Body Dysmorphic Disorder: When Does Preoccupation With Body Appearance Become Pathological?

Ekaterini Maria Lyras

PhD Student AG Priller, Charité Medical Neurosciences

It is probably safe to say that we have all experienced periods in which we were particularly concerned with our appearance. Such concerns increase with physical changes such as adolescence, pregnancy or the gradual process of aging, but can often occur without them as well.

Photo by Taylor Smith on Unsplash

Appearance Concerns and Body Dysmorphic Disorder

Worries about our appearance are so common that they are considered normative. There are instances, however, when such concerns become pathological. One such pathology is Body Dysmorphic Disorder (BDD), a psychiatric condition in which patients suffer from excessive and persistent preoccupation with alleged flaws or deficits in their physical appearance [3].The preoccupation of patients with BDD is not related to body fat, weight or anything that would characterize an eating disorder but rather focuses on perceived defects of the skin, nose, genitalia, hair or eyes. The “flawed” features might seem trivial or even unobservable to an outsider, but patients with BDD experience severe distress while engaging in repetitive thoughts, feelings and compulsive behaviors [3]. They might repeatedly check themselves in the mirror, seek constant reassurance, pick at their skin or spend great amounts of time trying to camouflage their perceived shortcomings.

The Stigma of Vanity

BDD is a chronic condition that usually results in a severe decrease in the quality of life.  It occurs in females and males to an equal extent. The prevalence in adult communities is estimated to be 1.9% [4] with striking rates of suicidal thoughts (17-77%) [5]. Despite its severity and impact, the disorder is often mis- or underdiagnosed. One reason for underdiagnosis is that patients with BDD might feel too ashamed or embarrassed to ask for health support for something that might be seen as vanity or self-obsession. They are unlikely to spontaneously disclose their appearance concerns. If they do consult a medical specialist, it is usually a dermatologist or cosmetic surgeon who may lack the insight or the motive to diagnose the disorder and provide the necessary support. Furthermore, BDD has a high comorbidity with other psychiatric conditions meaning that symptoms might be masked or even overlooked if not specifically asked about.

Could Nurturing a Positive Body Image be a Solution?

The onset of psychiatric disorders associated to a negative or distorted body image is typically in late adolescence – at around 16 years of age for BDD in particular [6],suggesting that the pathology often develops in childhood. A rather alarming meta-analysis of studies in children under 6 years old showed that 20-70% of children experience some form of body dissatisfaction [7]. This makes one wonder whether investing in prevention might not be just as important as improving current evidence-based treatments such as cognitive-behavioral therapy or the administration of anxiolytic/antidepressant medicine. Prevention would involve the fostering of a positive body image to circumvent the development of a negative body image [8]. Different steps to achieving positive body image would include increasing media literacy to protect against unrealistic media appearance ideals, nurturing body awareness and responsiveness with activities such as dance or yoga and cultivating a culture of appreciation for diverse appearances and functionalities of the body. By following such steps, our culture might finally embrace the notion that each body, as an entity with unique physical, emotional, intellectual and social qualities, is – by definition – beautiful.

3. American Psychiatric association, Diagnostic and Statistical Manual of Mental Disorders. 5th ed. VA: Arlington American Psychiatric Publishing, 2013
4. Veale et al., Body Image, 2016
5. Angelakis et al., Clin Psychol Rev, 2016
6. Bjornsson et al. Compr Psychiatry, 2013
7. Tatangelo et al., Body Image, 2016
8. Tylka and Wood-Barcalow, Body Image, 2015

A version of this post was originally published in Charité Neurscience Newsletter, Vol. 11, Issue 3

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