Body dysmorphic disorder

Body dysmorphic disorder (BDD) is characterised by a preoccupation with a real or an imagined defect in physical appearance, with a level of concern that is out of proportion to the perceived anomaly.

This chapter is set out as follows:

• The incidence of body dysmorphic disorder BDD is 1–2%, and increasing, probably as a result of social media
• It is more common in patients seeking aesthetic and cosmetic surgery, and there is a high degree of co‐morbidity with mood disorders, OCD and social phobia
• The female to male ratio is approximately 2:1 but the gap is narrowing
• BDD often starts in adolescence but may affect any age group

• Facial and hair symptoms are common
   
• Patients may present with symptoms according to their gender:
  • Women may focus on the skin of the face, the breasts, nose and stomach
  • Men may present with concerns about hair (usually thinning), nose, ears, genitals and body build
     
• Patients will show some of the following traits:
  • Take many photographs of themselves on their phone
  • Feel uncomfortable looking in mirrors
  • Have very persistent and intrusive thoughts about their perceived ’defect’
  • Hide their 'defect'
  • Socialize poorly
  • Pick at their skin
  • Repeatedly seek help from different health care professionals, including cosmetic surgeons

• From the outset it is important to treat the psychological disease whilst addressing the perceived skin anomaly - it is essential that all health professionals recognise the skin changes, however minimal, rather than dismissing them
   
• The level of psychological input needed will vary depending on the severity of symptoms, and can include:
  • Counselling
  • Cognitive behavioural therapy
  • Medication - selective serotonin reuptake inhibitors. Higher dosing regimens than those used for depression are usually required. Patients should receive a trial of 3 months before efficacy is assessed
     
• Surgery should be avoided if at all possible as often it will fail to meet the patient's expectations
   
• The prognosis for patients with BDD is variable, but good, when treated by dedicated BDD teams. Younger patients may have a better prognosis, in that relative dissatisfaction with appearance may be a relatively normal experience in this age group and may be self‐limiting