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Ask the Doctor: What is Body Dysmorphic Disorder?
Katharine A. Phillips, M.D., is chief of outpatient services and director of the Body Dysmorphic Disorder and Body Image Program at Butler Hospital in Providence, R.I., and assistant professor of psychiatry at the Brown University School of Medicine. Youth with body dysmorphic disorder (BDD) worry about some aspect of their appearance. They worry, for example, that they have pimples or that their skin is scarred or bumpy, their nose is too big, they are fat or too thin. Or they may think something else is wrong with how they look. When others tell them that they look fine or that the flaw they perceive is minimal (or nonexistent), youth with this disorder find it hard to believe this reassurance.
Adolescents with BDD think a lot about their perceived physical flaw, generally for at least an hour a day. Some say they're obsessed. Most find that they don't have as much control over their thoughts about the body flaw as they would like.
In addition, the appearance concern causes significant distress (for example, anxiety or depression) or it causes significant problems in functioning. Although some youth with this disorder manage to function well despite their distress, many find that their appearance concerns cause problems for them. For example, they may find it hard to concentrate on their job or schoolwork, which may suffer, and relationship problems are common. Adolescents with BDD may have few friends, avoid dating, and feel very self-conscious in social situations.
Obsessive mirror-checking may seem normal for teens in their formative years, but is the image some see causing severe angst-even causing some to contemplate suicide? "These adolescents have a very distorted view of how they look, and it does not match how other youth see them," says Dr. Katharine Phillips, who recently co-authored one of the first studies of BDD in youth. Teens plagued with BDD are obsessed with negative perceptions of their bodies. Many times they end up dropping out of school, suffering major depressive episodes, avoiding most social contact, and even attempting suicide in some cases. BDD can be a devastating disorder for adolescents, and it is thought to be caused by a chemical imbalance in the brain.
The severity of BDD varies. Some youth experience manageable distress and are able to function well, although not up to their potential. Others find that this disorder ruins their life. BDD also has some features that, while not necessary for the diagnosis, can provide clues to its presence, some of which are the following:
Some clues to the presence of BDD-
frequently comparing one's appearance with that of others, or scrutinizing the appearance of others;
often checking how one looks in the mirror;
camouflaging the perceived defect with clothing, makeup, a hat or a hand, or changing one's posture;
seeking surgery, dermatologic treatment, or other medical treatment for appearance concerns when doctors, parents, or peers have said such treatment is unnecessary;
constantly seeking reassurance about the perceived flaw or attempting to convince others of its repulsiveness;
excessive grooming (combing one's hair, shaving over and over, removing or cutting hair, applying makeup or cover-up creams);
picking at one's skin or squeezing pimples/blackheads for hours;
avoiding mirrors;
exercising or dieting excessively;
frequently touching the perceived defect;
measuring the "unpleasant" body part;
excessively reading about the supposed defective body part;
avoiding social situations in which the perceived defect might be exposed;
and feeling very anxious and self-conscious around peers because of the perceived defect;
BDD is often underdiagnosed
The diagnosis of BDD is often missed because of:
trivialization: BDD is easily trivialized, even though it is a serious and distressing condition;
secrecy and shame: many adolescents with BDD don't reveal their symptoms to others because of embarrassment;
lack of familiarity with BDD: many health professionals, including primary healthcare providers, are not aware that BDD is a known psychiatric disorder that often responds to psychiatric treatment;
or; pursuit of non-psychiatric, medical, and surgical treatment: many youth with BDD see dermatologists, plastic surgeons, and other physicians rather than mental health professionals. These treatments often are not helpful.
BDD can be misdiagnosed
BDD is often misdiagnosed as a different psychiatric disorder. This occurs because BDD can produce symptoms that mimic other disorders such as social phobia, agoraphobia, panic disorder, trichotillomania (excessive hair pulling), obsessive-compulsive disorder, and depression.
Hope for BDD sufferers
Psychiatric treatment is often effective in decreasing BDD symptoms and the suffering they cause. The treatments that appear most effective are certain medications, namely the selective serotonin reuptake inhibitors (SSRIs), and cognitive behavioral therapy.
The prescription-only SSRIs are not addicting and are usually well tolerated. They can significantly relieve BDD symptoms by diminishing bodily preoccupation, distress, depression, and anxiety and by significantly allowing increased control over the youth's thoughts and improving functioning. In some cases these medications are lifesaving, especially for those who have attempted suicide in their despair over their appearance.
During cognitive-behavioral therapy the specially trained therapist helps the person with BDD resist compulsive behaviors-for example, mirror checking-and face avoided situations like social situations. It's important to determine whether a therapist has been specifically trained in cognitive-behavioral therapy. Other types of talk therapy do not appear to be effective for BDD.
BDD treatment trial in adolescents
Drs. Katharine Phillips and Ralph Albertini are conducting the very first treatment trial in adolescents with BDD, funded by the National Institute of Mental Health. The trial, which will study 100 adolescents over the next four years, will take place at three sites: Providence, Rhode Island; Cincinnati, Ohio; and New York City.
For more information about BDD
The most comprehensive source on body dysmorphic disorder is The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder by Katharine A. Phillips, M.D. (Oxford University Press>
http://www.nami.org/youth/dysmorphic.html