Body dysmorphic disorder

The GP’s role

General practitioners have a role in identifying body dysmorphic disorder (BDD) in patients, referral to psychologists or other medical specialists, and assisting patients to understand and manage the disorder.

Overview

Body dysmorphic disorder (BDD) is characterised by a debilitating preoccupation with a perceived defect in one’s own physical appearance. The physical attribute of concern may be non-existent or so minor as to be unnoticeable by others.

Behavioural characteristics of BDD – such as constantly checking one’s appearance, comparing their appearance to others, repeated attempts at correcting the perceived disorder, seeking reassurance or excessive exercising – this often impacts daily functioning.

Muscle dysmorphia is a form of BDD characterised by a perceived lack of muscularity. Excessive exercise and specific dietary patterns are common behavioural consequences of muscle dysmorphia. Misuse or abuse of androgenic steroids appears common in males with muscle dysmorphia.

Males are more likely than females to have genital manifestations of BDD.

Body dysmorphic disorder is distinct from gender dysphoria, although both may occur in individuals.

Prevalence

Approximately 1 in 50 (2%) adults has body dysmorphic disorder. The disorder most commonly manifests in adolescence, with subclinical symptoms occurring for years before diagnosis. In general, BDD is more common in females than males (for every 5 females with BDD there are 4 males), but gender differences depend upon the group of people being assessed. Muscle dysmorphia occurs much more often in males.

Etiology

Body dysmorphic disorder is likely due to genetic, psychosocial, and cultural factors. BDD is more likely than usual to occur in people who:

Use of social media, especially image sharing services (e.g. Snapchat, Instagram), is associated with concern about body image but there is no high quality evidence linking social media use and formal diagnosis of BDD, and BDD likely results from a range of risk and predisposing biopsychosocial factors.

Comorbidities

Body dysmorphic disorder is a chronic condition, so it can persist throughout adulthood, and its influence on adolescent social and emotional development may have long term functional consequences⁵. However, treatment can lessen the symptom severity and the negative functional impact of BDD.

In males, body dysmorphic disorder often accompanies depression, social and generalised anxiety, emotional and behavioural difficulties, problems with peer relationships, hyperactivity, drive for masculinity and quality of life.

These co-occurrences  can have lasting deleterious effects on social functioning, romantic relationships, and educational and vocational achievements across the lifespan.

People with BDD are more likely to have suicidal thoughts or behaviours than people without the disorder, with increasing severity and presence of comorbidities related to increasing risk.

Screening and diagnosis

People with BDD may lack insight into their disorder, making them unlikely to seek direct help for the condition.

Some behaviours that accompany muscle dysmorphia, such as adherence to exercise routines and avoidance of unhealthy foods, can be misinterpreted as beneficial and positively reinforced.

Only a minority of people with BDD are diagnosed.

Body dysmorphic disorder occurs with muscle dysmorphia if there is a belief of insufficient muscularity or small build despite having a typical or even larger build (with or without preoccupations about other body regions).

Insight into BDD is typically low for people who are convinced their body dysmorphia beliefs are true, or for people who think the beliefs  are probably true.

Good or fair insight into BDD is attributed to people who consider their body dysmorphic beliefs to be definitely or probably false, or able to consider that the beliefs may not be true.

Treatment

Psychological and psychopharmacological treatment of BDD can moderate symptoms and improve functionality, but only a minority of people with the disorder receive therapy.

Barriers to treatment include shame and stigma, a perception that psychological and psychiatric treatments are ineffective, and low insight into  the disorder (and, hence, failure to seek treatment).

Many people with BDD seek cosmetic treatments to fix the perceived physical defect, but such procedures generally have poor outcomes and should be discouraged. In Australia, Body Dysmorphic Disorder (BDD) Screening is a mandatory requirement for patients considering cosmetic surgery.  The screening process involves a validated questionnaire that assesses the patient’s psychological readiness for the procedure and can help identify risk or presence of BDD. The practitioner is subsequently responsible for assessing the person for suitability for the cosmetic procedure in the context of BDD concerns. BDD screening is not mandatory for nonsurgical cosmetic procedures, however is still recommended

People with BDD should be counselled about the likely futility of pursuing cosmetic outcomes, the associated distress and cost that can arise, and that the procedure is unlikely to resolve the person’s body image concerns or distress.

People with BDD who seek referral for cosmetic procedures would likely be better served by discussion aimed at providing an understanding of the underlying psychological problem, and highlighting the benefit of appropriate treatment.

Cognitive behavioural therapy for BDD commonly consists of exposure with response prevention, over a period of 3-6 months, and seems effective at reducing symptom severity for some time; however, longer-term monitoring is recommended to detect symptom severity and relapse. Telehealth and internet-based therapy shows promise in treating BDD.

Selective serotonin reuptake inhibitors (SSRIs) may take weeks-to-months to be effective for BDD, and are usually needed in a higher dose than for treatment of depression.

In cases where SSRIs are ineffective, the tricyclic antidepressant clomipramine may be used, or alternatively, off-label use of some antipsychotics may be considered.