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Body dysmorphic disorder

The drive for perfection

Perkins, Amanda, DNP, RN

doi: 10.1097/01.NURSE.0000553273.24557.58
Feature: CE Connection
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Abstract: Body dysmorphic disorder (BDD) is an obsessive-compulsive and related disorder that pushes people toward perfection, affecting 5 to 7.5 million people in the US. Individuals with BDD spend a great deal of time focusing on perceived flaws and ways in which to hide these flaws. The time spent on these negative thoughts can interfere with quality of life and the ability to carry out daily tasks. This article discusses BDD, including symptoms, diagnosis, treatment, complications, and the nurse's role.

People with this body image disorder spend a great deal of time focusing on their perceived physical flaws. Time spent on negative thoughts can significantly interfere with their quality of life. This article discusses the nurse's role in assessing the disorder and helping patients cope.

Amanda Perkins is an assistant professor of nursing at Vermont Tech in Randolph, Vt.

This article originally appeared in the January/February 2019 issue of Nursing made Incredibly Easy!.

The author and planners have disclosed no potential conflicts of interest, financial or otherwise.

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EVERYTHING AROUND US focuses on beauty, from commercials to magazines, social media to movies. Already beautiful models are airbrushed to make them look “perfect” in a way that is unattainable. People can easily apply filters to their selfies, removing even the slightest imperfections. In this way, our society reinforces the need to be beautiful.1

Body dysmorphic disorder (BDD) is a body image disorder that pushes people toward perfection, affecting approximately 1 out of 50 people, or 5 to 7.5 million people in the US, according to the Anxiety and Depression Association of America (ADAA).2,3 Individuals who have BDD spend a great deal of time focusing on perceived flaws and ways in which to hide these flaws.2 The time spent on these negative thoughts can consume most of the day, interfering with quality of life and the ability to carry out daily tasks.

This article discusses BDD, including signs and symptoms, diagnosis, treatment, complications, and the nurse's role.

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The basics

BDD is newly classified as an obsessive-compulsive and related disorder.4 According to ADAA, it tends to affect both men and women equally.2 At this time, no cause has been identified, but it is believed that genetics, serotonin malfunction, personality traits, and life experiences such as abuse or trauma may play a role.2,5 It is also thought that stressors during adolescence may influence the development of BDD.5

In many cases, BDD develops during the adolescent years, typically between ages 12 and 13.2 This can be a challenging time when the peer group takes center stage. Adolescents often place emphasis on peer acceptance. It is common for adolescents to focus on their appearance and worry about how their peer group perceives them. For patients with BDD, this goes beyond the typical adolescent worries over appearance, reaching unhealthy levels.

Individuals with BDD are hyperfocused on perceived flaws, which often go unnoticed by others.5 The most common areas that patients with BDD focus on are their hair, skin, nose, chest, eyes, lips, and/or stomach, although they can focus on any area(s) of the body.2,5 These patients may worry about symmetry, size, and shape.

Patients with BDD become so focused on their perceived flaws that they feel threatened by them.1 These patients cannot control their negative thoughts, despite a desire to do so, leading to significant distress and impairment in functioning.2,6 In fact, many patients with BDD feel as if they are defined by their perceived flaw(s).5 Beliefs about appearance and perceived flaws can become so significant that they reach a delusional level.7 Over time, these individuals can become socially isolated, afraid to leave their home for fear of being seen, judged, and/or ridiculed by others. In some instances, individuals may become hyperfocused on someone else, such as a family member (see BDD by proxy).

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Snapchat dysmorphia

It is becoming more common for patients to ask plastic surgeons to surgically alter them so that they resemble Snapchat filters.8 Snapchat is a social media app in which pictures and messages are available for others to view for only a short time. Patients bring heavily edited selfies that have had a filter applied and ask surgeons to give them the look from the selfie.9 This phenomenon has been referred to as Snapchat dysmorphia.8

Selfies are often a driving force behind requests for surgery, with patients wanting surgery to look better in selfies.9 In individuals between ages 16 and 25, the need for a perfect selfie is so persistent that they spend an average of 16 minutes and 7 attempts to take an acceptable selfie.10

Social media filters, paired with an overabundance of selfies, alter a person's perception of beauty and may trigger BDD.8 At this time, anyone with a smartphone, tablet, or computer can use filters or editing tools to remove imperfections in their appearance, almost instantly. Many people love this ability to change their appearance instantaneously because we live in a society that places emphasis on instant gratification. Due to this need, many patients requesting plastic surgery expect things to happen quickly, which is typically an unrealistic expectation.9

In many cases, cosmetic procedures cannot reproduce the look created by these filters and editing tools because these filters portray an image that is surgically unattainable.8,9

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Signs and symptoms

Patients' signs and symptoms depend on the degree of BDD.3 In milder cases, patients may describe themselves as unattractive, whereas those with severe BDD may describe themselves as monstrous.3 Individuals who have BDD can experience severe distress and, for some, signs and symptoms may be significant.5 It is unknown how or why symptoms progress over time, but the main symptom associated with BDD is obsessive thoughts about appearance.2,6 These individuals will spend hours each day focusing on the flaws they have identified.2 In general, these individuals will have low self-esteem, a tendency to avoid social situations, and problems with work and/or school.2,5

The following compulsive or repetitive behaviors are also commonly seen in patients with BDD:

  • camouflaging
  • comparing themselves to others
  • seeking surgery
  • checking their appearance in a mirror
  • skin picking
  • excessive grooming
  • excessive exercise
  • frequently changing clothes
  • excessive tanning
  • excessive shopping.2,3

Camouflaging involves the use of makeup to cover flaws, repetitively fixing clothing or using clothing to hide body parts, and/or covering body parts with the hand.3 Excessive shopping may be concomitant with camouflaging and can lead to financial difficulties.

Patients with BDD frequently compare themselves to others. Additionally, individuals with BDD may frequently ask others if they look okay or they may persistently insist that they are ugly or unattractive, which can lead to strained relationships.3 Some patients are drawn to mirrors and will excessively check on their perceived flaw(s).5 Excessive grooming may be seen as vain by those who are associated with the patient.3 Individuals who excessively exercise or lift weights may have a type of BDD known as muscle dysmorphia (see More about muscle dysmorphia).3

Patients with BDD report feelings of shame, self-disgust, hopelessness, depression, anger, and anxiety.5,7 These individuals worry excessively about their appearance, reporting shame associated with the way they look.5 They also tend to fear rejection or humiliation.5 They may feel hopeless and distressed, which can escalate into suicidal ideation.1

For many of these patients, plastic surgery feels like the solution to the way they perceive themselves. Although they feel that surgery is their best option, plastic surgery often leads to increased distress. In many cases, patients with BDD who undergo surgery are not satisfied with the results, causing them to feel like they need additional surgery, or they will begin to focus on other areas of their body that they would like fixed.1,10 Another concern is that some patients will become addicted to surgery. It is important to prevent unnecessary surgery for these individuals because cosmetic treatment has been associated with negative outcomes.11

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Diagnosis

The typical patient with BDD will suffer in silence for 10 years before seeking assistance and receiving the diagnosis of BDD.5 Asking these patients if they worry about minimal or nonexistent flaws is not a beneficial diagnostic tool.12 Their poor insight can lead to a resistance in acceptance of the diagnosis and/or treatment.12 In addition to individuals with BDD failing to seek treatment, awareness of this disorder is lacking among healthcare professionals and the public, leading to delays in diagnosis.6 In many instances, this disorder is missed or misdiagnosed.6

Patients with BDD may be misdiagnosed as having:

  • obsessive-compulsive disorder (OCD)
  • social anxiety disorder
  • major depressive disorder
  • trichotillomania (hair-pulling disorder)
  • excoriation disorder (skin-picking disorder)
  • agoraphobia
  • generalized anxiety disorder
  • schizophrenia and schizoaffective disorder
  • olfactory reference syndrome (preoccupation with smelling bad)
  • eating disorder.12

Many patients with BDD are hesitant to discuss their thoughts and/or feelings because they are ashamed or embarrassed, making diagnosis a challenge.6 When clinicians are diagnosing a patient with BDD, they use the following criteria from the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, 5th edition:

  • appearance preoccupations
  • repetitive behaviors
  • clinical significance
  • differentiation from an eating disorder.12

Diagnosis depends on various factors, one of which is the amount of time spent focusing on perceived flaws.3 Patients diagnosed with BDD must spend at least 1 hour per day focusing on their perceived flaws.3 Although diagnosis hinges on a minimum of 1 hour per day focusing on flaws, many patients with BDD will spend 3 to 8 hours per day focusing on these flaws. The clinician diagnosing the patient with BDD will determine if he or she has repetitive behaviors, such as frequently applying makeup throughout the day.12 It is also important for clinicians working with these patients to determine if the “flaw” is easily visible.12 The clinician should determine if the symptoms affect the patient in a clinically significant way; for example, do the symptoms affect the patient's ability to work or go to school?

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Treatment

When treating patients with BDD, it is preferable to start treatment early before negative thoughts take hold.10

CBT may be used as a treatment option for patients with BDD. The goal of CBT for these patients is the identification and recognition of unhealthy thoughts and then changing those thoughts.2 The patient learns to replace negative ways of thinking with positive ones. When patients use CBT, they are learning new ways to think about themselves. CBT has been shown to assist in the reduction of symptoms for patients with BDD.11 Studies have shown that CBT improves depressive symptoms, insight, quality of life, and global functioning. Research has shown that CBT is beneficial to patients with BDD in the short term, but more research needs to be conducted to determine its long-term effects.11

In some cases, antianxiety and antidepressant medications may be prescribed.1 Thoroughly explain the medication to the patient, including the reason for use, potential adverse reactions, and how to take the medication. Monitor the patient for adverse reactions. Educate patients about the importance of taking all medications as prescribed. Treatment also involves assisting patients to be flexible with their thinking to help them learn to tolerate their anxiety until it lessens.1

It is important to be compassionate, patient, and flexible.7 The development of a strong, therapeutic relationship with the patient should take priority. If a strong relationship is not developed, the patient may not respond appropriately to treatment. Help the patient identify his or her personal reasons for wanting to change.7 When doing this, it may be important to help the patient determine how BDD has impacted his or her life.7 The perceived flaws threaten these patients' sense of self-worth as human beings and cause them to feel uncomfortable in their body.1 BDD can lead to negative impacts on emotional, educational, and social functioning.11 Determining and developing the patient's level of insight will help guide care.

In more severe cases, the patient with BDD may require psychiatric hospitalization.13 Nursing care of the patient in the psychiatric hospital depends on organizational policies and procedures. Regardless of whether the patient is hospitalized, treatment by a mental health professional is important for the patient with BDD.13 When patients are being cared for by mental health professionals, encourage them to attend all treatment sessions because missed sessions can lead to a return or worsening of symptoms.

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Complications

Maintaining employment and/or going to school can be a challenge for the individual with BDD.5 When these patients attempt to go to school or work, they may have trouble concentrating, spending much of their time focusing on their flaws or worrying about what others think about these flaws.1 They may spend hours researching surgeries and the best ways to cover up their flaws.1 In some cases, these patients may become housebound.5 Social anxiety can take hold, causing these individuals to avoid social situations due to worry over other people seeing their flaw(s).3 They start to believe that others are looking at them and talking about them.3 This can lead to difficulty forming or maintaining relationships, which may be strained due to the frequent need to seek reassurance from others and the mismatch between how others see the person with BDD and how the person views him- or herself.5

Often, the patient with BDD will also experience anxiety disorders, depression, eating disorders, and/or OCD.2 In some instances, the patient with BDD may be misdiagnosed with one of these disorders due to an overlap of signs and symptoms.2 Additionally, patients with BDD have an increased risk of both attempted and completed suicide.5 Approximately 80% of patients with BDD report suicidal thoughts and as many as one-fourth of these patients will attempt suicide.12 It is essential to assess these patients for suicidal ideation and treat them accordingly.

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Shining a light

BDD is a hidden disorder, with many patients not seeking assistance, often unaware that they have a treatable condition.5 Nurses can help bring attention to BDD by educating about it, providing support and encouragement to patients with BDD, and conducting research to gain a better understanding of the disorder.5 Through research, nurses can greatly impact the future of patients with BDD.

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BDD by proxy14

BDD by proxy is a type of BDD in which the patient is hyperfocused on another person, such as a family member, friend, or even a stranger. These individuals worry excessively about another person's appearance. The excessive worry can negatively impact their daily lives and lead to a decreased quality of life. Treatment for these patients is the same as treatment for the patient with BDD.

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More about muscle dysmorphia15

Muscle dysmorphia is a type of BDD in which the patient is preoccupied with his or her body build. This type of BDD is seen more often in men than women. These individuals worry about being weak and, as a result, may spend an excessive amount of time exercising. This condition is associated with increased rates of suicidality and substance abuse, and reports of a poor quality of life. Treatment for muscle dysmorphia is the same as for BDD and includes cognitive-behavioral therapy (CBT) as the treatment of choice.

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On the web

Anxiety and Depression Association of Americawww.adaa.org/understanding-anxiety/related-illnesses/other-related-conditions/body-dysmorphic-disorder-bdd

Body Dysmorphic Disorder Foundationhttps://bddfoundation.org

International OCD Foundationhttps://bdd.iocdf.org

Mayo Clinicwww.mayoclinic.org/diseases-conditions/body-dysmorphic-disorder/symptoms-causes/syc-20353938

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REFERENCES

1. Ehmke R. What is body dysmorphic disorder? Child Mind Institute. https://childmind.org/article/body-dysmorphic-disorder.
3. Phillips K. Signs and symptoms of BDD. International OCD Foundation. https://bdd.iocdf.org/professionals/signs-symptoms.
4. Schneider SC, Baillie AJ, Mond J, Turner CM, Hudson JL. The classification of body dysmorphic disorder symptoms in male and female adolescents. J Affect Disord. 2018;225:429–437.
5. Body Dysmorphic Disorder Foundation. About BDD. https://bddfoundation.org/helping-you/about-bdd.
6. International OCD Foundation. About BDD for professionals. https://bdd.iocdf.org/professionals.
7. Khemlani-Patel S. Motivating people with BDD to participate in treatment. International OCD Foundation. https://bdd.iocdf.org/professionals/motivation.
8. Welch A. “Snapchat dysmorphia:” Selfies, photo filters driving people to plastic surgery, doctors say. CBS News. 2018. http://www.cbsnews.com/news/snapchat-dysmorphia-selfies-driving-people-to-plastic-surgery-doctors-warn.
9. Chiu A. Patients are desperate to resemble their doctored selfies. Plastic surgeons alarmed by ‘Snapchat dysmorphia.’ The Washington Post. 2018. http://www.washingtonpost.com/news/morning-mix/wp/2018/08/06/patients-are-desperate-to-resemble-their-doctored-selfies-plastic-surgeons-alarmed-by-snapchat-dysmorphia.
10. BBC News. The ‘ugly truth’ about body dysmorphic disorder. 2015. http://www.bbc.com/news/health-33190297.
11. Krebs G, de la Cruz LF, Monzani B, et al Long-term outcomes of cognitive-behavioral therapy for adolescent body dysmorphic disorder. Behav Ther. 2017;48(4):462–473.
12. Phillips K. Diagnosis and clinical assessment in BDD. International OCD Foundation. https://bdd.iocdf.org/professionals/diagnosis.
14. Massachusetts General Hospital OCD and Related Disorders Program. BDD by proxy. https://mghocd.org/clinical-services/bdd-by-proxy.
15. Silverman M. What is muscle dysmorphia? OCD & Related Disorders Program. 2011. https://mghocd.org/what-is-muscle-dysmorphia.
Keywords:

behavioral health; body dysmorphic disorder; dysmorphia; mental health; obsessive-compulsive disorder; social media

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