BODY DYSMORPHIC DISORDER

Dr Shazeena Qaiser
CONTENTS

 INTRODUCTION
 HISTORY
 PREVALENCE
 ONSET
 ETIOLOGY
 DIAGNOSIS
 MANAGEMENT
 CONCLUSION
 Body Dysmorphic Disorder

dysmorphophobia/ body dysmorphia/

dysmorphic syndrome)

A psychological disorder in which the affected person is

excessively concerned about and preoccupied by a perceived defect
in his or her physical features (body image).
“ Body dysmorphic disorder (BDD) is an under-diagnosed and under-treated
psychiatric disorder and patients are likely to present to dental practices,
especially those advertising themselves as ‘aesthetic’ or ‘cosmetic. ”
 HISTORY

Recognized as a disorder by
the American Psychiatric
First described, documented Emil Kraepelin :a mental Association redefining
by Morselli as malfunction leading to beauty dysmorphobia into delusional
dysmorphophobia. based hypochondriasis. and nondelusional variant.

1886 1909 1930’s 1987

 PREVALENCE
• 0.7–3%
• Young = 2.2–28%.
• Phillips and Biby - F:M= 1.3:1 ; 1:1.
• Majority -unmarried and unemployed ; patients seeking cosmetic treatments
• Reported to be diagnosed in:
• 6%–15% of dermatologic and cosmetic surgery patients
• 7.5% of an orthodontic patient sample of 40 patients in London.

• Iranian study: 270 orthodontic patients evaluated for diagnosis of BDD

• 15 (5.5%) + for BDD.

• Dermatological = 8%–15%
• Plastic surgery patients= 3%–53%
 Survey of 40 patients attending for adult orthodontic treatment
●

Hepburn and Cunningham Estimated prevalence=7.5% for BDD

●

●
Two maxillofacial surgery outpatient clinics,
Recent investigation of patients: ●
10% of patients-demonstrate symptoms of BDD.

De Jongh and co-workers
●
Reported individuals preoccupied with a defect of appearance:
●
9x more likely to consider tooth whitening
●
6x more likely to consider orthodontic treatment
 ONSET

• Late adolescence
• Average age=16.4 years
• M=F
• Course of illness – continuous;
• Unusual for symptoms to show periods of remission.
• Comorbidity
• Commonly associated with psychiatric disorders (depression, anxiety, social
phobia and obsessive compulsive disorder)
 CLASSIFICATION
According to level of insight.

Absence of an insight/ delusional

Good/reasonable insight :
individual can recognize that
beliefs of BDD may not be true.
Poor insight:
state:
individual believes that it is most
individual is completely convinced
likely true. that his/her beliefs are true.
 BDD

Delusional Not Delusional

visual Overevaluates a little

hallucinations, in imperfection
which he/she
perceives his/ her
defect as
monstrous
 Causes
• Biological ●
deficiency of serotonin.

Genetic ●
20% -patients: first degree relative‑such as parent, child or sibling

• Personality ●
Neuroticism, perfectionism, introversion, sensitivity to rejection,

• Environmental Media pressure e.g., desire to look like glamour models

●

●
lead to unrealistic expectations

Teasing or criticism ●
contributory role in individuals-genetically/environmentally predisposed

Parenting style ●
Parents who either place excessive emphasis on aesthetic appearance or disregard it

Sexual trauma, insecurity or rejection

 Diagnostic Criteria For BDD

Leone et al

Repetitive behaviours (mirror

Preoccupation with an imagined
checking, excessive grooming) due to
defect in appearance.
concerns with appearance

Preoccupation is not better

 Common Symptoms

Pychological distress
Sufferer may complain Orthodontists may
-severe depression,
of several specific encounter patients with
anxiety, development of
features or a single disorder- mentally
other anxiety disorders,
feature, or a vague disturbed- magnify their
social withdrawal or
feature or general tiny flaws, believe that
complete social
appearance they are too ugly.
isolation.
• Men: preoccupied with their height, hair and body build,
• Women: preoccupied with their weight, legs
• Individuals have thoughts and concerns that everyone is staring at them
• Up to 77% of people with BDD could be said to be delusional in their beliefs at some
point in their disorder.

Hair Nose
Common behaviour :
• May engage in a variety of compulsive behaviours in relation to his/her body part.
• Behaviours termed ‘compulsive’ ;occur at very high rates and are repetitive.
• Examples include:
– Checking in the mirror;
– Comparing the self to others;
– ‘Skin picking
– Applying make up
– Camouflaging the body part with clothes.
Management of BDD in dental practice
 Identification of patients
Unrealistic
with BDD in dental practice expectations
prior to beginning any form regarding cosmetic
of facial aesthetic treatment
procedures

Dissatisfied
regardless of the
actual outcome
• Isolated reports of physical threats towards surgeons from patients with BDD

• 10–40% of surgeons reported: received threats of legal action from BDD sufferers.

• Based on the evidence, physical violence towards clinicians from patients suffering with BDD are

exceptionally rare (and often complicated by other psychiatric conditions and confounding factors such as

anabolic steroid use)

• BDD patients are at far greater risk of harming themselves than others.

• Recent meta-analysis reported:

– rates of suicidal thoughts= 17–77% making these thoughts 4x more likely in BDD compared to non-BDD

sufferers,

– rates of suicide attempts =3–63% with sufferers 2.6 times more likely to have attempted suicide than

controls.
• Patients totally unsuitable for cosmetic procedures

• Mild-to-moderate BDD, no significant functional impairment, localised aesthetic

concerns and realistic expectations may benefit from aesthetic procedures.

• The gold standard for a diagnosis of BDD: 24-question structured clinical interview

which may take 15 minutes to several hours to complete and this makes it highly

impractical in a busy clinical environment.

1. Do you worry a lot about the way you look and wish you could think about it
less?
2. What specific concerns do you have about your appearance?
3. On a typical day, how many hours per day is your appearance on your mind?
(more than 1 hour per day is considered excessive)
4. What effect does it have on your life?
5. Does it make it hard to do your work or be with friends?
 Reasons for patients to seek orthodontic treatment

• Asymmetry of chin

• Unesthetic smile

• Upper midface deficiency

• Asymmetry during smile

• Persistent unexplained dental pain

 Management strategies for people with BDD
Pharmacological treatment Cognitive behavioural therapy Surgery

Patient rarely Recent study:

Use of selective serotonin
reuptake inhibitors (fluoxetine,
paroxetine, clomipramine,
fluvoxamine)
Patient constructing a hierarchy of
satisfied with reported 32 of 41
these symptoms and keeping a body
surgery: defect is patients who did
image diary during treatment, which
mostly undergo were
is exposure therapy to overcome
imagined; is highly satisfied
self‑consciousness and response to
emotional, rather with the
decrease checking behaviour.
physical outcome.
 Provision of the requested cosmetic treatment
• Appears to be of little benefit to patient
• Crerand et al : 91% of procedures administered to people with BDD resulted in no
change in BDD symptoms.
• High levels of dissatisfaction with treatment.
• Leads to further treatment or the shifting of the preoccupation to another part of the
body.
• Numerous possible adverse effects for the treating clinician if he/she provides
cosmetic treatments for people with BDD

• Patients diagnosed with BDD should not undergo the cosmetic treatment requested.
• Instead, in a sensitive yet straightforward manner, clinicians should discuss with the
patient that the cosmetic treatment is not in the patient’s best interest and recommend
referral to psychological or psychiatric services for pharmacological or psychological
treatment.
 CONCLUSION

• Patients with BDD are likely to present for aesthetic or cosmetic dental treatment.

• This is potentially problematic since aesthetic dental treatment has little benefit for

people with BDD and has potentially negative consequences for patient and the treating

clinician.

• Clinicians should be aware of this possibility and be familiar with specific strategies to

recognize and assess people with suspected BDD and appropriately manage them by

referral to specialist services

 REFERENCES

• James M, Clarke P, Darcey R Body dysmorphic disorder and facial aesthetic treatments
in dental practice BDJ 2019; 227 (10) 929-933
• Patricia Tatiana Soler, Cristina Michiko Harada Ferreira, Jefferson da Silva Novaes and
Helder Miguel Fernandes Body Dysmorphic Disorder: Characteristics, Psychopathology,
Clinical Associations, and Influencing Factors Intech Open 2018
• Ahluwalia R, Bhatia NK, Kumar PS, Kaur P. Body dysmorphic disorder: Diagnosis,
clinical aspects and treatment strategies. Indian J Dent Res 2017;28:193-7.
• Suzanne E Scott and J Tim Newton, Body Dysmorphic Disorder and Aesthetic Dentistry
Dent Update 2011; 38: 112–118
THANK YOU