Towards the end of July, the British Medical Journal published an educational article on Body Dysmorphic disorder.
[BMJ 2015; 350: h2278]
What is this?
The article was written by Dr David Veale, a Consultant Psychiatrist in Cognitive Behaviour Therapy at the South London and Maudsley NHS Foundation Trust and Dr Anthony Bewley, a Consultant Dermatologist who runs a Psychodermatology service at St Bartholomew’s Hospital, London. It is not surprisingly, therefore, to learn that body dysmorphic disorder (or BDD) is a condition which is primarily a psychiatric one. Patients with this condition may present to dermatologists but may also present to general practitioners, plastic, maxillofacial and ear, nose & throat surgeons amongst others.
People with BDD have a preoccupation with a perceived defect(s) or ugliness in their appearance. The authors state that it is a relatively common condition, being prevalent in about 2% of the population, making it more common than schizophrenia or anorexia nervosa.
That could be me…
We can all be dissatisfied with some aspect of our appearance but worry about that aspect does not cause such distress or interference with life to prevent functioning with day-to-day activities. The perceived “flaws” in appearance in a patient with BDD are just a variant of normal physical appearance or appear only slight to anyone else and yet cause enormous distress, shame and interference. The patient will be excessively preoccupied with the defect or defects.
How preoccupied do you mean?
The key diagnostic criterion for BDD is a preoccupation with a perceived defect that is at the forefront of the mind for at least an hour a day, but commonly several hours a day. The perceived defect must cause substantial distress, to the degree that it interferes with day-to-day life.
How else do you know?
It is described that the person is likely to perform some sort of repetitive behaviour at some point during the course of the disorder. These include checking in mirrors, skin picking, checking by touching the area, constantly comparing the feature with the same feature in other people.
Not surprisingly, people with the disorder are extremely self-conscious and avoid social situations, may cover themselves up inappropriately for the weather or become housebound.
Do they get depressed too?
There is a high associated risk of attempted and completed suicide with this disorder.
[Phillips KA, Coles M, Menard W, et al. Suicidal ideation and suicide attempts in body dysmorphic disorder. J Clin Psychiatry 2005;66:717-25. ]
What if they get the perceived fault altered?
Many have cosmetic surgery or see a cosmetic dermatologist for treatment.
[Crerand CE, Menard W, Phillips KA. Surgical and minimally invasive cosmetic procedures among persons with body dysmorphic disorder. Ann Plastic Surgery 2010;65:11-6. ]
Many are not satisfied with the result and the cosmetic procedures and treatments are unlikely to alter the symptoms of BDD.
[Conrado LA, Hounie AG, Diniz JB, et al. Body dysmorphic disorder among dermatologic patients: prevalence and clinical features. J Am Acad Dermatol 2010;63:235-43. ]
What can be done about BDD?
It is important that the patient’s GP recognizes and is empathic with the disorder. Hence the article in the BMJ is helpful in educating general practitioners, enabling them to understand the patients’ distress, fears of rejection and feelings of shame.
There are successful treatments available but these will take time and commitment. It may be necessary to refer to a local or regional psycho-dermatology clinic for skin problems or a national specialist service for body dismorphic disorder.
[Aguilar-Duran S, Ahmed A, Taylor R, et al. How to set up a psychodermatology clinic.
Clin Exp Dermatol 2014;39:577-82. ]
What do they do there?
These specialist clinics provide access to a team that has specialist expertise in BDD. There may be several specialists in the clinic, a psychiatrist, a psychiatric nurse and a dermatologist with expertise in psychodermatology amongst others.
Cognitive behavioural therapy that is specific for body dysmorphic disorder which follows a protocol over 16-24 sessions is recommended by NICE guidelines for the management of BDD.
[National Institute for Health and Clinical Excellence. Obsessive-compulsive disorder: core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder: CG31. 2005. www.nice.org.uk/guidance/cg31. ]
Antidepressants such as selective serotonin reuptake inhibitors (SSRIs) may be recommended for at least 3 months.
[Phillips KA, Albertini RS, Rasmussen SA. A randomized placebo-controlled trial of fluoxetine in body dysmorphic disorder. Arch Gen Psychiatry 2002;59:381-8. ]
Are there other resources available?
Yes, there are some websites providing further advice and information for patients.
These include the Body Dysmorphic Disorder Foundation; http://bddfoundation.org
There is also the national charity for obsessive-compulsive disorder and BDD in the UK; http://ocdaction.org.uk
The article in the BMJ also provides information on some books on the condition too.
Dr Sandy Flann, Consultant Dermatologist.