Is the dysmorphic disorder of the BDD body real

Body Dysmorphic Disorders: The Imaginary Deficiency

SCIENCE

The popular plastic surgery rarely alleviates the suffering of the patient. The disorder is usually not diagnosed by doctors. Most of those affected lack insight into the psychological causes.

Many people cannot accept their body for what it is. Women in particular often discover something that is annoying or that does not correspond to current ideals of beauty. But more and more men are also dissatisfied with their appearance. In some cases, this dissatisfaction is due to a mental illness: body dysmorphic disorder or dysmorphophobia. It is clinically characterized by an excessive preoccupation with an imagined deficiency or a feared distortion of the external appearance that other people do not notice at all.
Most often, the belief in disfigurement relates to the appearance of the face, especially the texture of the skin, the shape of parts of the face such as the nose or eyes, but also the shape of parts of the body. Body dysmorphic disorder is characterized by permanent checking of the defect in the mirror and efforts to conceal the alleged defect through cosmetic and other measures (camouflaging). In addition, those affected compare their appearance with that of others and make sure in their social environment whether the defect is unattractive. Typical behaviors also include frequent combing, shaving and hair removal (grooming), touching the defect and tugging the skin. Many patients also avoid looking in the mirror or physical contact with the problematic part of their body. In addition, there is a strong tendency to avoid appearing in public, as derogatory and humiliating reactions to the disfigurement in appearance are feared. The individual behaviors are usually performed with a high degree of temporal intensity and as a compulsive act.
The symptoms on the action level can be divided into control behavior (comparison of one's own appearance with that of others, looking in the mirror, reassurance, touching the defect) and avoidance behavior (avoiding mirrors, social withdrawal, camouflage). Both behaviors serve to reduce the fear of being recognized as unattractive. However, the desired fear reduction is not achieved.
The conviction that one is distorted by the deficiency often has delusional features and is associated with perceptual disorders (hallucination, illusion) and thought disorders (overvalued ideas, obsession with observation, but also insight into illness).
The body dysmorphic disorder creates a high level of suffering and impairments in social, professional or other important functions. These impairments can result in complete social isolation, neediness, hopelessness, depressive symptoms, suicidal thoughts and suicide attempts.
To date, there is no precise information about the prevalence of the disorder. According to the literature, a point prevalence of 0.7 to five percent in the normal population is assumed; however, some experts suspect a significantly higher prevalence and a high number of unreported cases. A significantly higher prevalence is found among patients who seek dermatological-cosmetological, dermatological or plastic-surgical therapy.
Body dysmorphic disorder occurs roughly equally in men and women. The onset of the disorder is characteristically in adolescence or puberty. The course is usually chronic with a mean duration of 16 years. In the course of the disease, 40 percent of patients are initially only concerned about one region of the body. Other regions are added later without abandoning the primary region as the focus of excessive employment. The symptoms are often more pronounced in younger years than in old age. Patients with delusional thought disorders, depressive comorbidities and pronounced avoidance behavior have a poorer prognosis.
No uniform concept
to etiology
In addition to imbalances in the serotonin balance, excessive sensitivity to aesthetics, faulty perception and evaluation processes, an obsessive personality structure and psychosocial factors are discussed. Socio-cultural influences, the prevailing opinion on physical aging processes, ideals of beauty and ideals of femininity and masculinity are seen as co-responsible etiological factors. Critical life events, negative experiences with critical or derogatory comments with regard to the external appearance, trigger situations or previous physical illnesses, however, are etiologically considered to be of secondary importance.
As researchers at the Institute for Medical Psychology at the Charité in Berlin and at the Marburg University Hospital have discovered, discrepancies between the ideal and the real body image may also play a role in the development and maintenance of the disorder. In a survey of 2,552 test persons between 14 and 99 years of age, it turned out that the women questioned were more worried about their breasts, skin and legs than men and showed more reinsurance behavior. In addition, they rated their bodies overall more negatively and negatively than the male test subjects. The men, on the other hand, were more concerned about their genitals, their size, and their excessive body hair. In men, there was also a significant correlation between the severity of body dysmorphic symptoms and the signs of declining strength and vitality. Despite such findings, there is still a great deficit in research into the causes of body dysmorphic disorder.
Appearance dissatisfaction is a universal phenomenon with smooth transitions between normal and clinical manifestations. In the case of body dysmorphic disorder, however, the preoccupation with appearance, the discrepancy between experience and objective judgment, and the level of suffering reach extreme proportions. In addition to the differentiation from non-pathological forms, the body dysmorphic disorder in the clinical entities behavior, perception, thinking and leading affect from the obsessive-compulsive disorder, hypochondria, social phobia, (zoenesthetic) schizophrenia, paranoid personality disorder, eating disorder and disorder of gender identity, are to be considered distinguish.
The following are suitable for routine clinical examinations and screening for the presence of a body dysmorphic disorder:
- Rating scale for assessing the distortion
- Indicators of the presence of a body dysmorphic disorder
- Body Dysmorphic Disorder Diagnostic Module.
The following are available for recording the severity of the body dysmorphic disorder:
- Body Dysmorphic Disorder Examination (BDDE)
- Body Dysmorphic Disorder Questionnaire (BDDQ)
- Body Dysmorphic Disorder Modification of the Yale-Brown Obsessive Compulsive Scale (BDD-YBOCS).
It is also advisable to record depression and social anxiety.
Strong feelings of shame
The body dysmorphic disorder is accompanied by strong feelings of shame and is therefore also referred to as shame disease. Because of the feelings of shame, those affected usually keep silent about their symptoms. This not only prevents early diagnosis, but also leads to misdiagnosis. In addition, the severity of the symptoms can be underestimated. There is also a risk of confusing symptoms of body dysmorphic disorder with symptoms of other mental illnesses.
In addition to the feelings of shame, one finds a low self-confidence, a depressive mood or a comorbidity with depressive disorders. The "major depression" is the most common comorbid disorder, whereby the body dysmorphic disorder usually precedes the depression. There are also high comorbidity rates with anxiety disorders, especially with social phobias, and obsessive-compulsive disorder. In connection with depression, shame and self-esteem crisis, suicide fantasies and attempts can arise. The depressive symptoms as a result of the disorder or as a comorbid illness can also be in the foreground and lead to misdiagnosis.
In addition to the difficult differential diagnostic differentiation, the high comorbidity has been taken as an opportunity to express doubts about the justification of an independent diagnosis. Some scientists therefore use the term “complaints” instead of the term “disorder”.
So far, there are no empirically proven therapy recommendations. Selective serotonin reuptake inhibitors (SSRI), MAO inhibitors and antipsychotics are used for psychopharmacological treatment. Several studies have shown the effectiveness of SSRIs in body dysmorphic disorder. A response rate of 30 percent has been reported for the MAO inhibitors. A positive effect of antipsychotics, however, could not be demonstrated.
The effectiveness of cognitive-behavioral psychotherapy has also been proven in controlled therapy studies. For example, exposure to avoided social situations and reaction prevention (prevention of covering up or controlling the defect) are used. Further, cognitive restructuring of overestimation of appearance and defect is used as a yardstick for evaluating a person, and an adequate understanding of the problem is developed. Prof. Dr. Ulrich Stangier from the University of Jena divides the treatment into a preparation and motivation phase and an intervention phase. Due to the disturbances in social functions and perceptual disorders, the first phase of relationship building, behavior analysis and the placement of a therapy station can take up to a year. In the intervention phase, the focus is on building up competencies, cognitive restructuring and dealing with dysfunctional basic beliefs. Stabilization and relapse prevention should not be neglected either. No statement can be made about the effectiveness of psychodynamic therapy methods, since so far there have only been descriptions of individual cases.
According to the current state of research, the results of psychological treatment approaches are at least comparable with those of SSRIs, and even superior in terms of drop-out rates and long-term effects. That shouldn't give rise to high hopes, however. "Despite significant improvements in psychological treatment, most patients do not have a complete remission of the body dysmorphic disorder even after therapy," says Stangier.
Surgical interventions and cosmetic treatments are extremely critical in terms of effectiveness and long-term consequences. Those affected are particularly interested in them. The majority of those affected see somatic doctors in the course of the disease, especially dermatologists, ENT doctors and plastic surgeons, so that they can remove the subjectively perceived blemish by means of surgery, cosmetic treatment or special pharmacotherapy. Most of the time, however, the disorder goes undiagnosed and many treatments are performed without adequate indication. The results of the treatments seldom satisfy patients. However, dissatisfaction and suffering usually do not lead patients to seek psychotherapeutic help, as they lack insight into the psychological causes of the disease.
There are no prospective studies on the results of cosmetic and surgical interventions on the symptoms of body dysmorphic disorder. In retrospective studies on the question of the success of plastic surgery in the treatment of body dysmorphic disorder, failure clearly predominates. In the majority of patients, the symptoms remain the same after the procedure or sometimes worsen significantly, which can trigger suicidal thoughts and attempts. The therapies mentioned, through which a change in the external appearance is to be achieved, are therefore considered contraindicated.
The body dysmorphic disorder is becoming more topical in times when there is high social pressure for physical attractiveness and beauty is for sale. More and more providers, some with dubious training and a lack of experience in the field of cosmetic surgery and cosmetics, are entering the market in order to meet increasing demand. Patients with body dysmorphic disorder in particular run the risk of confiding in them and still not finding any relief from their psychological problems.
Dr. phil. Marion Sonnenmoser


Contact:
Prof. Dr. Ulrich Stangier, Clinical-Psychological Intervention, Institute for Psychology, Humboldt-Straße 11, 07743 Jena, phone: 0 36 41/94 51 70, email: [email protected]
Daig I, Albani C, Rief W, Brähler E: Body dysmorphic complaints: What role does the discrepancy between ideal and real body image play? Psychother Psych Med 2006; 56: 259-67.
Driesch G, Burgmer M, Heuft G: Body Dysmorphic Disorder. Neurologist 2004; 75: 917-31.
Rief W, Buhlmann Ul, Wilhelm S, Borkenhagen A, Brähler E: The prevalence of body dysmorphic disorder: a population-based survey. Psychol Med 2006; 36 (6): 877-85.
Stangier U: Skin Diseases and Body Dysmorphic Disorder. Göttingen: Hogrefe 2001.
Stangier U, Hungerbühler R: Imagined ugliness: the body dysmorphic disorder from a psychological point of view. Journal of Clinical Psychology and Psychotherapy 2001; 30 (2): 77-83.
Williams J, Hadjistavropoulos T, Sharpe D: A meta-analysis of psychological and pharmacological treatments for Body Dysmorphic Disorder. Behavior Research and Therapy 2006; 1: 99-111.
1. Daig I, Albani C, Rief W, Brähler E: Body dysmorphic complaints: What role does the discrepancy between ideal and real body image play? Psychother Psych Med 2006; 56: 259-67.
2. Driesch G, Burgmer M, Heuft G: Body Dysmorphic Disorder. Neurologist 2004; 75: 917-31.
3. Rief W, Buhlmann Ul, Wilhelm S, Borkenhagen A, Brähler E: The prevalence of body dysmorphic disorder: a population-based survey. Psychol Med 2006; 36 (6): 877-85.
4. Stangier U: Skin Diseases and Body Dysmorphic Disorder. Göttingen: Hogrefe 2001.
5. Stangier U, Hungerbühler R: Imagined ugliness: the body dysmorphic disorder from a psychological point of view. Journal of Clinical Psychology and Psychotherapy 2001; 30 (2): 77-83.
6. Williams J, Hadjistavropoulos T, Sharpe D: A meta-analysis of psychological and pharmacological treatments for Body Dysmorphic Disorder. Behavior Research and Therapy 2006; 1: 99-111.
Body Dysmorphic Disorders: The Imaginary Deficiency

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