ohic disorder are !et.



Anxiety disorders. -ocial an*iet and avoidance are co!!on in bod ds!or"hic disorder.

,owever% unli$e social an*iet disorder (social "hobia)% agora"hobia% and avoidant "ersonalitdisorder% bod ds!or"hic disorder includes "ro!inent a""earancerelated "reoccu"ation% which

!a be delusional% and re"etitive behaviors% and the social an*iet and avoidance are due to

concerns about "erceived a""earance de#ects and the belie# or #ear that other "eo"le will consider these individuals ugl% ridicule the!% or reect the! because o# their "hsical #eatures. 9nli$e

generali+ed an*iet disorder% an*iet and worr in bod ds!ohic disorder #ocus on "erceived

a""earance #laws.

Psychotic disorders. 8an individuals with bod ds!or"hic disorder have delusional

a""earance belie#s (i.e.% co!"lete conviction that their view o# their "erceived de#ects is

accurate)% which is diagnosed as bod ds!ohic disorder% with absent insight6delusional belie#s%not as delusional disorder. &""earancerelated ideas or delusions o# re#erence are co!!on in

bod ds!or"hic disorder however% unli$e schi+o"hrenia or schi+oa##ective isorder% bod

ds!ohic disorder involves "ro!inent a""earance "reoccu"ations and related re"etitive

behaviors% and disorgani+ed behavior and other "schotic s!"to!s are absent (e*ce"t #or a""earance belie#s% which !a be delusional).

3ther disorders and symptoms. 1od ds!or"hic disorder should not be diagnosed i# the

"reoccu"ation is li!ited to disco!#ort with or a desire to be rid o# ones "ri!ar and6 or

secondar se* characteristics in an individual with gender ds"horia or i# the "reoccu"ation#ocuses on the belie# that one e!its a #oul or o##ensive bod odor as in ol#actor re#erence

sndro!e (which is not a D-85 disorder)

Documents

Body Dysmorphic Disorder part 1