Advances in a cognitive behavioural model of body dysmorphic disorder
Introduction
Body dysmorphic disorder (BDD) is characterised by a preoccupation with an imagined defect in one’s appearance or, in the case of a slight physical anomaly, the person’s concern is markedly excessive. The person must also be significantly distressed or handicapped in his or her occupational and social functioning (American Psychiatric Association, 1994). There is frequent comorbidity in BDD especially for depression, social phobia and obsessive–compulsive disorder (OCD) (Neziroglu et al., 1996, Phillips and Diaz, 1997; Veale et al., 1996a). There is also heterogeneity in the presentation of BDD from individuals with borderline personality disorder with self-harming behaviours to others with muscle dysmorphia (Pope, Gruber, Choi, Olivardia, & Phillips, 1997), who are less handicapped. They share a common feature of a preoccupation with an imagined defect or minor physical anomaly. The most common preoccupations concern the skin, hair, nose, eyes, eyelids, mouth, lips, jaw and chin, however any part of the body may be involved and the preoccupation is frequently focussed on several body parts simultaneously (Phillips, McElroy, Keck, Pope, & Hudson, 1993). Complaints typically involve perceived or slight flaws on the face, asymmetrical or disproportionate body features, thinning hair, acne, wrinkles, scars, vascular markings and pallor, or ruddiness of complexion. Sometimes the complaint is extremely vague or amounts to no more than a general perception of ugliness. BDD is characterised by time consuming behaviours such as mirror gazing, comparing particular features to those of others, excessive camouflage, skin-picking and reassurance seeking. There is usually avoidance of social situations and of intimacy. Alternatively such situations are endured with the use of alcohol, illegal substances or safety behaviours similar to social phobia.
The prevalence rate of BDD in the community is reported as 0.7% in two studies (Faravelli et al., 1997; Otto, Wilhelm, Cohen, & Harlow, 2001) with a higher prevalence of milder cases in adolescents and young adults (Bohne et al., 2002). The prevalence of BDD is about 5% in a cosmetic surgery setting (Sarwer, Wadden, Pertschuk, & Whitaker, 1998) and 12% in a dermatology clinic (Phillips, Dufresne, Wilkel, & Vittorio, 2000). Surveys of BDD patients attending a psychiatric clinic tend to show an equal sex incidence and sufferers are usually single or separated (Neziroglu & Yaryura-Tobias, 1993; Phillips & Diaz, 1997; Phillips et al., 1993, Veale et al., 1996a). Veale et al. (1996a) found a greater preponderance of women but this may be because of a referral bias. It is also possible that, in the community, while more women are affected overall, a greater proportion experience milder symptoms.
Although the age of onset of BDD is during adolescence, patients are usually diagnosed 10–15 years later (Phillips, 1991; Phillips & Diaz, 1997; Veale et al., 1996a). Patients may be secretive because they may think they will be viewed as vain or narcissistic. They are therefore more likely to present to mental health practitioners with symptoms of depression or social anxiety unless they are specifically questioned about symptoms of BDD. BDD patients are the most distressed and handicapped of all the body image disorders with a high rate of depression and suicide or “do it yourself” (DIY) cosmetic surgery. Phillips (2000) used a quality of life measure and found a degree of distress that is worse than that of depression, diabetes or bipolar disorder.
BDD is probably best conceptualised as having both quantitative and qualitative differences from normal body dissatisfaction and body image. For example, the degree of importance attached to one’s appearance in defining one’s self might be at the extreme end of a normal dimension. However, the distorted imagery experienced by some BDD patients has a more qualitative difference to normal body image.
Section snippets
A cognitive behavioural model of BDD
There are similar features in psychopathology of BDD with OCD and social phobia, with frequent comorbidity. It is not therefore surprising that a cognitive behavioural model of BDD described below has some overlap with that of social phobia (Clark & Wells, 1995), OCD (Salkovskis, 1999) and health anxiety (Warwick & Salkovskis, 1990) which influence I would like to acknowledge. A model for BDD needs to focus on features, which are unique to BDD. One such feature is the relationship with
The self as an aesthetic object
The self as an aesthetic object refers to the experience of extreme self-consciousness and self-focussed attention on a distorted image. It is proposed that the cycle begins when an external representation of the person’s appearance (e.g. looking in a mirror) activates a distorted mental image (Fig. 1). A mental image is defined as “contents of consciousness that possess sensory qualities, as opposed to those that are purely verbal or abstract” (Horowitz, 1970). The process of selective
Negative appraisal of body image
The next step is the negative appraisal and aesthetic judgement of the image, by activation of assumptions and values about the importance of appearance. In BDD, appearance has become over-identified with the self and at the centre of a “personal domain” (Veale, 2002). The term, “personal domain”, was first used by (Beck, 1976) to describe the way a person attaches meaning to events or objects around them. At the centre of a personal domain are a person’s characteristics, his physical
Rumination and comparison with ideal
BDD is defined as a “preoccupation” with many individuals reporting that it is on their mind most hours of the day. Some of the cognitive processes that determine a preoccupation can be explained by the fixed attentional capacity on the distorted imagery and negative appraisal described above. However little is known in BDD about other cognitive processes that contribute to the nature of the “preoccupation” and the similarities or differences to worry or an obsession. For example, the process
Emotion
Emotions in BDD are complex and will depend upon the exact appraisal of the situation and event. The emotions include (a) internal shame (or self-disgust) when the individual compares and ranks his or her appearance as lower than others; (b) external shame and anticipatory social anxiety based on judgements about how others are likely to scrutinise, humiliate or reject them; (c) depression and hopelessness at the person’s failure to reach his or her aesthetic standard, perhaps living in social
Safety behaviours
BDD is frequently conceptualised as on the spectrum of OCD partly because of the similarities in psychopathology (e.g. “compulsive behaviours” such as mirror checking). This is incorporated in the most widely used outcome measure (Yale Brown Obsessive Compulsive Scale modified for BDD (Phillips et al., 1997). I believe however, it is better to conceptualise all the behavioural strategies to reduce the risk of danger in feared situations including escape and non-repetitive behaviours used by BDD
Risk factors
The cognitive behavioural model described is only relevant for factors that maintain a distorted body image. As yet, only limited data are available on risk factors for the development of BDD and the final pathway described above. One of the most important challenges for any epidemiological investigation in this area is distinguishing between risk factors that are specific to BDD and those that predispose to other disorders. Because of the similarity in phenomenology and reported comorbidity (
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