Body dysmorphic disorder is defined by the DSM-IV-TR as a condition marked by a preoccupation with an imaginary or minor defect in a facial feature or localized part of the body. The concern over one’s perceived defect is markedly excessive, and this preoccupation causes significant distress or impairment in one’s functioning (APA, 2000).
In addition, people with the disorder experience significant levels of negative thinking, self-criticism, shame, anxiety and depression (Phillips, 2004).From research, it has been shown that people with BDD have poor insight and almost half of them are delusional (Feusner et. al. , 2009).
Concerns can involve preoccupations with the face, the hair, or size and shape of any other body part. They can engage in a variety of behaviors that have become symptomatic of this disorder. Some camouflage themselves to hide their perceived defect. This may involve wearing heavy make-up or certain clothes and accessories that conceal any perceived flaws.
Checking one’s appearance either directly or in reflective surface, often referred to as mirror-gazing, and excessive grooming are other common behaviors. The most affected group is teenagers whose bodies are continually changing in shape and size (Alexandra, 2008). Though the prevalence of the disorder is considered low affecting only 2% of the US population, researchers believe that it is now rising especially with the development of better diagnosis techniques as well as the increasing desire for people to look good.Unlike eating disorders which are more prevalent in women, BDD equally affects both genders although teenagers who suffer the most are the girls (Veale, 2011).
6-15% of dermatologic and cosmetic surgery patients are afflicted with this disorder (Anderson & Black, 2003). Biology, genetic predisposition, psychological factors and sociocultural experiences all impact the etiology of the disorder. Clearly, our environment and the culture we live in affect our thoughts, behaviors and frames of reference.We are currently living in a culture obsessed with appearance and physical attractiveness.
This leads to unrealistic expectations and significant anxiety derived from trying to meet the current beauty ideal. Rosen (1996) suggested a key factor in the development of BDD involves critical events or traumatic incidents that involve an individual’s appearance. The most common example is being teased about weight or size, with many patients reporting repeated criticism about their appearance from members of their own family.More general vulnerability factors may involve being neglected as a child, leading to feelings of being unloved, insecure and rejected.
Other trauma, such as sexual and physical abuse may also be involed. According to Rosen, these critical events in childhood activate dysfunctional assumptions about the normality of physical appearance and the implications of appearance for personality, self-worth and acceptance. Once established, the disorder may be maintained by selective attention to perceived physical problems or information that supports these beliefs.People with BDD become hypervigilant for any minor changes that occur in their appearance.
In addition, Rosen suggested that rehearsal of negative and distorted self-statements about physical appearance results in them becoming automatic and believable. Finally, the positive emotional responses associated with avoidance, checking and reassurance-seeking behaviors reinforce and maintain the condition. With our knowledge on the development of the brain we can say that these experiences in early life can result in many of the brain dysfunctions that have to do with BDD.We know that in order for our frontal cortex to develop fully we need to be securely attached to our caregiver and be treated with love and affection.
In my opinion, the psychological factors for the etiology of BDD can result in the development of the brain dysfunctions that seem to be present in someone with BDD. Even though there is limited research on the biological factors for BDD, a review for Feusner et. al (2008) revealed a great deal of information regarding the parts of the brain that have to do with the causes of the symptoms.His main idea was that people with BDD have an abnormality in perceptual and emotional processing of information and, memory deficits.
He concluded that there is a dysfunction in frontal-stratial circuits and prefrontal regions that are responsible for executive functioning. There is a possible abnormality in memory structures such as the hippocampus and areas involved in facial emotion perception such as inferior-frontal, right-parietal and occipito-temporal cortices. It may be an overactivity in the amygdala which is a structure that has to do with mediating attentional biases and social anxiety (Feusner et al, 2008).A newer study by Feusner, Saxena and Yaryura-Tobias (2009) concluded that there is a greater left hemisphere activity in the inferior frontal gyrus and an abnormal amygdala activation.
An important finding was that symptom severity of BDD correlates with the size of left IFC and right amygdala. This hemispheric imbalance suggest that they rely more on extraction and processing of details, and the overactivation of amygdala is an explanation for the perceptual distortions (Feusner, Saxena & Yaryuna-Tobias, 2009).Finally, the positive outcomes of selective serotonin reuptake inhibitors treatment for BDD leads researchers to speculate that the etiology of BDD could be related to poor regulation and depletion of serotonin. However, we are not sure yet if the altered levels of serotonin is an indicator or a consequence of BDD (Feusner et al, 2008).
The disorder is often highly incapacitating, with many individuals showing marked impairment in social and occupational activities. It can lead a person into engaging in behaviors such as avoiding people, even to the extreme of avoiding family members where the individual becomes housebound.Isolation from society members often leads to avoidance of social gatherings and working environments. Other complications resulting are lack of support/friends, and other relationships, such as marriage.
Most attribute their limitations to embarrassment concerning their perceived defect, but the attention and time-consuming nature of the preoccupations and attempts to investigate and rectify defects also contribute. Superimposed depressive episodes are common, as are suicidal attempts and ideation (Philips, 2004).Levels of distress can be such that many people with the disorder experience other disorders such as social phobia, OCD, substance abuse and eating disorders due to a desire to keep a certain body size and shape (Watkins, 2004). Because of the amygdala’s over activation, anxiety is another very common effect of BDD which leads to behaviors such as panic or uneasiness.
A person suffering from BDD is likely to suffer from frequent emotional breakdowns, finding themselves crying whenever they think about their “defects”. It is not surprising that individuals with BDD are found most commonly among those who seek cosmetic surgery.Surgery or other corrective procedures rarely if ever lead to satisfaction and may even lead to greater distress with the perception of new defects attributed to the surgery or they don’t get satisfied to their expectations. In my opinion, since the patient’s perception about him or herself is already skewed, the results of any surgical procedure may range from dissatisfaction to aggression.
The two treatment options that have been researched and studied for BDD are the use of SSRIs medication and CBT. Treatment studies demonstrate a reduction in the distress and impairment associated with BDD after the use of these two.In response to SSRIs, most patients report a decreased preoccupation with their perceived defect and they experience a greater ability to control BDD related thoughts and behaviors, an improvement in their mood, suicidal thinking and general functioning (Philips, 2004). A treatment plan with CBT includes techniques such as self-monitoring, exposure and cognitive restructuring.
These interventions help people to recognize their repetitive thoughts and unconscious behaviors and begin to confront their fears and anxieties.This increased awareness helps the patients to see their maladaptive thought patterns and incorporate more adaptive cognitions, which can lead to significant improvement. With this kind of therapy we can achieve a full integration of the brain (top-down, left-right, amygdale-hippocampus, ompfc-dlpfc) due to the continuous challenging of the patients thoughts and the externalization of these thoughts. Rosen, Reiter and Orosan (1995) conducted a promising controlled study of CBT for persons with BDD and provided evidence that this is an effective method.
BDD has become an increasingly prevalent disorder that results in significant deleterious consequences for people who suffer from it. Even though research about the etiology of the disorder is still in its infancy, we have sufficient knowledge to believe that early childhood experiences result in the abnormalities of the brain regions that seem to play a crucial role and the lack of integration throughout the brain. Our role as therapists is to facilitate an environment that a full integration of the brain can be succeeded.ReferencesAlexandra.
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