The types of disorders that the American Psychiatric Association places in this group are disorders that have aspects of dysfunctional behaviors that are also commonly seen in individuals without mental health disorders, but are expressed less rigidly and less intensely.
Body Dysmorphic Disorder
Anyone reading this article can most certainly find some feature about their physical body that they would like to change. Some individuals think their noses are a bit too big, and some people would like to lose some weight. Other individuals think they would look better with a different hair color, etc. Indeed, a number of businesses make millions and millions of dollars each year helping people to alter and change minor aspects of their appearance. In a number of cases, individuals become very focused on changing their appearance and may resort to surgically alternating their appearance, such as having plastic surgery, some type of weight loss surgery, hair transplants, etc. The vast number of individuals who engage in these actions do not have formal diagnosable psychiatric/psychological disorders.
There is a very small group of people who develop rigid fixations with perceived deficits in their physical appearance that are actually not considered to be flaws or defects by the vast majority of individuals in their culture, the medical profession, or other individuals who have nearly the same or similar appearances. A small proportion of these individuals may perform very repetitive and even dysfunctional behaviors associated with changing or altering these aspects of their appearance that are considered to be rigid, extreme, and potentially hazardous. These individuals may actually receive a diagnosis of body dysmorphic disorder (BDD) if their presentation meets certain diagnostic criteria.
The important thing to remember is that it is very common for individuals to believe that they have flaws in their physical appearance, and it is also common for individuals to resort to a number of different means to attempt to correct these potential flaws. In order for a person to receive a diagnosis of BDD, the perceived physical flaw must either be very minor or nonexistent; the individual must demonstrate a rigid fixation on this physical aspect of their appearance as being far more noticeable than it is; and the individual must engage in a behavioral set that results in extreme distress or functional impairment. BDD is not diagnosed in individuals who are simply dissatisfied with some aspect of their appearance.
According to the current Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition (DSM-5), the diagnostic criteria for BDD are:
- The individual demonstrates a preoccupation with a perceived physical deficit (or more than one perceived physical deficit) that the vast majority other individuals do not perceive as being detrimental to the person’s physical appearance (obsessive-type behaviors).
- The person vastly exaggerates their perception of their physical flaws such that they believe they are unattractive despite the overwhelming majority of other opinions that these perceived flaws are not detrimental to the person’s appearance (obsessive-type behaviors). This includes the majority of other medical professionals.
- The person begins to perform or performs repetitive behaviors or mental acts (compulsions) as a method to cope with their concerns about their physical appearance. These behaviors begin to occupy a significant amount of time and energy, and they are analogous to the types of behaviors observed in individuals who have an obsessive-compulsive disorder. These acts can consist of but are not limited to:
- Mental actions that can include continually measuring parts of their body or continually comparing their fixated body part(s) with other people’s bodies.
- Repetitive behaviors that can include continually checking oneself in the mirror, continually picking the skin, continually grooming, continually trying to get reassurance from others that they look fine, etc.
- The above repetitive acts most often continue to increase the individual’s anxiety regarding their own perceived appearance and often result in other issues, such as becoming depressed or engaging in substance abuse.
- The person’s preoccupation with their body part or parts must result in clinically significant distress or a clinically significant impairment in their individual functioning that is displayed in their personal relationships, occupation, school, or other important areas of life.
- The above behaviors cannot be better explained as a result of some other psychological/psychiatric disorder (e.g., an eating disorder and preoccupation with weight), the use of medications or drugs, or as a result of some medical condition.
- Some individuals may have insight regarding their preoccupation with their appearance, such that they recognize that their preoccupation is not realistic, whereas others may have little insight regarding their behavior. The diagnosis can include a modifier specifying the person’s insight regarding their behavior, so BDD can be diagnosed with good or fair insight, poor insight, or absent insight and delusional beliefs. Individuals diagnosed with absent insight or delusional beliefs are obviously going to be very difficult cases to treat.
A subtype of BDD can be diagnosed when individuals are preoccupied with the notion that their physique is insufficiently muscular. Such individuals would still need to meet the diagnostic criteria for the disorder, but they are diagnosed with body dysmorphic disorder with muscle dysmorphia.
The important thing to remember is that this is a diagnosis of a mental health disorder that represents a severe manifestation of a form of psychological/psychiatric illness.
These individuals engage in extreme behaviors regarding their preoccupations and attempts to cope with these fixations.
Statistics and Comorbidities
A number of sources regarding BDD indicate that individuals within this diagnostic category can come from a very broad range of ages. The age of the diagnosis can range from 5 to over 80, and in a good number of cases, individuals with this diagnosis are considered to have had at least aspects of the diagnosis before they were 18. The prevalence rate for this disorder appears to be around 2-3 percent of the population, with an equal prevalence between males and females (although there is some evidence to suggest that it may have a higher prevalence in females).
Individuals diagnosed with the disorder are more likely to be divorced, unemployed, and have comorbid (co-occurring) psychological/psychiatric disorders. The most common comorbid disorders associated with BDD are major depressive disorder (often with significant suicidal thoughts or tendencies), other obsessive-compulsive disorders, anxiety disorders, eating disorders, and substance use disorders. There is no recognized cause associated with this severe psychological/psychiatric disorder, and there is probably a combination of a strong genetic component and an interaction with environmental factors that result in its presentation.
The high rate of co-occurrence of BDD and substance use disorders should not be surprising. A general estimate of the comorbidity between BDD and all substance use disorders based on research findings would suggest that around 40 percent of individuals diagnosed with BDD will display some type of substance abuse or substance use disorder. The most common substance of abuse among these individuals is alcohol.
Other common drugs of abuse in this group include cannabis and hallucinogenic drugs, such as LSD, mescaline, magic mushrooms, etc. The rates of abuse for these drugs associated with this particular psychological/psychiatric disorder should not be surprising, as these types of drugs are obviously used in attempts to alter or escape from aspects of reality. Individuals who are diagnosed with BDD have fixated notions that are centered on their dysfunctional perception of reality. Substance abuse to cope with this impaired and altered perception of reality would seem to be a common path for these individuals.
Addressing and Treating BDD Symptoms
As BDD can only be diagnosed by a licensed mental health professional, any formal treatment for individuals who have this disorder can also only be implemented by a trained, licensed, mental health professional. Treatment is often a combination approach that consists of medications and therapy. Cognitive Behavioral Therapy (CBT) is the therapy of choice for this disorder, as it addresses the person’s attitudes and beliefs, challenges those attitudes and beliefs that are irrational or dysfunctional, and assists the person to develop a more realistic and functional belief system and approach to living.
Medications commonly used in the treatment of BDD consist of selective serotonin reuptake inhibitors, which are antidepressant medications. These medications are also believed to address issues with anxiety. Depending on the individual case, other medications can be added, such as benzodiazepines (which are more intensive anti-anxiety medications); in cases where individuals have issues with pain as a result of their attempts to change their appearance, narcotic medications may be used. The use of medications in the treatment of BDD should only be implemented by licensed physicians for obvious reasons.
CBT treatment can be delivered on an individual or group basis, and in many cases, it is administered in both individual and group sessions. The therapist treating an individual with BDD will devote quite a bit of time to developing rapport with the individual and gaining trust before implementing any active and challenging interventions. Individuals with this disorder can also supplement their therapy by attending community support groups and even 12-Step groups, such as Emotions Anonymous, to develop contacts with those who have similar problems.
When an individual has a co-occurring BDD and substance use disorder, both of these disorders need to be addressed simultaneously. Treatment for either disorder will be ineffective if only one disorder is addressed. Treatment for co-occurring disorders requires the use of a multidisciplinary team consisting of physicians, counselors and psychologists that specialize in one or both of these disorders, social workers, vocational rehab specialists, and other therapists and specialists as needed.
In some cases, individuals may have to attend withdrawal management programs for alcohol or other substance abuse that has resulted in physical dependence. Following the withdrawal management program, treatment should continue using medical management, counseling and therapy, and other needed supports. Treatment for these disorders is often a long-term endeavor, and individuals often need to maintain some participation in ongoing treatment, such as community health groups or 12-Step groups for many years.
Important skills that need to be developed in treatment are the identification of one’s irrational beliefs, the ability to alter one’s beliefs to coincide with reality, stress management, relapse prevention, and the development of a strong social support group.
Often, the support group consists of family members, other individuals in recovery from BDD, and other individuals who are in recovery for substance use disorders. Individuals with these disorders should not be isolated from social support but should continue to engage and interact with others long after the initial phases of recovery have been completed.