excessive concern with an imagined or minor defect in physical appearance. (Pavan et al., 2008)
In DSM V, BDD has been included in the new OCRDs chapter due to similarities between BDD
and OCD. While the core feature of BDD has remained unchanged - that is distressing or
impairing preoccupation with perceived appearance defects or flaws that are not observable or
appear slight to others - there have been added new features to this condition (Phillips et al.,
2010). The new criterion (Criterion B) emphasises the similarities between OCD and BDD,
referring to the repetitive behaviours (Saxena S., 2011). Other notable changes are represented
by the inclusion of a muscle dysmorphia criterion (Grohol, 2013) and of the delusional form of
the disorder (absent/delusional beliefs). (Phillips et. al., 2012) Clinical literature has suggested
that BDD is characterized by poorer insight than OCD, an important similarity to OCD. In terms
of treatment, BDD, as OCD, is using pharmacological treatment with SRIs and psychological
Diagnostic Features
According to criterion A, individuals with body dysmorphic disorder are preoccupied with one or
more perceived defects or flaws in their physical appearance, which they believe look ugly,
unattractive, abnormal, or deformed, even though the perceived flaws are not observable or
appear only slight to other individuals. The preoccupations are intrusive, unwanted, time-
consuming (occurring, on average, 3-8 hours per day), and usually difficult to resist or control.
Criterion B involves the fact that excessive repetitive behaviours or mental acts are performed in
response to the preoccupation. These acts are time-consuming, difficult to resist or control and
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are not pleasurable, increasing anxiety and dysphoria. Also, the preoccupation must cause
functioning, according to Criterion C. The last criterion states that appearance preoccupation is
not better explained by concerns with body fat or weight in an individual whose symptoms meet
diagnostic criteria for an eating disorder. Body dysmorphic disorder must be differentiated from
an eating disorder. Muscle dysmorphia, a form of body dysmorphic disorder occurring almost
exclusively in males, consists of preoccupation with the idea that one's body is insufficiently lean
or muscular. Body dysmorphic disorder may be associated with three levels of insight regarding
body dysmorphic disorder beliefs: good or fair , poor and absent insight. (Association, 2013)
Course of illness
Subclinical concerns usually evolve gradually to the full disorder, although some individuals
experience abrupt onset of body dysmorphic disorder. The disorder appears to usually be chronic,
clinical features appear largely similar in adolescents and adults. (Pavan et al., 2008)
Epidemiology
The most common age at onset is 12-13 years. Regarding gender distribution, BDD appears to be
largely similar in females and males; however, men are more likely to be preoccupied with their
small body build (muscle dysmorphia), whereas women are more likely to be preoccupied with
weight. Considering the comorbidity, major depressive disorder is the most common comorbid
disorder, with onset usually after that of body dysmorphic disorder. Comorbid social anxiety
disorder , OCD, and substance-related disorders are also common.( Phillips et. all, 2015)
Etiology
2
Genetic Factors: Several twin studies similarly suggest that there is a genetic overlap between
BDD and OCD, although they examined the broad concept of dysmorphic concern rather than
the disorder BDD (e.g., Monzani et al., 2012b). One small candidate gene study found an
association for the GABA-A-2 (5q31.1-q33.2) receptor gene (Phillips et al., 2010a).
Neurobiological Factors: BDD is associated with abnormal visual processing. Preliminary data
also suggest abnormalities in executive functioning (e.g., Dunai et al., 2010). One study found a
leftward shift in caudate asymmetry and one found smaller orbitofrontal cortex and anterior
cingulate and larger thalamic volumes (Phillips et al., 2010a). Small studies suggest that BDD
may be characterized by compromised white matter fibres and inefficient connections or poor
integration of information between different brain areas, which is associated with poorer BDD-
related insight (Buchanan et al., 2013; Feusner et al., 2013). Another study found relative
hyperactivity in the left orbitofrontal cortex and bilateral head of the caudate when subjects
viewed their own face versus a familiar face, which may possibly reflect obsessional
Psychological Factors: Individuals with BDD appear to have difficulty identifying emotional
facial expressions and have a bias toward interpreting neutral faces and scenarios as threatening
parental care, a history of teasing, and childhood neglect and/or abuse (Phillips, 2009).
Neural substrates
Regarding the neural substrates associated with the BDD, using functional MRI and a face-
viewing task, there were discovered abnormalities in functional connectivity in visual processing
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systems in BDD that were not present in other disorders (Anorexia Nervosa) (Zhang et al.,
2016).
Neuropsychological profile
Using the Repeatable Battery for the Assessment of Neuropsychological Status, studies provided
measured by total RBANS, was established in BDD and OCD groups relative to the Healthy
Control group. On the whole, the BDD group tended to do worse than the OCD group. For
Immediate Memory and Attention, BDD participants performed at roughly one standard
deviation below the mean, whereas respective deficits in OCD participants constituted about half
a standard deviation below the mean. Given substantial clinical overlaps between these disorders,
albeit with poorer insight and greater delusional ideation in BDD (Eisen, Phillips, Coles, &
Rasmussen, 2004), such trends are perhaps not surprising. (Toh, Castle, and Rossell, 2015)
Treatment
Somatic Treatments: Psychiatric treatment of BDD envisages the use of selective serotoninergic
antidepressants (fluoxetine and fluvoxamine) and tricyclics (e.g., clomipramine). SRI treatment
often decreases core BDD symptoms and associated features such as depression, anxiety, anger-
hostility, psychosocial functioning, and quality of life (Rosen et al., 1995; Veale et al., 1996;
Wilhelm et al., 2013). Small open-label trials suggest that the SNRI venlafaxine and the
antiepileptic medication levetiracetam may be helpful for BDD; however, these medications are
not currently recommended as first-line treatments for BDD (Phillips & Hollander, 2008)
psychotherapy of choice for BDD (Phillips, 2009). Motivational interviewing techniques are
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often needed to enhance motivation for treatment initially and at later points during treatment.
Treatment ends with relapse prevention; booster sessions may be provided if needed. Patients
should continue to practice CBT skills after treatment has ended. (Pavan et al., 2008)
Combined Treatments: The efficacy of combined pharmacotherapy and CBT versus either
treatment alone has not been investigated. From a clinical perspective, combined treatment is
especially recommended for more severely ill patients. (Pavan et al., 2008)
Treatment-Refractory Patients: Despite the lack of empirical data, combined treatments may be
considered for treatment-refractory cases. Case series suggest that low doses of typical or
atypical antipsychotics may be useful in the augmentation of SSRIs in TTM (Stein & Hollander,
1992).
Response to treatment
The study by Hollander demonstrated that improvement in symptoms was greater for subjects
intervention is cognitive- behaviour therapy used to change specific beliefs and assumptions
Overall prognosis
After 1 year, the probability of complete spontaneous remission was 9% and that of partial
remission was 21%, without significant gender or ethnic differences. BDD had an extremely low
Bibliography
5
1. Ameringen, M. V., Patterson, B., & Simpson, W. (2014). Dsm-5 Obsessive-
3. Pavan, C., Simonato, P., Marini, M., Mazzoleni, F., Pavan, L., & Vindigni, V.
doi:10.1002/9781118753378.ch58
body dysmorphic disorder using the Repeatable Battery for the Assessment of
6. Zhang, A., Leow, A., Zhan, L., Gadelkarim, J., Moody, T., Khalsa, S., . . . Feusner,
doi:10.1017/s0033291716001458