Body dysmorphic disorder

Whereas vanity involves a quest to aggrandize the appearance, BDD is experienced as a quest to merely normalize the appearance.[2] Although delusional in about one of three cases, the appearance concern is usually nondelusional, an overvalued idea.[3]

The bodily area of focus can be nearly any, yet is commonly face, hair, stomach, thighs, or hips.[5] Some half dozen areas can be a roughly simultaneous focus.[2] Many seek dermatological treatment or cosmetic surgery, which typically do not resolve the distress.[2] On the other hand, attempts at self-treatment, as by skin picking, can create lesions where none previously existed.[2]

BDD shares features with obsessive-compulsive disorder,[6] but involves more depression and social avoidance.[1] BDD often associates with social anxiety disorder.[7] Some experience delusions that others are covertly pointing out their flaws.[2] Cognitive testing and neuroimaging suggest both a bias toward detailed visual analysis and a tendency toward emotional hyper-arousal.[8]

Most generally, one experiencing BDD ruminates over the perceived bodily defect several hours daily or longer, uses either social avoidance or camouflaging with cosmetics or apparel, repetitively checks the appearance, compares it to that of other people, and might often seek verbal reassurances.[1][2] One might sometimes avoid mirrors, repetitively change outfits, groom excessively, or restrict eating.[5]

BDD's severity can wax and wane, and flareups tend to yield absences from school, work, or socializing, sometimes leading to protracted social isolation, with some becoming housebound for extended periods.[2] Social impairment is usually greatest, sometimes approaching avoidance of all social activities.[5] Poor concentration and motivation impair academic and occupational performance.[5] The distress of BDD tends to exceed that of either major depressive disorder or type-2 diabetes, and rates of suicidal ideation and attempts are especially high.[2]

As with most mental disorders, BDD's cause is likely intricate, altogether biopsychosocial, through an interaction of multiple factors, including genetic, physical (e.g. disabilities), developmental, psychological, social, and cultural.[9][10] BDD usually develops during early adolescence,[5] although many patients note earlier trauma, abuse, neglect, teasing, or bullying.[11] In many cases, social anxiety earlier in life precedes the development of BDD. Family influence has also been linked to the development of BDD. Though twin studies on BDD are few, one estimated its heritability at 43%.[12]There have been studies done that show a link between mother and daughter, as well.[13] Yet BDD's cause may also involve introversion,[14] negative body image, perfectionism,[9][15] heightened aesthetic sensitivity,[10] and childhood abuse and neglect.[10][16] A study done by the Osnabrück University and Ruhr-University Bochum, found a connection between BDD in mothers and their daughters.[13] In the study, they tracked mother’s and daughter’s eye movements and found that there were significant similarities in attention distribution. It was found that the participants paid more attention to the negative body areas of themselves and peers than the positive body areas.[13] The study concluded that there was a strong correlation between mother’s viewing patterns and body image and their daughter’s.[13]

Media influence has also been identified as a factor causing poor body image.[17] The increased use of body and facial reshaping applications such as Snapchat and Facetune have been identified as potential triggers of BDD. Recently, a phenomenon referred to as 'Snapchat dysmorphia' has appeared to describe people who request surgery to look like the edited version of themselves as they appear through Snapchat Filters.[18] Snapchat Dysmorphia is part of Body Dysmorphia, but people often get plastic surgery in order to look like their “Snapchat filter.” According to the Women’s Health Magazine[19], the 2017 Annual American Academy of Facial Plastic and Reconstructive Surgery Survey, conducted that 55 percent of plastic surgeons reported patients getting surgery done for their “selfies.” Snapchat filters are bringing new beauty fantasies to reality. WebMD [20] argued that in recent reports, the majority of surgeons saw a major shift in cosmetic, or injectable surgery for patients under 30 years old. The doctors also noted that these applications are making up unrealistic expectations of beauty. Plastic surgery isn’t the solution for people who suffer from Body Dysmorphia. Patients should seek psychological help and cognitive behavioral therapy.

While BDD is more prevalent in certain groups of people, anyone can develop it. Overall, women are more likely to be affected than men according to a study done by University of South Florida.[21] Women are 3 times more likely to develop BDD than men.[21] Another factor that could increase one’s risk of developing BDD is their sexual preference. It was found that sexual minorities are at a higher risk for developing BDD.[21] Sexual minority women are more likely to develop BDD that straight women, sexual minority males, or straight males.[21] Race and ethnicity can also play a role in one’s chances of developing BDD. African Americans have a lower chance of developing BDD than Asian Americans,  Latinos/as and Caucasian Americans.[21] It turns out that Latinos/as and Caucasian Americans are both over two times more likely to develop BDD than African Americans, with Caucasian Americans being at the highest risk[21]. Although anyone can develop BDD, there are groups who are at a higher risk.

Many U.S. Military personnel suffer from BDD, as well. In a study done on 1150 active duty military personnel, it was found that BDD is much more common in enlisted personnel than it is for the civilian population. Up to 2.4% of the average population is affected by BDD.[2] For enlisted military, it was found that an average of 15.3% of the population was affected by BDD.[22] More often than the normal population, those suffering with BDD in the military do not get treatment mostly due to misdiagnosis.[22] Military personnel suffering from BDD are weary to acknowledge the issue because they feel shameful.[22] If they do bring it up, their doctors may misdiagnose them due to having little knowledge on BDD or the patient may have other symptoms that overshadow the BDD, leading to misdiagnosis. Like the normal population, enlisted women are more likely to develop BDD than enlisted men.

Estimates of prevalence and gender distribution have varied widely via discrepancies in diagnosis and reporting.[1] In American psychiatry, BDD gained diagnostic criteria in the DSM-IV, but clinicians' knowledge of it, especially among general practitioners, is constricted.[23] Meanwhile, shame about having the bodily concern, and fear of the stigma of vanity, makes many hide even having the concern.[2][24]

Via shared symptoms, BDD is commonly misdiagnosed as social anxiety disorder, obsessive-compulsive disorder, major depressive disorder, or social phobia.[25][26] Correct diagnosis can depend on specialized questioning and correlation with emotional distress or social dysfunction.[27] Estimates place the Body Dysmorphic Disorder Questionnaire's sensitivity at 100% (0% false negatives) and specificity at 92.5% (7.5% false positives).[28]

Anti-depressant medication, such as selective serotonin reuptake inhibitors (SSRIs), and cognitive-behavioral therapy (CBT) are considered effective.[5][29] SSRIs can help relieve obsessive-compulsive and delusional traits, while cognitive-behavioral therapy can help patients recognize faulty thought patterns.[5] Before treatment, it can help to provide psychoeducation, as with self-help books and support websites.[5]

In 1886, Enrico Morselli reported a disorder that he termed dysmorphophobia.[30] In 1980, the American Psychiatric Association recognized the disorder, while categorizing it as an atypical somatoform disorder, in the third edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM).[3] Classifying it as a distinct somatoform disorder, the DSM-III's 1987 revision switched the term to body dysmorphic disorder.[3]

Published in 1994, DSM-IV defines BDD as a preoccupation with an imagined or trivial defect in appearance, a preoccupation causing social or occupational dysfunction, and not better explained as another disorder, such as anorexia nervosa.[3][31] Published in 2013, the DSM-5 shifts BDD to a new category (obsessive–compulsive spectrum), adds operational criteria (such as repetitive behaviors or intrusive thoughts), and notes the subtype muscle dysmorphia (preoccupation that one's body is too small or insufficiently muscular or lean).

[1]

[2]

• Looks that Kill, TV documentary by a recovered person with BDD, John Furse
• International Obsessive Compulsive Disorder Foundation BDD website
• Chaney, M.P., 2008. Muscle dysmorphia, self-esteem, and loneliness among gay and bisexual men. International Journal of Men's Health, 7(2), p. 157