Research Updates In PsychiatryOne evening while flipping through TV channels, I stumbled on one of those make-over shows. A young man who looked physically fit to me was explaining to the host that he almost had the “whole package” to be desirable to “ladies.” But his calves, he stated, weren’t right. No matter how much he exercised, he couldn’t get the muscle size or definition he thought he needed. “See these calves?” he said, in obvious distress. “They ruin the whole thing.”

I was riveted. I was appalled. Did he really want plastic surgery to change his calf muscles? Yup. Did he really think that a change in his lower extremities would bring him love? Also yup. And to my deep distress, he was being supported in that request by the panel of interviewers.

I wish the scene had shifted to a psychologist talking to the contestant about the possibility that he had Muscle Dysmorphia, a form of Body Dysmorphic Disorder, not grotesque calf muscles. Sigh. That didn’t happen. For all I know he did undergo surgery. If he did, it is likely that he was soon disabused of the notion that defined calves would bring him love.

Prevalence of BDD

Body Dysmorphic Disorder may be more prevalent than you think. The International OCD Foundation reports that it effects1.7% to 2.4% of the general population — about one in 50 people. This means that more than five million people to about 7.5 million people in the United States alone have BDD

Body Dysmorphic Disorder is characterized by obsession about a physical “flaw” that others can’t see. Almost any part of the body can become the focus: thighs, teeth, stomach, butt, chin, eyebrows. I had a patient who didn’t leave his house for months because he was convinced his eyes were the wrong shape. Another had had multiple surgeries to fix what she believed was a double chin. By the time I saw her, she had almost no chin at all. Still another was on probation at her job because of chronic lateness. She spent hours every morning in front of a mirror popping pimples and then repairing the damage with makeup.

The common denominator among such patients is the belief that a body part is exceptionally misshapen even though its appearance is normal. Usually the person engages in repetitive attempts to fix or hide the “flaw.” Often, they are further distressed by the belief that others are looking at them with distaste or laughing at them.

Just about everyone has some physical characteristic they wish were different. That’s normal. But a person with BDD experiences clinically significant distress about the perceived problem. Many believe that they are exceptionally ugly or even grotesque despite feedback to the contrary form family, friends and lovers. They often miss work or school because they are spending time trying to fix or hide their “defect.”  It’s not surprising that these clients often have co-morbid depression or anxiety (or both). Some become suicidal.

Unlike people with eating disorders, the individual with BDD may have perfectly normal and appropriate eating behaviors. Their primary concern is about their appearance, not an idealized weight. What complicates the clinical picture is that the distinction isn’t always clear. It is possible for a client to have both.

A slight majority of cases of BDD are female. Brought up on Barbie dolls and the media ideal of a size four with, large breasts, small waist, thick flowing hair, perfect skin and the face of a goddess, they grew up feeling physically defective by comparison.

Data shows that the number of men with BDD is increasing. From the time, they are very young, boys are exposed to grotesque images of muscle bound men in cartoons and toys, in movies and in advertising, leading them to think that the ideal male physique is that of a serious body-builder.

It’s not yet known why some people are more sensitive and responsive to these cultural messages than others.

BDD differs from obsession compulsive disorder in that the repetitive behaviors are in the service of changing the individual’s appearance for the better. Sadly, the very behaviors they engage in often make the problem worse. It’s not surprising that many of these clients have spent many hours and a great deal of money going to dermatologists, cosmetic dentists, plastic surgeons, personal trainers and estheticians, obtaining multiple interventions from multiple professionals in the quest for physical perfection. Also not surprising, at least some of these clients are never satisfied with the results.

Treatment

Treatment of these clients starts with a good assessment. During our initial intake, it’s important to simply ask if the client is concerned about how he or she looks and, if so, what they do about it. As with many things, if we don’t ask, we often don’t find out that BDD is part of the whole clinical picture. Treatment is then-modal and often includes:

  • Treatment of co-morbid anxiety and depression.
  • Cognitive Behavior Therapy to challenge the maladaptive thinking that is characteristic of those with BDD.
  • Discouraging the patient from cosmetic therapy. It is unlikely to help and the person will end up feeling even worse. It is often helpful to suggest to the clients that they put off surgery until other, non-invasive (and less expensive) therapy has been tried.
  • Mindfulness Based Stress Reduction (MBSR) or some other type of mindfulness techniques to help them resist compulsions.
  • As with any of the Obsessive Compulsive behaviors, high doses of SRIs are often helpful.