Deceptive appearances: imagined physical defects take an ugly personal toll.
Yet only those whose bodies succumb to the force can see the bizarre physical mutations. Families and friends look on in confusion and exasperation as afflicted individuals continually check their appearance in mirrors, try to hide their defects with makeup or clothing, and sink into years of social isolation and depression. Some haunt the offices of plastic surgeons, going under the knife again and again until they take on a distorted look that ironically confirms their fears of ugliness.
This scenario may resemble an eerie fantasy, but it reflects the
experiences of real people. For instance, 33-year-old Ted has complained of repulsive facial freckles and acne for more than a decade. He picks his skin constantly and thinks people stare at him whenever he makes one of his rare appearances outside. Heavy drinking helps to dull his anxiety about social encounters. Ted's wife left him after tiring of his inability to talk about anything other than his perceived skin problems. Years of treatment by dermatologists and psychotherapists left Ted as miserable as ever.
Consider Helen, a woman of uncommon beauty who as a teenager became convinced that her nose was repugnantly small. After undergoing three separate cosmetic surgery procedures, she still viewed her nose as misshapen. Helen went to a psychotherapist who spent 2 years trying to convince her that her nose looked lovely, to no avail. A host of prescribed psychoactive drugs made no dent in Helen's despair.
Finally, psychoactive medications that boost the amount of the chemical messenger serotonin available to brain cells lessened the bodily preoccupations and lifted the spirits of Ted and Helen (not their real names). Katharine A. Phillips, a psychiatrist at Butler Hospital in Providence, R.I., notes that Ted responded favorably to fluoxetine (Prozac), and Helen showed considerable improvement on clomipramine (Anafranil).
Research conducted by Phillips and other investigators, described in May at the annual meeting of the American Psychiatric Association (APA) in Miami, is beginning to unravel the prevalence and nature of what clinicians refer to as body dysmorphic disorder (BDD).
"This problem strikes a chord with almost everyone living in modern cultures," contends Eric Hollander, a psychiatrist at Mount Sinai School of Medicine in New York City. "BDD patients come in all shapes and sizes, and there are nearly as many males as females."
For much of the last century, clinicians have written about people bedeviled by an unwarranted belief that their bodies have changed in weird or disgusting ways. Until the past decade, investigations of what has often been called dysmorphophobia have occurred mainly in Europe and Japan.
The official manual of psychiatric diagnoses, published by APA, included BDD for the first time in 1987. In its latest version, the manual treats BDD as one of several "somatoform disorders." These include hypochondriasis and other conditions characterized by physical symptoms not attributable to a medical illness or to another mental disorder.
BDD involves preoccupation with one or more imagined defects in appearance, resulting in marked emotional distress and severe problems at work and in social situations (SN: 2/13/93, p.108).
Some investigators now suspect that BDD stems from an as yet unspecified brain disturbance that also contributes to obsessive-compulsive disorder (OCD), social phobia (an intense fear of being seen or scrutinized by others in public situations), and perhaps major depression. Serotonin and another chemical courier, dopamine, probably play important roles in this core cerebral ailment, the scientists theorize.
Although the details of BDD's underlying biology remain murky, the condition does seem to occur relatively frequently in combination with OCD. A national survey of 419 people treated for OCD, directed by Mount Sinai's Hollander, finds that nearly one in four suffers from BDD as well. Although no one knows how prevalent BDD is, OCD afflicts about 2.4 million people in the United States at some time in their lives.
Both disorders, marked by obsessive thoughts and compulsive acts that disrupt daily life, tend to emerge in late adolescence and to last well into adulthood. OCD provokes ritual behaviors often intended to quell fears of contamination, aggressive or sexual impulses, or doubts about previous actions (such as whether doors have been locked). BDD usually involves a preoccupation with several imagined bodily defects, often including the nose, hair, skin, and mouth. Sometimes, perceived physical abnormalities appear on a family member or close friend.
BDD stands apart from OCD in some important ways, notes Mount Sinai psychiatrist Daphne Simeon. BDD patients rarely realize that their fears are unfounded, get little relief from constant examination of themselves in mirrors, and often cannot work or otherwise function in public. In contrast, many OCD patients recognize the strangeness of their obsessive thoughts, feel better after performing rituals (such as hand washing or door checking), and function relatively well in the social world.
Simeon bases her observations on a study of 442 people diagnosed with OCD, 51 of whom also suffered from BDD.
In another investigation, Butler Hospital's Phillips and her colleagues determined that 47 of 134 BDD patients had first developed social phobia, while many others experienced intense fear of public scrutiny and exposure as a result of their perceived ugliness. In fact, Japanese and Korean researchers treat BDD as a form of social phobia, Phillips notes.
Moreover, BDD occurs in about 15 percent of people who suffer from "atypical" major depression and 5 percent of those with more common symptoms of major depression, according to Phillips. She and her associates studied 172 outpatients diagnosed with major depression, including 53 atypical cases. Symptoms unique to atypical depression include increased appetite, oversleeping, a tendency to feel cheered up temporarily in response to positive events, and extreme sensitivity to perceived rejection by others.
To top it off, preliminary studies indicate that severe personality disorders commonly accompany BDD. Patients exhibit a variety of symptoms, including social anxiety, clinging dependency on others for approval, fears of intimacy, manipulation of others in close relationships, and impulsive fighting, says Fugen A. Neziroglu of the Institute for Bio-Behavioral Therapy and Research in Great Neck, N.Y..
A study directed by Neziroglu identified widespread signs of personality disorder in 13 of 17 BDD patients undergoing a 4-week trial of cognitive-behavioral therapy. Weekly therapy sessions attempted to reduce faulty beliefs about physical appearance and expose patients to their perceived defects without allowing them to engage in compulsive reactions (such as picking their skin or checking repeatedly in the mirror).
This approach reduced BDD symptoms modestly and left personality
disturbances largely intact, Neziroglu notes.
Available data cannot resolve whether BDD represents a form of obsessive-compulsive disorder or arises from severe personality disturbances, she asserts.
Whatever its origins, BDD often sparks an unyielding belief in the reality of the imagined physical defects--a certainty that qualifies as delusional, Phillips contends. For instance, her patient Helen's absolute conviction that her nose was misshapen couldn't be changed by contrary opinions or repeated plastic surgery.
In contrast, Phillips' other patient, Ted, displayed a greater sense that his skin complaints were strange and had created enormous problems in his life.
Interviews conducted by Phillips and her colleagues have uncovered strong delusions in 73 of 130 people diagnosed with BDD. Delusional patients showed more severe symptoms of the disorder and had performed more poorly in jobs and at school, Phillips reported at the APA meeting.
Serotonin-boosting drugs such as Prozac and Anafranil (the latter is often prescribed for OCD) offered significant relief to delusional BDD patients, she notes.
"This finding needs to be confirmed in controlled trials," Phillips holds. "But the data so far fly in the face of our standard treatment for delusional disorders, which is to prescribe neuroleptic [antipsychotic] medication."
Clinicians need to treat delusions as an aspect of BDD that can wax and wane, depending on the circumstances, she adds. For example, some people cite a fair amount of insight into the unreality of their bodily complaints when they are at home but become certain of their perceived ugliness when they go out in public or to a physician's office.
Some BDD patients apparently experience vivid visual illusions that bolster their certainty of the reality of physical defects, Phillips asserts. "When they get better on [serotonin-enhancing] drugs, some patients say that they see the spots on their face disappear or the unsightly body hair fall out," she remarks.
Not surprisingly, plastic surgery proves more alluring to many BDD sufferers than psychiatric help. Still, the proportion of plastic surgery patients plagued by imaginary physical defects may be far greater than now assumed, contends Mount Sinai psychologist Bonnie Aronowitz.
About 1 person in 50 who request plastic surgery exhibits BDD, according to a currently accepted estimate. But a survey directed by Aronowitz found that nearly one patient in two at an urban, hospital-based plastic surgery clinic met diagnostic criteria for BDD.
"We don't yet know if this high rate generalizes to all plastic surgery patients," Aronowitz says. "Further surveys need to be done at private and community clinics."
She and her coworkers administered questionnaires to 75 women and 16 men seeking help at Mount Sinai's plastic surgery clinic between January and May 1995. About two-thirds wanted cosmetic surgery; the rest cited medical problems that required surgical help.
Aronowitz found that 39 survey participants, or 43 percent, displayed BDD. Preoccupations with imagined defects in appearance and related BDD symptoms appeared more often in cosmetic surgery patients. However, several patients cited plastic surgery as a medical expense on Medicaid forms when they in fact sought cosmetic procedures, Aronowitz maintains.
Researchers do not yet know whether people with BDD can be screened out at plastic surgery clinics or, if that proves possible, whether plastic surgeons should refuse them surgery, referring them instead to psychiatrists.
Plastic surgeons now follow BDD research closely, Aronowitz points out. Of particular concern is the tendency of BDD sufferers to go from one physician to another and end up receiving numerous cosmetic procedures--as many as 15 in some cases--while experiencing an escalating sense of dissatisfaction with the results.
Psychiatrists also express concern over the lack of controlled treatment studies of BDD, Hollander asserts. Preliminary findings of an 8-week pilot trial, funded by the Food and Drug Administration and directed by Hollander, suggest that clomipramine provides more relief from BDD symptoms than does desipramine, an antidepressant that alters dopamine transmission.
Excessive serotonin activity in the brain may significantly influence the imagined physical defects at the heart of BDD, Hollander theorizes. A surplus of dopamine transmission may also play a role in some aspects of BDD, he adds, such as anxiety about imaginary physical defects and unwavering confidence in their reality.
"This is a real disorder that is relatively common," he argues. "We need to pay more scientific attention to it."