Body dysmorphic disorder in adolescence: Imagined ugliness
By Keith Brewster, PhD
Everyone experiences concerns about their physical appearance. This truth rings especially clear during adolescence. Some individuals, however, can become some so overly distressed, anxious, and fearful about their appearance that it begins to interfere with many aspects of their daily life (Phillips, 2004). These exaggerated fears, and the array of delusional thoughts and maladaptive behaviours that accompany them, may suggest the onset and development of a severe psychological condition known as body dysmorphic disorder (Reese et al., 2011).
Body dysmorphic disorder (BDD) is a devastating psychological condition that is all too often under recognized and misunderstood, specifically in the adolescent population (Buhlmann & Winter, 2011). As its name suggests, BDD is characterized by preoccupations with perceived bodily flaws and physical appearance. These flaws are often unwarranted, minimal, or nonexistent (Windheim et al., 2011). However, individuals with BDD genuinely believe that they are deformed in every sense of the word. As such, they tend to experience debilitating anxiety stemming from fears of deformity, inadequacy and judgments by others (Phillips, 2004).
The development and maintenance of BDD has major implications adolescent social development, adjustment, and transitioning (Phillips, 2004). Unfortunately, due to the nature of the symptomology, BDD often goes unnoticed and unrecognized amongst teachers, friends, family, and health care professionals alike (Buhlmann & Winter, 2011). Given its adverse effects on adolescent psychosocial functioning, understanding the intricacies of BDD is paramount in improving awareness, acceptance, and care.
BDD was first described in 1886 by Italian psychiatrist Enrico Morselli (Morselli, 1891). Initially coining the disorder “dysmorphophobia,” Morselli reported that patients experienced sudden fears of deformity and painful desperation (Phillips, 2001). Over the years, BDD has attracted the attention of some of the most prominent figures in psychology. In 1909, Emil Kraepelin described it as a mental malfunction leading to beautybased hypochondriasis (Kraepelin, 1909). Similarly, Sigmund Freud also encountered the disorder while treating a patient in the late 1930’s. Freud described his patient as being so preoccupied about his nose that he was unable to function outside of his obsessive thoughts (Gunsted, 2003). Despite its historical relevance, BDD was only officially recognized as a member of the somatoform disorders in the Diagnostic and Statistical Manual (DSM-III) in 1987 (Phillips, 2001). Although our understanding of BDD has grown considerably since the early work of Morselli, Kraepelin and Freud, many aspects of the disorder remain relatively unknown and understudied.
The onset of BDD typically begins in early adolescence although it has been shown to develop in mid-late childhood (Phillips, 2004). Although the clinical features of BDD may vary dependent on age of onset, the central theme of the disorder remains intact: Individuals maintain constant delusional obsessions centered on their physical appearance (Korkina, 1965; Phillips, 2001). Sufferers of BDD may describe themselves as unattractive, deformed, and even obese with little evidence to warrant such a label (Rosen et al., 1995). Typically, appearance concerns center on the head or facial area with special interest on skin tone, facial asymmetries, skin appearance, a misshapen nose, and hair loss (Buhlmann & Winter, 2011). Although the facial area has been the primary source of concern, adolescents with BDD have shown to extend their concerns to one or many other regions of the body, as well (Windheim et al, 2011).
The delusional preoccupations appear to be relatively difficult to inhibit or control in individuals with BDD. Dependent on symptom severity, individuals may spend between 2-8 hours a day focusing on or attempting to modify their appearance (Cotterill, 1996). In some cases, individuals may also engage in a series of behaviours aimed at examining or modifying their perceived flaws (Phillips, 2004). Such behaviours may include extreme levels and frequencies of mirror gazing, picture taking, grooming, make-up application, hairstyle changes, clothing changes, exercising, dieting, and grasping of the body (Phillips, 2001; Bohne, 2002; Cotterill, 1996).
Adolescents with BDD may also engage in a series of ritualistic maladaptive behaviours that are typically associated with extreme anxiety (Gunstad & Phillips, 2003). These behaviours may include body rocking, skin picking, lack of sleep, inability to focus, decreased appetite, lack of empathy, lethargy, selfassurance seeking, social withdrawal, aggressive outbursts, and suicidal ideation (Phillips, 2001, 2004). These behaviours also tend to be consistent with a variety other psychological disorders and conditions including social anxiety, depression, social phobia, obsessive compulsive disorder, eating disorders (anorexia nervosa, bulimia nervosa, and binge-eating), and a variety of personality disorders (Buhlmann & Winter, 2011; Hollander et al., 1989). These similarities can often mask the recognition of BDD in adolescents, further complicating the diagnostic process (Korkina, 1965).
In the DSM IV, BDD is classified as a somatoform disorder because of preoccupations with somatic complaints (Phillips, 201). As such, BDD is often compared to hypochrondriasis, another somatoform disorder, as both disorders are characterized by exaggerated beliefs (Cotterill, 1996). Although the two share similar traits, BDD is concerned with bodily appearances, whereas hypochondrias focuses on disease and illness (Buhlmann & Winter, 2011). BDD also has some overlap with a variety of eating disorders. In both disorders, individuals experience body image disturbances and participate in ritualistic behaviours aimed at improving appearance (Gunstad & Phillips, 2003). However, whereas individuals with BDD have several bodily preoccupations (hair, nose, skin, hands,), the preoccupations experienced by individuals with eating disorders are primarily centered on weight and body shape (Buhlmann & Winter, 2011).
Although BDD is primarily associated with delusional thought processes, it also affects psychosocial development and functioning. Adolescents with the disorder typically have trouble engaging, interacting, and empathizing with peers (Neziroglu et al., 2002). As they age, individuals also display marked deficiencies in the ability and desire to develop and maintain close friendships and intimate relationships (Phillips, 2000). These difficulties are believed to arise from increased fear of bodily persecution, feelings of shame, guilt, unworthiness, and embarrassment (Phillips, 1993). Adolescents with the disorder also tend to have poor insight into their disorder, failing to recognize that they suffer from a disorder at all (Rosen et al., 1995).
Although our understanding of BDD has greatly improved, a direct cause of BDD has yet to be found (Phillips, 2003). Rather, it is believed that a combination of multiple factors contributes the development and maintenance of the disorder (Phillips, 2000). Many experts attempt to describe the cause of BDD using a multi-faceted, biopsychosocial model. This approach cites a possible connection between multiple biological, psychological, and sociological factors as causation for BDD (Cotterill, 1996).
Biologically, a growing body of evidence suggests BDD may be caused by neurological anomalies (Bohne et al., 2002). Evidence of such has spawned primarily from research examining the high comorbidity between BDD and obsessive compulsive disorder (OCD). Said research has found structural differences in neural scans between OCD patients and healthy controls (Phillips et al., 1993). These abnormalities, found primarily in the limbic and basal ganglia regions, are believed to extend into the development of BDD (Phillips, 2002). However, the nature and direction of that relationship has yet to be elucidated.
Psychologically, research has also demonstrated a series of personality traits to be associated with the development and maintenance of BDD (Wilhelm et al., 1999). Specifically, insecure, sensitive, anxious, narcissistic, introverted, and schizoid personality traits are common among individuals (adolescents and adults) with BDD (Windheim et al., 2011). In a study conducted by Hollander (1993), 38% of BDD patients were shown to have comorbid personality disorders in addition to other psychological disorders (Hollander, 1993). Some researchers also believe that deficient cognitive processes may contribute to the development of BDD (Buhlmann & Winter, 2011). A study conducted by Buhlmann et al. (2002), outlined deficits in attention, visual processing, emotional recognition, and memory as possible causes for the disorder. Although these abnormalities influence perception, their effect on the delusional components of BDD remains highly debated.
Sociological factors are also believed to play a part in the development of adolescent BDD. Researchers argue that the cultural emphasis on beauty, specifically phenotypical beauty, promotes beauty based psychological disorders like BDD and eating disorders that are more common in today’s youth (Phillips, 2001). It is believed that adolescents continually exposed to “beautiful” people, typically through main stream media (television, internet, magazines), can negatively respond in two ways; (1) increase internal pressure aimed attaining similar features and/or (2) initiate feelings of self-doubt and inadequacy upon realizing that such features cannot be attained (Phillips, 2003).
Despite the common belief that BDD is a strictly Western phenomenon associated with females, the disorder is equally distributed across gender and culture (Phillips et al., 1996). Unlike other psychological disorders outlined in the DSM IV-TR (2000), there has yet to be a large epidemiological survey determining a precise measure of BDD prevalence in the general population (Phillips, 2004; Rosen 2003). Rather, studies from community samples suggest the general prevalence rate at between 0.7 and 1.1 % while rates in clinical samples are significantly elevated with reported rates of 2.2%, 4%, and 6% (Grant, 2001; Phillips, 1996).
One of the main difficulties in determining exact prevalence of BDD in adolescents in both community and clinical settings is its elevated rate of comorbidity (Phillips, 2003). As noted earlier, BDD tends to be highly correlated with a host of other psychological disorders and conditions (Phillips, 2004; Rosen, 1995). As such, the recognition and accurate diagnose of the disorder is often masked, thereby complicating prevalence estimates.
Although research remains relatively limited in BDD, the continuous administration of psychotropic drugs (antidepressants) and integration of cognitive behaviour therapy (CBT) appears to provide the best outcomes for individuals with BDD (Phillips, 2001, 2004; Willhelm, 1999). Selective serotonin reuptake inhibitors (SSRIs) are the most successful psychotropic drugs used to treat individuals with BDD, specifically those suffering from moderate-severe delusions (Phillips, 2004). Phillips et al. (1993) found that 58% of patients positively responded to SSRIs while only 5% responded to other pharmaceutical based medications. Although the administration of SSRIs has been moderately successful in the past, their usage in conjunction of psychotherapy, specifically CBT, is believed to be in the most effective form of treating individuals with BDD (Cromarty, 1995; McKay, 1999; Neziroglu, 1996; Willhelm, 1999).
CBT is designed to solve problems concerning dysfunctional behaviours and cognitive patterns through goal directed therapy (Neziroglu et al., 1996). CBT is described as cognitive restructuring as it seeks to change the negative thought patterns of individuals with a variety of disorders and mental illnesses (Reese and et al., 1995). In BDD, CBT may present multiple social scenarios in which individuals be forced to systematically expose their flaws without covering them up (Wilhelm et al., 1999). These exercises help reduce negative thought patterns and behaviours while providing reassurance that flaws are of little concern to themselves, and most importantly others around them (Cromarty et al.,1995).
BDD is a severe psychological condition that induces debilitating anxiety stemming primarily from bodily preoccupations (Phillips, 2001). The disorder has been shown to negatively affect the psychosocial functioning in all affected, specifically adolescents. Although the disorder is marked by delusional symptomolgy, it goes relatively unnoticed amongst teachers, friends, family, and health care professionals alike (Rosen, 1995). Given the sensitivity of the population primarily affected (adolescents), promoting the awareness understanding of the disorder, specifically school psychologists in educational settings, is integral in improving acceptance and care for adolescents with BDD.
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