Whether by means of television, newspapers or magazines, we are constantly presented with images of perfect faces and bodies. While maturing in such an environment, the impressionable adolescent develops a mental image of how the ideal man or woman should appear. Persons who become preoccupied with perfection often view themselves as imperfect and may develop a distorted picture of their own body and face. This perception can lead to unhealthy behaviors such as eating disorders and body dysmorphic disorder (BDD). Often, the primary care physician has the first opportunity to intervene with these patients.

Definitions and Etiology

Body image is defined as a mental picture of the size, shape and form of our body. It also describes our feelings about these physical characteristics. Body image is divided into the following two components: how we perceive the appearance of our body and our attitude toward our body. A significantly distorted perception of the body may lead to self-destructive behaviors aimed at improving the appearance of the body.

Three areas of concern involve body image distortion: neurologic disorders, in which patients exhibit a perception of their body (e.g., in neglect syndromes); eating disorders; and BDD.¹ Patients with BDD have an excessive preoccupation with a slight or imagined defect of a specific body part that results in impaired social, academic or occupational functioning.^2,3 BDD must be distinguished from eating disorders such as anorexia nervosa that involve a preoccupation with overall body shape and weight. Table 1^4–6 contrasts the features of BDD and eating disorders.

The proposed etiologies of BDD are primarily represented by psychologic and neurochemical hypotheses. Factors that may predispose persons to BDD include low self-esteem, critical parents and significant others, early childhood trauma and unconscious displacement of emotional conflict.^1,3,5,7–10 Patients seem to be at least partially responsive to medications that increase serotonin levels, indicating that neurochemical factors may include lower levels of serotonin.^11–13

Illustrative Cases

CASE 1

A 21-year-old woman in her senior year of college is so preoccupied with the shape of her thighs that every morning she stands in front of the mirror wondering if they look any thinner. Her morning ritual consists of staring into the mirror for an extended length of time while slapping her thighs with her hands in an unconscious effort to make them smaller or to make the fat she sees disappear. She asks her sorority sisters if her thighs are fat. Often, she fears appearing in public unless she is wearing loose slacks or long skirts that cover up her thighs. She believes that every pound she gains will show up on her thighs, while extra weight might not show up on the thighs of a taller person. She tells her physician that she has considered liposuction but cannot afford the procedure.

CASE 2

A 33-year-old woman is extremely preoccupied with the appearance of her nose. She has undergone an initial surgical reconstruction of her nose with three subsequent revisions, one resulting from a postoperative wound infection. She describes a daily preoccupation since adolescence with the shape and size of her nose. She notes that it is too large and quite ugly, despite reassurances to the contrary from her family and her personal physician. She tells her physician that she is seeking yet another surgery to “fix it.”

Clinical Manifestations

BDD is a chronic disorder that is equally common in men and women, and usually presents during adolescence and young adulthood. The average age of onset is 17 years.^{2–4,7,8,11,14}

Persons who have BDD are most often concerned with the following: skin imperfections, such as wrinkles, scars, acne and blemishes; hair (head or body hair, too much or too little); and facial features (e.g., a misshapen nose, overall shape, size and symmetry of a feature).^2,5,8,11 Such persons are preoccupied with their perceived “gross imperfection(s)” and may ask their primary care physician to correct the perceived defect, or they may seek referral to a dermatologist or plastic surgeon. In a British study,³ 62 percent of patients with BDD had discussed their symptoms with their primary care physician. Of the patients in the study, 48 percent had seen a cosmetic surgeon or dermatologist at least once, and 26 percent had undergone at least one operation.³ About 2 to 7 percent of persons who have undergone plastic surgery have BDD.^14,15

Subsyndromal BDD occurs when patients have an excessive preoccupation with a particular feature, but they have not yet sought help to fix the perceived defect and their social, academic or occupational functioning has not yet been affected. Subsyndromal presentations of BDD may occur but, as yet, no cases or studies have reported the frequency of subsyndromal BDD.

Persons who have BDD spend many hours focusing on their physical features and engaging in repetitive and time-consuming behaviors, resulting in decreased social, academic and occupational functioning. They tend to avoid social interaction, spend countless hours checking their features in reflective surfaces, discover ways to camouflage the perceived defect, constantly seek reassurance from others that their defect is indeed present or is not so bad, and develop grooming behaviors to make the defect more presentable. Many are unable to stay in school, to maintain significant relationships or to keep steady jobs. Some may go so far as suicide.¹⁶ In a study of 100 patients with BDD, nearly one half had been hospitalized for a psychiatric condition, and 30 percent had made at least one suicide attempt.²

Some persons with BDD realize that their concerns may be exaggerated, while others lack such insight.^4,14,17–20 Approximately 50 percent of patients with BDD meet criteria in the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM–IV), for a delusional disorder, somatic type.^2,4,6 These delusional patients are convinced that their defect is real and believe that others view the defect as hideous or disgusting. Table 2 lists the psychiatric criteria in DMS–IV for the diagnosis of BDD.⁶ Psychiatric conditions, such as depression, anxiety and obsessive-compulsive disorder, that may further complicate BDD are listed in Table 3.^3,17,21,22

Treatment

Treatment approaches to BDD involve the use of therapeutic agents, principally selective serotonin reuptake inhibitors (SSRIs)^{2,11–13,23,24} and cognitive-behavioral psychotherapy.²⁵ Three retrospective studies demonstrated improvement of BDD with the use of SSRIs.^2,11,23 These results lead to speculation that the etiology of BDD is related to poor regulation and depletion of serotonin, although altered serotonin physiology may be either a consequence or a marker of this disorder. Two prospective studies that used open-label SSRIs demonstrated clinical efficacy, including decreased preoccupation with the perceived defect, decreased ritualistic behavior, improved insight, and improved social, academic and occupation functioning.^11,24

Dosages of SSRIs may need to be higher than those typically recommended for eating disorders.^2,11,24 For resolution of BDD, suggested dosages of SSRIs include the following ranges: fluvoxamine (Luvox), 200 to 250 mg per day; fluoxetine (Prozac), 40 to 80 mg per day; paroxetine (Paxil), 40 to 60 mg per day; or sertraline (Zoloft), 100 to 200 mg per day. Neuroleptics alone may not cure BDD but may be useful adjuncts to SSRIs in alleviating symptoms of BDD that are unresponsive to SSRIs alone.²

Because BDD by definition involves an “irrational” belief or conviction associated with considerable obsessiveness and anxiety, cognitive-behavioral psychotherapy may be beneficial. The false belief and obsession may respond to cognitive therapy. Aberrant social interaction and coexisting anxiety may respond to behavioral intervention. Cognitive-behavioral techniques were used in the situation and with imagery with response prevention to improve the symptoms of BDD in a study of 10 patients.²⁵ In this study, all 10 patients responded favorably to a six-week treatment program.²⁵

In another study, exposure therapy, thought stopping and relaxation resulted in significant clinical improvement in 22 of 27 patients with BDD who were treated with two-hour sessions of cognitive-behavioral therapy over eight weeks.²⁰

Clinical Implications in Primary Care

Awareness of BDD may assist the family physician in early detection. Patients may visit a family physician to seek referral to a dermatologist, plastic surgeon or otorhinolaryngologist to remedy a perceived defect when none is actually present. The family physician then has an opportunity to discuss the situation. These patients are highly anxious, and the first step in the discussion should be validation of the patient's concern. Next, the physician should seek additional information to determine the severity of the disorder.² A discussion about how much time and worry is devoted to the perceived defect will help. The physician should also ask what the patient has done to remedy the defect, and how the defect has altered the patient's social, academic or occupational activities (Table 4).²

Once the family physician is convinced that the patient has BDD, treatment options may be discussed in a positive way. Treatment may require normal or higher-than-normal dosages of an SSRI for at least a three-month trial period.^2,11 If one SSRI is ineffective, another may be tried with success.¹¹ The potential benefits of psychiatric or psychosocial referral may be discussed, although the family physician should not insist on referral because these patients may subsequently be lost to follow-up. A trusting, therapeutic relationship between patient and physician may bridge the gap and allay the patient's anxiety.