Body dysmorphic disorder ( BDD), previously known as dysmorphophobia or “imagined ugliness,” is a chronic mental illness that was formally recognized and recorded as a disorder in 1987 in the DSM III R (Diagnostic and Statistical Manual of Mental Disorders, third edition). It is defined as preoccupation with an imagined defect in appearance that causes clinically significant distress or impairment in social, occupational or other important areas of functioning. If a slight physical anomaly is present, the person’s concern is markedly excessive.

The face is often the focus of concern with some common preoccupations being that the nose is too long or the eyes are too close together. Concern may settle on other body parts like the breasts that are frequently perceived as too large, too small or asymmetric. Reassurance from other people has little effect becuase the defect persistently exists in the mind of the beholder. People with BDD often seek cosmetic surgery, which usually makes the problem worse. Patients are frequently not satisfied with the outcome of the surgical procedure, and If they are, they start to focus on another body area and become preoccupied trying to fix the new “defect.” Ironically, BDD is widely misunderstood as a vanity-driven obsession, whereas it is quite the opposite. Chronic low self-esteem is characteristic of those with BDD, because the perception of self-value is too closely linked to the perception of one’s appearance. Dr. Sigmund Freud, the well-known neurologist and founder of psychoanalysis, had a famous Russian patient, Sergei Pankejeff, who would today be diagnosed with BDD. He had a preoccupation with his nose to such an extent that it greatly limited his functioning.

The course of BDD is chronic, with the level of concern waxing and waning over time. There is a high degree of co-morbidity with other psychiatric disorders like major depression, social phobia and obsessive compulsive disorder. Suicidal ideation has been found in 58% to 78% of patients with BDD. Ideas of reference, or the concern that others are staring at them or talking about them, are common. Some people may spend hours checking their appearances in the mirror; conversely, some will avoid any reflecting surface for fear of seeing their deformity. In a minority of patients, the concern becomes a delusion (a fixed false belief).

The prevalence of body dysmorphic disorder in the general population is unknown; in cosmetic surgery clinics, it has been calculated as 2 %. It typically starts in the mid to late teens, and it is equally common in adult females and males.

Treatment of body dysmorphic disorder is often successful. However, it can be difficult, especially if the patient is not a willing and active participant of the care plan. The ideal treatment is the combination of psychotherapy and medications. Psychotherapy can help people learn about their condition, feelings, thoughts and behaviors. Using the insight and knowledge gained in psychotherapy, patients can learn to stop automatic negative thoughts and to see themselves in a more realistic and positive way. People can also learn healthy ways to handle urges or rituals such as mirror checking. Because BDD is thought to be caused in part by problems related to the brain chemical serotonin, the medications most commonly used to treat this condition are the SSRIs (selective serotonin reuptake inhibitors).

While much remains to be learned about BDD, available therapies are very promising for those who suffer from this distressing and sometimes disabling condition.

Ana C Posada Diaz, MD 
Psychiatrist