History of the concept

Although body dysmorphic disorder has only recently been included in diagnostic systems, recognisable descriptions date to the 19th century. The characteristic features of ‘dysmorphophobia’ were first described in 1886 by Morselli. Subsequently, Kraepelin also described patients with the disorder and Freud's description of ‘the Wolf Man’ can be seen as a probable case of body dysmorphic disorder (Reference BrunswickBrunswick 1928).

Eventually, dysmorphophobia was renamed body dysmorphic disorder, to distinguish it from primary phobic conditions, and listed as an atypical somatoform disorder in the American Psychiatric Association's DSM-III in 1980. No diagnostic criteria were included until the 1987 revision (DSM-III-R), in which it was classified as a separate disorder, with delusional and non-delusional subtypes.

With the publication of DSM-IV (American Psychiatric Association 1994), the criteria for body dysmorphic disorder were altered so that beliefs of a delusional nature were removed and coded separately on Axis I as delusional disorder, somatic type. Body dysmorphic disorder is included in the ICD-10 under ‘hypochondriacal disorder’ (F45.2), alongside hypochondriasis (World Health Organization 2007), which seems a less satisfactory classification. Furthermore, ICD-10 suggests a diagnosis of ‘Other persistent delusional disorder’ (F22.8) as an alternative in those whose beliefs are delusional, rather than this being an additional disorder as in DSM-IV. A DSM-5 working group is currently considering whether body dysmorphic disorder should be included within the category of obsessive–compulsive spectrum disorders (Reference PhillipsPhillips 2009). The key points of the DSM-IV and ICD-10 criteria are compared in Box 1.

Reliability and validity of the diagnosis

Concern about appearance is very common and the boundary between mild body dysmorphic disorder and normal concern is often unclear. However, as with mood and anxiety disorders, the threshold for ‘caseness’ rests on the extent of impairment and preoccupation (often proposed as an hour a day at the forefront of one's mind). The perceived defect(s) or flaw(s) in physical appearance should not be observable or should appear slight to others. Cultural variables may play a significant part in the subjectivity behind determining which physical appearances are considered to be within the normal range, but any preoccupation should be considered abnormal.

Symptoms of body dysmorphic disorder overlap with those of other psychiatric disorders, such as major depressive disorder, obsessive–compulsive disorder (OCD), social phobia and eating disorders. In one study comparing body dysmorphic disorder with social phobia, 39.3% of 178 individuals with current body dysmorphic disorder had comorbid lifetime social phobia (34.3% had current social phobia) (Reference Coles, Phillips and MenardColes 2006). Social phobia onset was typically before that of body dysmorphic disorder and unrelated to appearance concerns. Individuals with body dysmorphic disorder, with and without lifetime social phobia, were similar in many characteristics such as age at body dysmorphic disorder onset, gender distribution, body dysmorphic disorder severity and overall functional disability (Reference Coles, Phillips and MenardColes 2006).

Although body dysmorphic disorder is categorised as a somatoform disorder in DSM-IV, many now view it as more closely related to OCD, due to its obsessive–compulsive symptoms and positive response to similar therapy and drug treatments. It appears to differ in several important respects however. Only 30% of people with OCD have an additional diagnosis of depression, compared with 80–90% of people with body dysmorphic disorder (Reference Phillips, Pinto and MenardPhillips 2007). Although in this series there was considerable overlap between the disorders, differences also emerged over the degree of insight, suicidal ideology and depressive comorbidity (all higher in body dysmorphic disorder). In contrast to OCD, individuals with body dysmorphic disorder do not normally find relief of anxiety by performing rituals such as mirror checking or grooming rituals – instead these may increase feelings of despair. Unlike other anxiety disorders, body dysmorphic disorder is much more likely to be accompanied by feelings of shame, guilt, disgust, self-hatred and depression.

The distinction between delusional and non-delusional forms of body dysmorphic disorder has been questioned. Reference Phillips, McElroy and HudsonPhillips et al(1994) compared 48 patients with non-delusional body dysmorphic disorder with 52 patients with delusional body dysmorphic disorder and found that they did not significantly differ in terms of sociodemographics, phenomenology, course of illness, associated features, comorbidity or treatment response. Patients with delusions had higher total scores on the modified Yale–Brown Obsessive Compulsive Scale questionnaire, suggesting that the delusional variant of body dysmorphic disorder may be a more severe form of the disorder.

Epidemiology

The incidence of body dysmorphic disorder is uncertain as population-based studies are lacking. Most individuals are first aware of symptoms during adolescence or early adulthood but in some, symptoms begin to appear in middle childhood and in others, quite late in life, often after a traumatic event. Reported rates vary depending on the gender ratio, the diagnostic threshold and instrument used to measure body dysmorphic disorder, the culture and the survey method used. For example, a German population study (Reference Rief, Buhlmann and WilhelmRief 2006) involving 2552 individuals aged 14 and above gave a prevalence of 1.7% (95% CI 1.2–2.1).

Unlike eating disorders, which are much more prevalent in women, body dysmorphic disorder appears to be as common in men as in women (at least in Western societies), although fewer men seek help for the disorder than women (Reference PhillipsPhillips 2005a). Surveys of body dysmorphic disorder in cosmetic surgery settings and dermatology clinics suggest that the disorder is relatively common in these populations, with a prevalence of between 3 and 10%. In psychiatric settings the diagnosis (although relatively easy to make) is often missed, as clinicians do not routinely ask about it. Thus in a study of consecutive adult psychiatric in-patients (Reference Grant, Kim and CrowGrant 2001), 16 of 122 individuals (13.1%) were diagnosed as having body dysmorphic disorder, although none had been diagnosed as such by their treating psychiatrist. All 16 patients reported that they would not raise the issue with their doctor unless specifically asked because of feelings of shame.

Reference Conroy, Menard and Fleming-IvesConroy et al(2008) found a similar rate of 16% among psychiatric in-patients. A high proportion of patients reported that body dysmorphic disorder symptoms contributed to their suicidality, but only 1 out of the 16 (6.3%) had reported symptoms to the in-patient psychiatrist; the other 15 were too embarrassed to do so.

Both of these studies underline the importance of routinely asking a screening question for body dysmorphic disorder in psychiatric service users, particularly in-patients and those presenting with depression, social phobia, OCD, alcohol or substance misuse or suicidal ideation.

Because patients do not readily volunteer their symptoms, the National Institute for Health and Clinical Excellence (NICE) guidelines for body dysmorphic disorder (National Collaborating Centre for Mental Health 2005) suggest that a simple open question should be used in a psychiatric assessment interview. An example is: ‘Some people worry a lot about their appearance. Do you worry a lot about the way you look and wish that you could think about it less?’ When answered positively, this should be followed up with further questions to clarify the extent and nature of bodily concerns and, for example, to distinguish body dysmorphic disorder from a possible eating disorder.

Clinical features

This personal account illustrates how distressing the disorder can be. To some extent, the preoccupations of body dysmorphic disorder can lie at one end of a continuum of ordinary appearance concerns. However, the disorder covers a large spectrum of functionality, with some individuals merely being preoccupied with obsessive thoughts about appearance and others being completely housebound or subject to suicidal ideas.

Body dysmorphic disorder may lead to avoidant behaviours, culminating in extreme social isolation. In some cases, multiple surgery and attempts at body modification (including self-mutilation) are employed, although these generally fail to improve the person's view of their ‘defect’. Depression is very common and occasionally leads to suicide. Body dysmorphic disorder sometimes occurs in episodic ‘attacks’, which are followed by a spell of normal functioning. In such episodes, the person will be consumed with self-doubt, comparing themselves to others and feeling extremely anxious.

Many of the symptoms (Box 2) and behaviours (Box 3) associated with body dysmorphic disorder are determined by the nature of the individual's perceived defect (Box 4), for example, the (over) use of cosmetics is common in those with a perceived skin defect. Although the most frequent obsessions concern facial appearance, many women are plagued with body proportion concerns, while men tend to be preoccupied with the need to be larger and more muscular. Reference Phillips and DiazPhillips & Diaz (1997) assessed gender differences in 188 individuals with body dysmorphic disorder (93 women and 95 men). Men and women did not significantly differ in terms of most variables examined, including rates of major depression, although women were more likely to be preoccupied with their hips and their weight, pick their skin and camouflage their skin with makeup, and have comorbid bulimia nervosa. Men were more likely to be preoccupied with body build, genitals and hair thinning, be unmarried and misuse alcohol. Men were as likely as women to have sought cosmetic surgery.

Comorbidity

Comorbidity with other psychiatric disorders is common. About 80% of people with body dysmorphic disorder will experience major depressive disorder at some point in their life, significantly more than the 10–20% expected in the general population (Reference PhillipsPhillips 2005a). About 37% also have social phobia and about 32% fulfil criteria for OCD. Eating disorders such as anorexia nervosa and bulimia nervosa are also sometimes found in women with body dysmorphic disorder, as are generalised anxiety disorder and trichotillomania. As comorbidity is the rule, it is more important clinically to differentiate when body dysmorphic disorder is the main problem and which comorbid features would disappear if the disorder was effectively treated, and which are true coexisting disorders.

Aetiology

Body dysmorphic disorder usually develops in adolescence, a time when people are generally most sensitive about their appearance. As with other anxiety and somatic disorders, a multifactorial aetiology is presumed. Most likely, the cause comprises a complex combination of biological, psychological and environmental factors.

Treatment

Conclusions

Body dysmorphic disorder remains poorly understood and rarely identified within generic mental health services. Guidance from NICE and revised classification systems which highlight links with obsessive–compulsive disorders should help establish the validity of the condition and clarify potential treatment approaches.

MCQs

Select the single best option for each question stem

1. 1 Females with body dysmorphic disorder:

   1. a outnumber males by 10 to 1

   2. b are more commonly preoccupied with their legs than their face

   3. c commonly use masking skin products

   4. d rarely have comorbid eating disorders

   5. e make frequent demands on primary care services.

2. 2 Patients with body dysmorphic disorder:

   1. a usually experience onset of the disorder before puberty

   2. b are attention-seeking and enjoy social occasions

   3. c commonly check their appearance in mirrors

   4. d are highly critical of others’ appearance

   5. e usually have a noticeable physical defect.

3. 3 Pharmacological treatment:

   1. a is not indicated for body dysmorphic disorder

   2. b is effective in body dysmorphic disorder

   3. c comprises a benzodiazepine or similar anxiolytic

   4. d using SSRIs may require a higher dose than for depression

   5. e may reduce comorbid depression, but not the underlying dysmorphia.

4. 4 Non-psychiatric medical treatment:

   1. a rarely produces a lasting benefit

   2. b is more effective than psychotropic drugs

   3. c comprising a single surgical procedure is generally effective

   4. d should include colonic irrigation

   5. e comprises a course of many operations.

5. 5 The long-term outcome of body dysmorphic disorder:

   1. a often includes spontaneous remission

   2. b is unaffected by treatment

   3. c is better if the preoccupation focuses on the face

   4. d is better for men than women

   5. e may include suicide.

MCQ answers

1

c

2

c

3

d

4

a

5

e