Body dysmorphic disorder and appearance enhancing medical treatments

This article reviews the literature on body dysmorphic disorder (BDD) in persons who seek appearance enhancing medical treatments such as cosmetic surgery and dermatological treatment. We begin with a discussion of the growing popularity of cosmetic surgical and minimally invasive treatments. The literature investigating the psychological characteristics is briefly highlighted. Studies investigating the rate of BDD among persons who seek appearance enhancing treatments are detailed and, collectively, suggest that approximately 5–15% of individuals who seek these treatments suffer from BDD. Retrospective reports suggest that persons with BDD rarely experience improvement in their symptoms following these treatments, leading some to suggest that BDD is a contraindication to cosmetic surgery and other treatments. The clinical management of patients with BDD who present for these treatments is briefly described and directions for future research are provided.     

Discrimination of facial appearance stimuli in body dysmorphic disorder

Cognitive-behavioral models of body dysmorphic disorder (BDD) propose that information-processing biases--in particular, selective attention to a defect in one's appearance as well as improved aesthetical perception--might contribute to the development or maintenance of the disorder. In the present study, the authors tested the hypothesis that patients with BDD discriminate facial appearance stimuli more accurately than controls. Sixty female patients from a dermatological clinic participated in the study: 21 patients with BDD, 19 patients with disfiguring dermatological conditions, and 20 patients with nondisfiguring dermatological disorders. Participants rated dissimilarities between pictures of neutral faces that had been manipulated with regard to aesthetic characteristics. Manipulation ratings of participants with BDD were significantly more accurate than those of both control groups. Implications of these results for cognitive theories of BDD are discussed.     

Reality monitoring in patients with body dysmorphic disorder

Patients with body dysmorphic disorder (BDD) typically have very poor insight into their disorder. Their conviction in their ugliness is often of delusional intensity. Reality monitoring is the ability to distinguish in memory between things that one has imagined and things that one has perceived. Deficits in reality monitoring have been associated with the development of other delusional beliefs. Therefore, in the present study we investigated whether individuals with BDD (n = 20) demonstrate impairments in reality monitoring relative to individuals with obsessive-compulsive disorder (OCD; n = 20) and healthy controls (n = 20). This hypothesized impairment might predispose people with BDD to confuse memories of how they imagine themselves to appear (i.e., ugly) with memories of how they actually appear (i.e., normal). All participants completed a memory task assessing reality-monitoring ability for verbal stimuli. The BDD patients did not exhibit a reality-monitoring deficit despite elevated levels of focal delusionality. The results suggest that impairments in reality monitoring do not contribute to the development or maintenance of appearance-related beliefs in BDD.     

Multidimensional body image comparisons among patients with eating disorders,body dysmorphic disorder,and clinical controls: A multisite study

Body image disturbance is considered a core characteristic of eating disorders and body dysmorphic disorder (BDD), however its definition has been unclear within the literature. This study examined the multidimensional nature of body image functioning among individuals with either anorexia nervosa (AN; n = 35), bulimia nervosa (BN; n = 26), or BDD (n = 56), relative to female (n = 34) and male (n = 36) psychiatric controls. Participants were recruited from 10 treatment centers in the United States and England and completed psychometrically validated and standardized self-report measures of body image. Overall, the AN, BN, and BDD groups were characterized by significantly elevated disturbances in most body image dimensions relative to their gender-matched clinical controls. There was variability, however, in the comparisons among the three groups of interest, including foci of body dissatisfaction and body image coping patterns. On omnibus indices of body image disturbance and body image quality of life, patients with BDD reported more body image impairment than those with eating disorders. Although AN, BN, and BDD are characterized by body image disturbances, similar and partially distinctive cognitive, behavioral, and emotional elements of body image functioning exist among these groups. The study's empirical and clinical implications are considered.     

Facial asymmetry detection in patients with body dysmorphic disorder

Cognitive-behavioral models of body dysmorphic disorder (BDD) propose that individuals with BDD may possess a better or more developed sense of aestheticality than do individuals without BDD. Evidence for this proposition, however, is limited. One perceptual process that could contribute to heightened aestheticality is the ability to detect differences in symmetry. In this experiment we tested whether individuals with BDD (n = 20), relative to individuals with obsessive compulsive disorder (OCD; n = 20) and healthy controls (n = 20), show an enhanced ability to detect differences in the symmetry of others’ faces, symmetry of dot arrays, and/or show a greater preference for symmetrical faces. Individuals with BDD were not significantly more accurate in detecting differences in facial symmetry or dot arrays relative to individuals with OCD and healthy controls. Individuals with OCD took longer to make facial symmetry judgments than did individuals in the other two groups. All participants, regardless of diagnostic group, preferred more symmetrical faces than nonsymmetrical ones. Taken together, our results do not support a heightened perceptual ability or evaluative preference for symmetry among individuals with BDD.     

Computerized perceptual analysis of patients with body dysmorphic disorder: a pilot study

Many factors influence the development of body image, one of which is the perception we have of our body. Perception can refer to actual visual input or the interpretation of vision; in other words, cognitive appraisal. The goal of this preliminary study is to determine if three groups (body dysmorphic disorder, obsessive-compulsive disorder, and a non-psychiatric control group) differed in the perception of their faces. Thirty individuals, 10 in each group, were asked to make changes to a computerized image of their face. In addition, affective and perceptual tests were administered. The groups did not differ on affective and perceptual organizational measures, although the obsessive-compulsive disorder group reported a higher level of anxiety than the body dysmorphic disorder group. Imaging software showed that facial features were modified by patients with body dysmorphic disorder and obsessive-compulsive disorder in about 50% of cases. No modifications were made in the control group. Future studies need to investigate the possible causes of these differences.     

Rates of abuse in body dysmorphic disorder and obsessive-compulsive disorder

Body dysmorphic disorder (BDD) continues to challenge professionals due to symptom severity, co-morbidity, suicidal ideation, and overvalued ideation. Despite the disorder's severity, little research exists. Clinical observation suggests a noteworthy history of abuse; therefore the present study investigated the reported rate of physical, sexual, and emotional abuse in BDD patients. OCD patients were chosen as a comparison group because BDD is considered to be an obsessive-compulsive spectrum disorder. A group survey design was used (N = 50 for each group). Results show significantly higher levels of emotional and sexual abuse in the BDD sample versus the OCD sample. No significant differences were found in physical abuse. Abuse may be a contributing factor in BDD, but not in OCD.     

Treating body dysmorphic disorder with medication: evidence, misconceptions, and a suggested approach

Body dysmorphic disorder (BDD) is a relatively common and often disabling disorder with high morbidity and mortality. Both psychotropic medication and cognitive behavioral therapy (CBT) are considered first-line treatments for BDD, and medication treatment is often essential for more severely ill and suicidal patients. In this practical overview of the pharmacotherapy of BDD, we briefly describe BDD's clinical features, associated morbidity, and how to recognize and diagnose BDD. We describe the importance of forming a therapeutic alliance with the patient, the need for psychoeducation, and other essential groundwork for successful treatment of BDD. We review available pharmacotherapy research, with a focus on serotonin-reuptake inhibitors (SSRIs, or SRIs), which are currently considered the medication of choice for BDD. Many patients have substantial improvement in core BDD symptoms, psychosocial functioning, quality of life, suicidality, and other aspects of BDD when treated with appropriate pharmacotherapy that targets BDD symptoms. We also discuss practical issues such as dosing, length of treatment, and potential side effects associated with the use of SRIs. In addition, we discuss pharmacotherapy approaches that can be tried if SRI treatment alone is not adequately helpful. Finally, some misconceptions about pharmacotherapy, gaps in knowledge about BDD's treatment, and the need for additional research are discussed.     

Severity of interpersonal problems in individuals with body dysmorphic disorder

Body dysmorphic disorder (BDD) is a relatively common and often severe disorder. Although individuals with BDD have markedly poor psychosocial functioning, the nature of interpersonal problems has been only minimally investigated. This study examined the severity, domains, and correlates of interpersonal problems in 51 individuals with BDD using the Inventory of Interpersonal Problems-64 (IIP-64) and other reliable and valid measures. Compared to norms for a U.S. community sample, individuals with DSM-IV BDD reported greater severity of interpersonal problems across most IIP-64 domains. BDD subjects' scores were most elevated on the Socially Inhibited and Nonassertive subscales. More severe BDD symptoms were significantly correlated with higher scores on the Socially Inhibited, Nonassertive, and Vindictive/Self-Centered subscales and with IIP-64 total score. In a logistic regression analysis, BDD severity and a personality disorder were independently associated with severity of interpersonal problems. These findings suggest that individuals with BDD have significant problems with interpersonal relationships, particularly in the areas of social inhibition and nonassertiveness.     

The importance of aesthetics in body dysmorphic disorder

It is hypothesized that body dysmorphic disorder (BDD) patients are firstly more "aesthetical," an attribute much like being musical, which varies between different individuals. This results in a greater emotional response to more attractive individuals and placing greater value on the importance of appearance in their identity compared with healthy individuals. Some BDD patients may have greater aesthetic perceptual skills. This is manifested in their education or training in art and design. Secondly, BDD patients may have higher aesthetic standards than the rest of the population. Their failure to achieve an unrealistic aesthetic standard is at the core of BDD, leading to severe distress and handicap.     

Perceptual and cognitive biases in individuals with body dysmorphic disorder symptoms

Given the extreme focus on perceived physical defects in body dysmorphic disorder (BDD), we expected that perceptual and cognitive biases related to physical appearance would be associated with BDD symptomology. To examine these hypotheses, participants (N=70) high and low in BDD symptoms completed tasks assessing visual perception and cognition. As expected, there were significant group differences in self-relevant, but not other-relevant, cognitive biases. Perceptual bias results were mixed, with some evidence indicating that individuals high (versus low) in BDD symptoms literally see themselves in a less positive light. Further, individuals high in BDD symptoms failed to demonstrate a normative self-enhancement bias. Overall, this research points to the importance of assessing both cognitive and perceptual biases associated with BDD symptoms, and suggests that visual perception may be influenced by non-visual factors.     

Personal and appearance-based rejection sensitivity in body dysmorphic disorder

Although rejection sensitivity may be an important feature of body dysmorphic disorder (BDD), no studies have examined rejection sensitivity in a clinical sample and compared types of rejection sensitivity in individuals with BDD. Personal and appearance-based rejection sensitivity scores in forty-six patients diagnosed with BDD were compared with published norms. Associations between rejection sensitivity, BDD severity, and other clinical variables were examined. Personal and appearance-based rejection sensitivity scores were 0.6 and 1.1 standard deviation units above published norms, respectively. Greater personal rejection sensitivity was associated with more severe BDD and depressive symptoms, poorer mental health, general health, and physical and social functioning. Greater appearance-based rejection sensitivity was associated with more severe BDD and depressive symptoms, and poorer general health. Appearance-based rejection sensitivity contributed more unique variance to BDD severity than personal rejection sensitivity did; however, personal rejection sensitivity contributed more unique variance to general health than appearance-based rejection sensitivity did.     

Neuroanatomical correlates and somatosensorial disturbances in body dysmorphic disorder

Body dysmorphic disorder (BDD) is a condition characterized by an intense preoccupation with an imagined or slight defect in physical appearance. Although there is a general consensus that psychosocial factors play a major role in the development of BDD, there is some evidence suggesting that an organic somatosensorial disturbance may also exist in this condition. Several psychiatric and neurological disorders, including the interparietal syndrome, Gertsman's syndrome, inferoparietal syndrome, phantom limb syndrome, genital retraction syndrome, panencephalitis, cerebrovascular syndromes, and pharyngeal streptococcia affecting the basal ganglia, can present with somatosensorial disturbances similar to BDD. The cerebral pathology in all these disorders appears to be localized in the parietal-occipital region, indicating that cerebral involvement may also be associated with BDD. An interdependence exists between cerebral regions through integrated neural networks that enable efficient processing of information. Disturbances in these association pathways can lead to an imbalance in the extensive cerebral loops. Therefore, it is possible that a defect in information-processing may play a role in the pathogenesis of BDD.     

Spontaneously occurring images and early memories in people with body dysmorphic disorder

A semi-structured interview assessing the presence and characteristics of spontaneous appearance-related images was designed and administered. A total of 18 patients with body dysmorphic disorder (BDD) and 18 normal controls took part. The BDD patients were found to have spontaneously occurring appearance-related images that were significantly more negative, recurrent, and viewed from an observer perspective than control participants. These images were more vivid and detailed and typically involved visual and organic (internal body) sensations. The study also found that BDD images were linked to early stressful memories, and that images were more likely than verbal thoughts to be linked to these memories. Implications for theory and clinical practice are discussed.     

Spontaneously occurring images and early memories in people with body dysmorphic disorder

A semi‐structured interview assessing the presence and characteristics of spontaneous appearance‐related images was designed and administered. A total of 18 patients with body dysmorphic disorder (BDD) and 18 normal controls took part. The BDD patients were found to have spontaneously occurring appearance‐related images that were significantly more negative, recurrent, and viewed from an observer perspective than control participants. These images were more vivid and detailed and typically involved visual and organic (internal body) sensations. The study also found that BDD images were linked to early stressful memories, and that images were more likely than verbal thoughts to be linked to these memories. Implications for theory and clinical practice are discussed.     

The role of aesthetic sensitivity in body dysmorphic disorder

Individuals with a higher aesthetic sensitivity may be more vulnerable to developing body dysmorphic disorder (BDD). Aesthetic sensitivity has 3 components: (a) perceptual, (b) emotional, and (c) evaluative. Individuals with BDD (n = 50) were compared with a control group of individuals with an education or employment in art and design related fields (n = 50) and a control group of individuals without aesthetic training (n = 50). A facial photograph of each participant was manipulated to create a 9-image symmetry continuum. Presented with the continuum on a computer, participants were required to select and rate the image representing their self-actual, self-ideal, idea of perfect, most physically attractive, most pleasure, and most disgust. Control symmetry continua examined the specificity of the disturbance. As predicted, BDD participants displayed no distortion in their perceptual processing but were disturbed in their negative emotional/evaluative processing of their self-image. A significant discrepancy between their self-actual and self-ideal, resulting from an absent self-serving bias in their self-actual (a bias exhibited by controls) appears to be the source of their disturbance. They also overvalued the importance of appearance and self-objectified. These aesthetic evaluations may predispose individuals to BDD and/or maintain the disorder.