Body Dysmorphic Disorder: 21st Century Challenges

ABSTRACT

Body dysmorphic disorder, now recognized as an obsessive‐compulsive and related disorder, combines ideas of beauty and glamour with inordinate widespread concern, mainly affecting young people and those seeking to remain youthful. We update concepts of this disorder in an era with multiple social media providing a setting for communication and information sharing.

1. Introduction

Ideas of beauty and glamour have changed hastily, owing largely to image‐based social media, which is inordinately widespread among young people. While these platforms have provided a setting for communication, information, and sociability for millions of individuals, including during the COVID‐19 pandemic, they have facilitated a subculture that thrives on interpersonal comparisons, irrational archetypes, and thus an elevated and oftentimes undue awareness of oneself, especially one's appearance [1]. The surge of body dysmorphic disorder or BDD has been amalgamated with one's usage of social media platforms. A positive correlation between BDD and social media has been observed over the past decade, with an uptick during the COVID‐19 pandemic. In a recent study conducted on patients at an oculoplastic and reconstructive surgery clinic at an academic facility, of the patients who screened positive for BDD, 70% were social media users [2].

It is pivotal to develop and sustain a high clinical premonition for BDD and contemplate screening for it if a founded concern exists. BDD is a recurrent psychiatric condition that affects many dermatology patients, including those living with chronic cutaneous disease. BDD is signaled by fixation with unreal or unsubstantial imperfection in one's appearance, leading to anguish and sometimes even impairment [3]. BDD must be distinguished, however, from clinical cases with patients affected by cutaneous disease or aesthetic conditions that might involve subliminal aesthetic distress to even social exclusion in diseases such as leprosy. The regularity of image‐based social media platform usage was significantly and positively associated with BDD indicators in another recent study, with this association remaining significant in adjusted models [4]. In the aforementioned study, perfectionism factored in the linkage of image‐based social media platforms and BDD. Neologisms have appeared in the literature relating to BDD, focused on the potentially vexatious effects of increased webcam usage, especially during the COVID‐19 pandemic [5]. Notably, patients with BDD symptoms who undergo cosmetic intervention seldom have a lessening of their concerns. It has been delineated that physicians should look for BDD with approved scales before a cosmetic intervention to determine the patient's appropriateness for this procedure [6]. Celebrating introspection, diversity in appearance, and reducing stigma surrounding cutaneous disease by popular figures could prove advantageous.

2. Definition

The term “body dysmorphic disorder” was created in 1980. Although it was classified as a somatoform disorder in 1987, it now falls under the category of “obsessive‐compulsive and related disorders” in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM‐5) [7]. However, the history of this disorder goes back to its original description by the Italian psychiatrist Enrico Morselli, who in 1891 named this disorder dysmorphophobia. He derived this diagnostic term from the Greek word dysmorfia, which translates as ugliness, to delineate a phobia or fear of it. Sigmund Freud highlighted a patient of his who was obsessed with minor nasal alterations as “Wolf Man,” a clinical description that fits well into this category [8]. BDD has been most recently defined as a preoccupation with a normal‐appearing aspect of one's physical appearance that is perceived as flawed or defective, to the point that individuals will partake in repetitive behaviors that impair their functioning in a variety of areas, including socially, academically, and occupationally [8]. The degree of BDD may range in severity, with some forms being severe to the point where patients will be in a state of delusion [9]. BDD is related to major depressive disorder, substance use disorder, social phobia, obsessive‐compulsive disorder, and personality disorders [10]. Diagnosing BDD involves using its unique symptoms to differentiate it from other mental disorders with similar manifestations.

3. Prevalence

It is estimated that about 2% of the population in the United States suffers from body dysmorphic disorder, which typically begins in adolescence [11]. In a study on British adolescents, it was found that 10.4% had BDD and that the prevalence of BDD was much higher in women (14.8%) than in men (6.8%) [12]. A study on university students in the Kingdom of Saudi Arabia found that BDD was associated with increased levels of anxiety, stress, and depression [13]. In another study on patients seeking cosmetic dermatology procedures in a South Indian population, 6.1% of patients were found to have BDD [14].

4. Pathophysiology and Etiology

It was previously thought that a disruption in certain neurotransmitters, such as serotonin, may play a role in BDD. In a study comparing a group of patients with BDD and other OCD‐related disorders to a group of patients with OCD as well as another control group, a significantly lower platelet 5‐hydroxytryptamine (5‐HT) transporter binding density was found in the OCD and OCD‐related disorder group as compared to the control group [15].

In two separate studies comparing BDD patient groups with control groups matched for age and sex, it was found that brain volumes were reduced in the right orbitofrontal cortex (a region that is involved in decision‐making) and the left thalamus (a region that helps communicate information from the body to the cerebral cortex). In one of these studies, the volume of the left amygdala (a region involved with emotional responses) was also found to be reduced in addition to other regions, such as the left dorsal anterior cingulate cortex (a region with many different functions including emotional control and behavior regulation) [16].

When asked to identify facial emotions in a study, participants with BDD showed a higher rate of incorrectly identifying facial emotions and were more likely to associate neutral facial expressions with negative emotions such as anger [17]. This result suggests abnormalities in the brain regions that process facial emotion. Additionally, a high level of degree connectivity has previously been found between the orbitofrontal cortex (OFC) and the basal ganglia in OCD. When the degree of connectivity between these areas was assessed in BDD patients, results suggested similar connectivity between these areas as in the OCD patients [18]. This would indicate that the brain patterns of BDD patients are similar to those that cause the obsessive‐compulsive thoughts and behaviors shown by OCD patients [18].

Genetics appear to contribute to increased susceptibility of a person to BDD. It was found that of those diagnosed with BDD, 8% had a family member who had also been diagnosed [19]. Another study on twins showed that obsession with a perceived flaw in one's appearance was a heritable trait [20]. There was also found to be a higher rate of BDD diagnoses in patients with relatives who had been diagnosed with obsessive‐compulsive disorder or related disorders [21]. A candidate gene, the GABA‐A‐gamma‐2 (5q31.1‐q33.2) receptor gene, was delineated in one limited study as being more frequent among those with BDD than in the controls [8].

5. Clinical Manifestations

Social media may cause individuals to want to change aspects of their appearance. In a study on “selfies” (or pictures that one takes of themselves) performed on individuals of different ages in Saudi Arabia, it was found that 5.8% of participants had a cosmetic procedure due to a desire to look better in selfies [22]. Additionally, 37.8% of respondents said that “selfies” were the reason they wanted a cosmetic procedure [22].

Filters on applications such as Snapchat may cause people to actually make physical changes in real life. In response to a survey asking if patients had shown filtered photographs of themselves to surgeons as their desired end result, 55% of surgeons responded yes [23]. Although this study did not assess symptoms of BDD, it seems likely that seeing “enhanced” versions of their faces may cause people to be unsatisfied with their appearance and thus desire to change it.

Similarly, it is likely that viewing edited photographs on social media has raised the beauty standard to unrealistic levels and has caused people to find issues with their appearance that they may not have previously found. Social media users often compare themselves to unrealistically edited photographs, which may negatively impact their self‐esteem and cause them to believe they are less attractive than they really are. A study evaluating women's satisfaction with their bodies after viewing “real” versus “ideal” images found that the “ideal” images decreased bodily satisfaction compared with the “real” images [24].

If individuals using social media exhibit BDD symptoms, this may induce feelings of social anxiety. This social anxiety may prompt them to avoid interacting with others due to feelings that they will be judged or rejected because of their perceived flaws [25]. The increased self‐consciousness that individuals may exhibit due to BDD may cause them to avoid social situations, which may take a large toll on their quality of life and well‐being.

Individuals with BDD develop fixations on self‐perceived flaws in their appearance that are unnoticeable or barely noticeable to others. They think other people feel similarly to themselves about their flaws and feel that it impacts their lives much more than it actually does [26]. As a result, they are often caught in a loop of obsessive behaviors that involve checking, hiding, or trying to enhance their perceived flaws, which may be disruptive to their lives due to the amount of time these behaviors may take up. Common behaviors that BDD patients display include comparing parts of their bodies that they dislike to the same body parts of others, checking themselves in mirrors, repeatedly grooming themselves, or dieting [27]. Despite the BDD patient's best efforts to avoid these obsessive thoughts and behaviors, they are often extremely difficult to manage and take up an average of 3–8 h per day. Although these behaviors are meant to alleviate the patient's mental suffering, they often end up exacerbating it. Additionally, many BDD patients attempt to hide their self‐perceived flaws from others using things like hats, makeup, or clothing in order to avoid potential judgment.

Common body parts of patient concern include hair, face, lips, nose, and skin [4]. With regard to gender‐specific concerns, 50% of females reported breasts, and 57% of males reported genitals as their primary insecurity [28]. The skin is one of the main areas of concern in BDD patients, and it has been found that 11.9% of dermatology patients have BDD [29]. About half of BDD patients are thought to have visited a dermatologist at some point, and one of their most common concerns is often related to their skin and acne vulgaris specifically [30]. Patients will often come to dermatologic practices with concerns about acne vulgaris, pigmentations, and vascular lesions and will many times insist that the doctor use harsh treatments, including oral isotretinoin therapy and laser abrasions. In a sample of 250 patients, 35% of treatments requested by patients were not performed as they were considered medically unnecessary by a physician [31]. Similarly, in men, muscle mass is a common area of concern, and BDD in male patients may often manifest as thinking that they do not have adequate muscle or “muscle dysmorphia” when oftentimes men with BDD are typically very muscular [32]. This leads these individuals to engage in behaviors such as overexercising and sticking to extreme diets as a means to build muscle. Similarly, dietary supplements and anabolic steroids are often used by males with muscle dysmorphia [33]. A high rate of substance abuse has also been found in these individuals.

The quality of life of individuals with BDD is severely impacted by a fixation on their perceived imperfections and the thoughts and behaviors that are involved with it. The fixations that BDD patients develop are often very troubling and difficult to repress, similar to the obsessive thoughts experienced by patients with OCD [27]. Behaviors exhibited by BDD patients may also resemble those in OCD patients and may include things like seeking reassurance, skin picking, camouflaging, and frequently checking mirrors [34]. Individuals with BDD are often unable to be in relationships or to attend school or work [27]. In a study conducted on BDD patients, 38% of participants were currently unemployed [35]. Those who were not currently employed experienced more severe BDD symptoms as well as depressive symptoms [36].

A person's preoccupation with a part of their appearance that they view as inadequate can be extremely time‐consuming. In a study comparing obsessive‐compulsive disorder and body dysmorphic disorder, those with BDD typically spent an average of 3 to 8 h per day thinking about their appearance [37]. In a study evaluating the quality of life in undergraduate students with BDD symptoms, depression had the most substantial impact on students' quality of life, suggesting that it may be a significant comorbidity of the disorder.

Physicians may find it challenging to approach speaking to BDD patients since there are instances in which these patients may become violent or take measures like suing their doctor if they do not provide the requested treatment [28]. Telling patients that their concern is not valid or trying to get them to stop a particular behavior, such as checking or skin picking, is generally ineffective, even if patients do not respond in extreme ways [29]. This is why physicians must employ empathy when speaking with these patients and make them feel heard without agreeing that they have the flaws they say they do.

Rather than focusing on physical concerns, physicians should focus on how these patients are affected by their concerns and the treatment options available that may improve their quality of life [28]. Additionally, physicians should make sure to inform patients of the potential side effects of any drugs that may be available [38].

Body dysmorphic disorder may have a variety of causes, from genetic inheritance to personality traits that make one more likely to develop the disorder [39]. Approximately 20% of patients with BDD have a first‐degree relative who also has it [39]. With regard to personality traits, narcissistic and obsessional traits, as well as qualities such as perfectionism, introversion, and sensitivity, have been associated with BDD [40]. Additionally, 37.6% of BDD patients have said that a stressful event triggered the onset of their BDD [41]. These triggering events were often interpersonal and usually occurred during elementary or grade school [41]. They were most frequently bullying events, including events where a specific cultural standard of beauty was perpetuated [41]. Similarly, the increased use of social media in society may contribute to unrealistic beauty standards that cause anxiety and obsession with one's appearance [42]. Due to the fact that filters are often used, and photographs are frequently edited, people are exposed to unrealistic images that make them adopt an impractical standard of what is considered ‘attractive’ [23]. People may critique themselves more harshly or develop insecurities that might otherwise not be there due to consistently viewing these photos on social media.

Comorbidities that have been associated with BDD include social phobia, major depressive disorder, and substance use disorder [43]. A study on a sample of BDD patients found that participants had an average of more than 2 lifetime comorbid axis I disorders [44]. Suicidal ideation has also been found to be prevalent in BDD patients, and 22% of BDD patients have attempted suicide [43]. The rates of attempted suicide in individuals with BDD range from 2.6% to 62.5% [45]. Accordingly, those with BDD and active suicidal ideation or behavior may merit inpatient hospitalization [8].

6. Diagnosis

Body dysmorphic disorder may be difficult to diagnose as patients may not be open about certain behaviors they are engaging in due to embarrassment. However, since these patients often pursue dermatologic and cosmetic treatment rather than psychiatric approaches for their bodily concerns, it is up to physicians to be aware of potential signs of BDD [46]. Physicians must keep in mind that BDD patients may purposely try to hide the reality of the symptoms they are experiencing in order to get their intended treatment [39]. Using common clinical features of BDD patients, physicians should be able to recognize common behaviors and emotions displayed by individuals with BDD.

Signs of BDD that may be more recognizable to doctors may include excessive concern about extremely minor or nonexistent imperfections, issues in social or work settings, and being continually frustrated with different dermatologists and plastic surgeons' recommendations or proposed treatments [39]. Additionally, suppose patients approach physicians with photos of others from social media or filtered photographs of themselves and express their desire to look a certain way. In that case, this may be a possible sign of body dysmorphic disorder [47, 48, 49]. Patients may be given a BDD questionnaire to fill out themselves or may be interviewed [39]. Using a questionnaire with questions about social media use may be beneficial in the current age, but no such survey has been created for widespread use [39]. At present, five screening tools have been validated for use in aesthetic dermatological settings: BDD (Self‐Report) Questionnaire (BDDQ), BDD (Self‐Report) Questionnaire Dermatology Version (BDDQ‐DV), The Dysmorphic Concern (Self‐Report) Questionnaire (DCQ), BDD (Self‐Report) Questionnaire Aesthetic Surgery (BDDQ‐AS), and the Cosmetic Procedure Screening Questionnaire (COPS) [48].

7. Prognosis

Body dysmorphic disorder typically begins in childhood or adolescence, with the average age of onset being 16.7 years [35]. Most cases of BDD have been shown to be chronic (82%) and last an average of 15.7 years [35]. BDD can have detrimental effects on just about every part of a person's mental health and functioning, including schooling and relationships [14]. If BDD is untreated, it can potentially lead patients to attempt suicide, as 45%–70% of patients report experiencing suicidal ideation as a result of BDD [14]. The majority of patients benefit from pharmacotherapeutic treatments like SSRIs, and more significantly from CBT, over the course of months or even years [14].

8. Treatment

BDD is a treatable psychiatric disorder. Physicians must emphasize the need for psychiatric treatment for BDD patients, which may be difficult considering they are often resistant to such treatment [36]. Nonpsychiatric medical treatments such as lip injections, isotretinoin, and dermabrasion often proved ineffective at alleviating BDD, with 91% of patients experiencing no change in their BDD symptoms [50]. Similarly, if medical procedures are performed, they may not only exacerbate symptoms but may also expose the patients to unnecessary risks associated with these procedures [51].

Effective treatments for BDD include serotonin‐reuptake inhibitors (SRIs), selective serotonin‐reuptake inhibitors (SSRIs), and cognitive‐behavioral therapy (CBT) [10]. In a study by Krebs et al. [52] on the long‐term symptom progression of adolescents with BDD after undergoing CBT, a marked reduction in BDD symptoms was found, and improvements were shown in all secondary outcome measures (such as global functioning, depressive symptoms, and quality of life) after 12 months. When patients who fully believed that their self‐perception of their appearance was correct (“delusional” BDD patients) were given SRI monotherapy, they were found to improve significantly [53]. Treatment with fluoxetine, an SRI, was found to significantly improve BDD symptoms (53%) when compared to placebo (18%) [53]. The SRI clomipramine was also found to be highly effective, even more so for delusional BDD patients than for nondelusional patients [54]. In a study that compared clomipramine to desipramine, a non‐SRI antidepressant, clomipramine was more effective than desipramine in improving functional disability and BDD symptoms [54]. Overall, SSRIs have been found to be the most effective medications for BDD, and most BDD patients have improved while being on them.

For milder cases of BDD, treatment with solely CBT or SSRIs may be successful [46]. For moderate or severe cases of BDD, however, pharmacotherapy may be necessary to allow therapeutic treatments such as CBT to work and also to prevent extreme symptoms of BDD such as suicidal ideation [55]. BDD symptoms need to be recognized rather than solely the depressive symptoms associated with the disorder, as BDD treatment requires a higher dose of SSRIs to be effective. Since BDD is a chronic disorder, long‐term treatment and symptom management are extremely important. SSRIs should be tapered off rather than abruptly discontinued, as there is a high rate of relapse (84%) [7]. Similarly, a study from Ipser et al. [7] found that there was a low relapse rate after a trial of CBT and suggested that there may be lower relapse rates associated with CBT than SSRIs. Treatment with medication (mainly SSRIs) in addition to CBT showed improvements similar to the level of treatment with only CBT, suggesting that CBT may be a compelling enough treatment for BDD on its own. Similarly, a study was done in which BDD patients were placed in either a maintenance group involving education on topics such as relapses, changes in symptoms, and symptom management or a control group [56]. The maintenance group showed the lowest rate of relapse and better symptom management after 2 years, suggesting that this may be the best way for BDD patients to wean off CBT.

Although SSRIs can help treat BDD, they may also lead to the development of cutaneous side effects that may be unsightly and sometimes dangerous, which may cause further psychiatric distress in BDD patients [56, 57, 58]. These cutaneous reactions may include petechiae, angioedema, alopecia (telogen effluvium), ecchymoses, Stevens–Johnson syndrome, spontaneous bruising, erythema nodosum, and toxic epidermal necrolysis. Additionally, when patients taking SSRIs are exposed to UV radiation, there may be adverse reactions. These include phototoxic reactions such as photodermatitis or urticaria on exposed areas such as the neck, face, and back of the hands. However, SSRIs are generally well tolerated, with minimal side effects.

Further research on treatment for BDD is needed, especially with regard to present‐day social media use. Eating disorders are often comorbid with body dysmorphic disorder, with one‐third of BDD sufferers having an eating disorder in their lifetime [59]. It has been found that increased time spent on social networking sites, such as Snapchat and Instagram, was related to greater concerns about body image and disordered eating [60]. It has been recently documented that internet‐based cognitive‐behavioral therapy can be effective, especially when combined with medication. Long‐term remission rates following cognitive‐behavioral therapy for BDD require further evaluation [61].

Conflicts of Interest

The authors declare no conflicts of interest.