A 52-year-old man becomes intoxicated with alcohol so he can lie in his backyard and get a tan. Convinced that his skin is too pale and that he looks “like a ghost,” he is so self-conscious about how he looks that he can’t go outside without drinking excessively.
An attractive 23-year-old woman dropped out of the 10th grade because of her “hideous” appearance and has hidden in her bedroom in her parents’ house ever since. She leaves her room no more than once a month, only after covering her face with a veil, not letting even her family see her face.
A middle-aged man cuts his nose open with a razor blade, trying to remove his nasal cartilage and replace it with chicken cartilage, in the desired shape.
These patients have body dysmorphic disorder (BDD), a somatoform disorder that the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV) defines as a preoccupation with an imagined defect in appearance; if a slight physical anomaly is present, the person's concern is markedly excessive. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning that are not attributed to another mental disorder.
Most of us are dissatisfied with some aspect of how we look. In fact, more than half of all women and nearly half of all men in the United States are dissatisfied with their overall appearance.1 As the preceding cases illustrate, however, BDD does not consist simply of normal appearance concerns.
BDD is a relatively common disorder2 (Box 1) that occurs in children as well as adults. It usually begins during the early teenage years.2 BDD has been described around the world for more than a century.3 It causes notable distress and impaired functioning, and can lead to suicide.4 This disorder typically goes undiagnosed in clinical settings, however, in part because many patients are too embarrassed and ashamed to discuss their symptoms with their physicians unless specifically asked.2,5 BDD often masquerades as other psychiatric disorders, and misdiagnosis appears common6 (Table 1). Diagnosing BDD is usually straightforward, however, and can be achieved using the questions in Box 2.4 Clues to the presence of BDD are presented in Box 3; patients who present with any of them should be carefully evaluated for BDD.
BDD IS A RELATIVELY COMMON DISORDER, OCCURRING IN APPROXIMATELY:
- 1 in 8 psychiatric inpatients (13%)
- 1 in 7 to nearly half of outpatients with atypical major depression (14%-42%)
- 1 in 8 to 9 outpatients with social phobia (11%-13%)
- 1 in 3 to 12 outpatients with obsessive-compulsive disorder (8%-37%)
- 1 in 8 patients seeking dermatologic treatment (12%)
- 1 in 7 to 15 patients seeking cosmetic surgery (6%-15%)
- Nearly 1 in 100 to more than 1 in 50 people in the general population (0.7%-2.3%)
Perceptions of patients with BDD
Individuals with BDD obsess that there is something wrong with their appearance when in fact they look fine; the perceived flaw is actually minimal or nonexistent.7 Prior to treatment, insight is usually poor or absent, however, so that most patients are convinced or fairly certain that they look abnormal.2,8 They may describe the perceived flaw as unattractive or deformed, or they may even say that they look like a freak, a monster, or the “elephant man” (Box 4). Individuals with this disorder think about the perceived appearance flaws, on average, for 3 to 8 hours a day, and they usually find the thoughts difficult to resist or control.9 Diagnostic errors that cause BDD to be missed
Table 1
Diagnostic errors that cause BDD to be missed
| Misdiagnosis | Diagnostic error | How to avoid the error |
|---|---|---|
| Depression | The depressive symptoms that often coexist with BDD are diagnosed and BDD is missed; or BDD symptoms are considered a symptom of depression. In the author’s clinical experience, this is the most common diagnostic error. | Look for BDD in all depressed patients; appearance concerns may not be simply a symptom of depression. |
| Social phobia | Social anxiety is a common consequence of BDD, which may be misdiagnosed as social phobia or avoidant personality disorder. | Explore the cause of social anxiety or avoidance and determine whether it is secondary to BDD. |
| Agoraphobia | Many BDD patients are housebound at some point, which may be misdiagnosed as agoraphobia. | Explore the cause of avoidance and determine whether it is due to BDD. |
| OCD | BDD’s prominent obsessions and compulsive behaviors may be misdiagnosed as OCD. | If the obsessions and behaviors focus on physical appearance, BDD is the more accurate diagnosis. |
| Panic disorder | Panic attacks that occur when looking in the mirror or experiencing referential thinking can be misdiagnosed as panic disorder. | Determine whether panic attacks have BDD-related triggers; if so, BDD should be diagnosed. |
| Trichotillomania | Some BDD patients remove their body, head, or facial hair in an effort to improve their appearance, which may be misdiagnosed as trichotillomania. | Determine whether hair removal reflects thoughts that the hair does not look right and is intended to improve appearance; if so, the patient may have BDD. |
| Schizophrenia. | Because BDD beliefs are often delusional, and many patients have referential thinking, occasionally patients are misdiagnosed with Schizophrenia | If psychotic symptoms are largely limited to a nonbizarre delusional belief about one’s physical appearance and/or related delusions of reference, BDD is the more accurate diagnosis. |