Session Fifteen (Body Dysmorphic Disorders) Flashcards
What are the “OCD-related disorders”?
A group of conditions, including OCD, which are classified together based on clinical utility.
Common phenomena = Tendency towards repetitive behaviours and failure to inhibit these behaviours
Include:
- OCD
- Hoarding Disorder
- Body Dysmorphic Disorder
- Skin-picking
- Trichotillomania
- Hypochondriasis
- Olfactory Reference Disorder
What are the main arguments for and against classifying BDD as an OCD-related condition?
Pros:
- Helps with primary care diagnosis and referral to group things together in this way
- Increases awareness of lesser known problems
- Many shared characteristics
- Many shared treatment pathways (SSRIs)
Cons:
- Some argue form (i.e. what the patient does in their compulsion) shouldn’t take importance over function (i.e. why the patient does it). Vital differences within this grouping, OCD is for verification/fear but trichotillomania is motivated by under stimulation
- Many OCD-RCs have more in common with the anxiety conditions than with OCD itself
- Incorrect to assert that similar treatment responses means shared features, SSRIs work in lots and lots of things
- Grouping conditions together forces clinicians to focus on a diagnosis, when it might be more beneficial to focus on disease processes instead (e.g. avoidance, rumination, comparison….)
What is Body Dysmorphic Disorder?
- Preoccupation with imagined ugliness, which can cause intense shame and even lead to self harm or suicide
- Subjective feeling of ugliness or physical defect which the patient feels is noticeable to others
- Condition exists on a spectrum, doubt to delusions (where doubt is constantly thinking maybe you look ugly but delusions is being convinced of it)
How common is BDD?
- Approx 1 / 50 teenagers in the UK
- Although difficult to judge properly as exists on a spectrum with normal teenage self-doubt
- 2% in community
- 5% in psych in-patient unit
- Makes up about 10% of cosmetic surgery patients
Why can BDD be difficult to treat?
- Stigma
- Low levels of awareness amongst community and health practitioners
- Tend to present to dermatologist or cosmetic surgeon not psychiatrist
- Patients have a tendency to be secretive over their condition
- Often treated inappropriately (e.g. given anti-psychotics)
Who gets BDD more often, men or women?
Equal, although women present far more often.
What is a normal disease course for BDD?
- Onset during adolescence
- 10-15 year gap before seeking treatment
- Equal sex ratio
- Commonly have co-morbidities such as depression, social phobia or OCD
- Many will attempt suicide at some point (25%, 0.3% successful)
What are the DSM5 diagnostic criteria for BDD? (long answer)
1) Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others
2) At some point during the course of the disorder, the individual has performed repetitive behaviours (e.g. mirror checking, skin picking, excessive grooming) or mental acts (e.g. comparing appearance to that of others) in response to their appearance concerns
3) Preoccupation causes significant clinical distress OR impairment in social/occupational areas of functioning
4) Preoccupation is not better accounted for by concerns with body fat or weight in an individual who meets diagnostic criteria for an eating disorder
What are the DSM5 diagnostic criteria for BDD? (short answer)
1) Preoccupation with perceived defect/flaw which others don’t see
2) Displays repetitive behaviours or acts in response to these perceived defects
3) Causes significant distress/ impairment in functioning
4) Not better explained by an eating disorder
When DSM says “must cause significant distress or impairment in functioning”, give some examples of what they mean?
Distress =
- Depressed mood
- Anxiety
- Shame
Impairments in functioning =
- Avoidance behaviours
- Effects on social life
- School, relationship, household
What conditions overlap with BDD significantly?
Eating disorders:
- Can have both
- But must be careful to not misdiagnose ED as BDD
Muscle Dysmorphia:
- Part of BDD
- People think they’re light weight babies
Why is BDD so handicapping?
- Causes people to avoid any social and public activities
- Creates relationship difficulties that often lead the sufferer to be single or in unhealthy relationships
- Employment difficulties
- Can interfere with education
- Debt from cosmetic procedures
- Housebound or severe avoidance
- Can cause hospitalisation
- Suicide attempts
What avoidance behaviours are commonly seen in individuals with BDD?
- Avoid social situations altogether
- Use clothes or hair to hide perceived defect
- Maintain certain postures
- Excessive make up use
How significant is the heterogeneity seen in BDD?
Very significant
- Some present with a focus on external shame e.g. social anxiety, fear of negative evaluation by others
- Others present with internal shame e.g. depression and self-disgust
- Many present with primarily Obsessive Compulsive symptoms e.g. everything about them must be symmetrical
- Can get paranoid psychosis symptoms
- Excoriation (skin picking)
- Borderline
- Muscle dysmorphia symptoms
- Sub-clinical eating disorder
What is the link between BDD and Depression?
- Frequent co-morbidity
- Driven by internal shame or disgust, hopelessness of altering appearance in the way they’d like
- Typically develops after the onset of BDD (although can occur in recurrent depression)
CRUCIAL: Assess suicide risk
What is the link between BDD and Borderline Personality?
- High prevalence of BDD within BPD
- Unclear whether this is BDD as we understand it or merely a part of this patients BPD
- Very difficult to treat
Approach involves two key questions:
- Which is the main problem that requires help first
- Will borderline features interfere in therapy
What is Body Integrity Disorder?
- Condition where patients feel a limb doesn’t belong to them
- Nothing really to do with BDD
- Potentially a reverse of the processes seen in phantom limb syndrome; have the limb but do not have proprioception feeling telling you its yours
- Very rare
What screening questions should be asked to look for BDD?
- Routine history
- Especially ask for depression, substance abuse, social phobia, OCD
- Surgical history
“Some people are very bothered by the way they look, is this a problem you deal with?”
If someone appears to screen positive for BDD, what follow up questions can be asked?
- What concerns do you have about your appearance (get into specifics)
- On a typical day, how many hours is your appearance at the forefront of your mind
- Is this very distressing to you
- How do you cope with these feelings
- Do you have difficulty with eye contact
- Does it interfere with your ability to study or work
- Does it interfere with your dating or relationship life
- Does it interfere in your social life
What observations in a patient might be suggestive of BDD?
- Wears a hat, sunglasses, scarf, baggy clothes to cover themselves up
- Visible piercing or tattoo
- Heavy make up
- Shaved head
- Long hair to hide their face
- Does the person sit in a peculiar way (so as to hide their bad side)
- Difficulty with eye contact
- Scars from skin picking
What defects do people with BDD most commonly feel they deal with?
Frequently multiple of:
- Thinning hair
- Too much hair
- Acne
- Greasy
- Open pores
- Cysts
- Wrinkles
- Scars
- Pale
- Asymmetrical
- Too masculine or feminine
Commonly entered around the face (nose, skin, hair, eyes, teeth, lips, chin…)
How does BDD affect kids/teenagers differently?
- Similar to adults but exists on more of a continuum from normal adolescence
- Beliefs tend to be more delusional
- Teens have higher lifetime rate of suicide
- Handicaps include school refusal, family discord, social isolation
What role does imagery play in BDD?
Osman et al (2004):
- Compared imagery in 18 BDD patients and 18 controls
- BDD patient imagery was more vivid, recurrent, distorted
- Viewed themselves predominantly from an outside perspective
- Define themselves as an aesthetic object
- Associated with early memories (e.g. teasing, bullying)
When asked to draw themselves, drew almost caricatures of what they really look like.
What cognitive behavioural factors influence the way individuals with BDD think?
- Extreme self-consciousness an self-focused attention on constructed body image
- View themselves from an observer perspective
- Loss of rose tinted glasses
- Attentional bias away form overall appearance and onto specific features/defects
- Idealised values concerning the importance of appearance
- Define the self as an aesthetic object
- Over-comparison to others
- Rumination
- Various avoidance and safety seeking behaviours develop
What avoidance/safety-seeking behaviours occur in BDD?
- Mirror gazing or avoiding
- Checking, inspecting, measuring
- Comparing self with others or old photos
- Grooming, combing, smoothening, straightening, plucking or cutting hair
- Skin cleaning, picking, face peels, bleaching
- Trying to convince others that defect is real and exists
- Facial exercises
- Cosmetic procedures
- Seek dermatological interventions
Broad aim = to monitor, camouflage or enhance certain features about themselves
What are some known risk factors for BDD?
- Real dermatological problem or physical stigmata
- History of teasing/bullying about their appearance
- Naturally increased aesthetic sensitivity
- Family/cultural factors (more common in cultures with a heavy influence on appearance)
- Genetic predisposition
- Shyness, perfectionism, anxious temperament
- Childhood adversity (poor attachment, peer relationships, social isolation…)
What did Veale et al’s 2014 study into penis size teach us about what potentially could cause a person to develop BDD?
- Looked into men who had BDD associated with their penis size
- Reported high levels of stigma, isolation
- Sought help on the internet through things such as enhancers
Compared risk factors amongst men with small dicks who did and did not develop the condition, found;
- Abuse and neglect
- Teasing in history
- Smaller penis length
- Older
- Higher BMI
to be factors associated with the development of BDD
Teaching about penis size could act as a protective factor
