Expert answer:Body Dysmorphic Disorder
Solved by verified expert:APA formatThe handout on your mental health disorder should be a good preparation for what you will be discussing during your presentation. It is meant to be the outline for your presentation so that you are not stressing out before the big day thinking that you don’t have enough to talk about. You’ve been preparing all semester for the presentation, so the handout is like a little confidence-booster to remind you that you know what you’re talking about and have a lot of scholarly and informed things to say! Your handout can have pictures if you wish, or none at all. It’s up to you. Some of you are visual people and prefer pictures or charts while others like a clean, typed look. You won’t be given extra or docked points for either style, as long as all of the information required is present.Your handout needs to have citations after each piece of information so that I (and your peers), know where the information is coming from. For example: “The following are symptoms of bipolar disorder I:….(Diagnostic and Statistical Manual of Mental Health Disorders (5th ed.).” Your handout should also contain the following: -References to the three peer-reviewed journal articles that you worked on during and outside of class. -A reference page at the end of the presentation that contains at least 10 references upon which your information is based. -Diagnostic information for your disorder that comes DIRECTLY from the Diagnostic and Statistical Manual of Mental Health Disorders (5th edition), DSM-5. -Explanation of symptoms in your OWN words–words and concepts that are unique to the disorder that need to be described in general terms to the class. – Statistics about your disorder-Risk factors-History of the disorder-Treatment options (focus on medical, therapies, other…)
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Body dysmorphic disorder and
obsessive–compulsive disorder:
similarities, differences and the
classification debate
Expert Rev. Neurother. 8(8), 1209–1218 (2008)
Anne Chosak, Luana
Marques, Jennifer L
Greenberg, Eric Jenike,
Darin D Dougherty
and Sabine Wilhelm†
†
Author for correspondence
Harvard Medical School,
OCD & Related Disorders
Program, Simches Research
Building, Massachusetts General
Hospital, 185 Cambridge Street,
Boston, MA 02114, USA
Tel.: +1 617 724 6146
Fax: +1 617 643 3080
sabinewilhelmwilhelm@
earthlink.net
www.expert-reviews.com
Obsessive–compulsive disorder and body dysmorphic disorder have many similarities in clinical
presentation. Obsessive–compulsive disorder has historically been considered an anxiety disorder,
whereas body dysmorphic disorder has been grouped among the somatoform disorders.
Researchers in these areas are currently debating whether the similarities warrant the inclusion
of body dysmorphic disorder within a proposed category of obsessive–compulsive spectrum
disorders. This article describes the association between obsessive–compulsive disorder and
body dysmorphic disorder as evidenced by the emerging literature, and presents theoretical and
clinical implications of this association.
KEYWORDS : body dysmorphic disorder • dysmorphophobia • obsessive–compulsive disorder • obsessive–compulsive
spectrum disorders • somatoform disorders
Conceptual and practical disputes surround
the nosology of obsessive–compulsive disorder
(OCD) and body dysmorphic disorder (BDD).
Although BDD is classified as a somatoform
disorder and OCD as an anxiety disorder
in the Diagnostic and Statistical Manual of
Mental Disorders (DSM)-IV there has been
much debate regarding the classification of
and the relationship between these disorders.
For instance, the similar pathophysiology and
treatment response of OCD to other disorders
with repetitive thoughts and behaviors has led
many researchers to group OCD under its own
entity with similar disorders, the obsessive–
compulsive spectrum disorders (OCSDs).
Similarly, controversies surround the classification of BDD, including its current classification as a somatoform disorder, its relationship
to the affective spectrum, and its relationship to
OCD. Diagnosis around the delusional variants
of both disorders has also incited debate. The
classification of BDD and OCD has important
diagnostic and treatment implications for these
disorders and the general taxonomic system.
The present article reviews current literature on
clinical features, biological bases, and treatment
options for OCD and BDD, and then describes
the contemporary classification debate.
10.1586/14737175.8.8.1209
Obsessive–compulsive disorder:
definition & key features
In the DSM, OCD is currently classified as a
unitary disorder under the anxiety disorders.
However, OCD is a clinically heterogeneous disorder, which has long been noted in the literature
[1] . In 1869 Falret made the distinction between
folie du doute (madness of doubt) and délire du
toucher (delusion of touch) [1] , and several factor analytic studies have attempted to delineate
OCD into more homogeneous subtypes. These
factor-analytic studies have yielded mixed results;
however, at least four symptom dimensions (symmetry/ordering, hoarding, contamination/cleaning and obsessions/checking) have consistently
emerged, each associated with distinct patterns
of pathophysiology, comorbidity and treatment
response [1] .
In its current classification as an anxiety disorder, the DSM defines the central feature of
OCD as recurrent obsessions or compulsions
that are time-consuming, distressing or impairing [2] . Obsessions are intrusive thoughts,
images or impulses, whereas compulsions are
repeated behaviors or mental actions designed
to reduce distress. Common obsessions include
excessive concerns with contamination, doubt
whether an action has been performed correctly,
© 2008 Expert Reviews Ltd
ISSN 1473-7175
1209
Review
Chosak, Marques, Greenberg, Jenike, Dougherty & Wilhelm
order/symmetry, and aggressive or sexual thoughts or impulses.
Obsessions cause distress or anxiety, and consequently the person
with OCD tries to ignore, suppress or neutralize the thoughts via
compulsions. Typical compulsions include washing, counting,
checking, seeking reassurance and ordering/arranging. Often
individuals with OCD will avoid situations, people or activities
that trigger OCD-related anxiety.
For an adult to meet criteria for OCD, the obsessions or compulsions must be recognized as somewhat unreasonable or excessive at some time during the course of the disorder (may be absent
in children). Insight in OCD occurs on a continuum, and patients
with good and poor insight are similar in terms of demographic
and clinical characteristics [3] . Obsessions must be different from
real-life worries such as finances or relationship issues. The individual must also understand that the thoughts, images or urges are
generated internally, as opposed to believing some external force
is causing the intrusions. Compulsions are performed in response
to an intrusion or are performed according to a specific and rigid
routine. Compulsions are intended to decrease distress or prevent
an adverse event, but are not appropriate responses (for instance,
washing hands for hours at a time to prevent a cold).
In adults, OCD tends to co-occur with other DSM-IV diagnoses, such as depression, other anxiety disorders, eating disorders,
tic disorders, obsessive–compulsive personality disorder, avoidant
personality disorder and dependent personality disorder. Children
with OCD may have co-occurring learning disorders or disruptive behavior disorders. OCD symptoms at subclinical levels are
common, and the diagnosis should only be given when the symptoms cross a threshold of distress or impairment, or are significant
enough to be time-consuming.
The lifetime prevalence of OCD is estimated at approximately
1.6%, making it a relatively common psychiatric disorder [4] .
OCD frequently begins during early adolescence, although some
cases do have onset in early childhood and some in adulthood.
OCD symptoms tend to persist over the lifespan, although symptoms may change in content and severity. OCD is as common
among females as it is among males in adulthood, although
because symptoms may start earlier in boys, it is more common
in childhood among boys than among girls [2] .
Body dysmorphic disorder: definition & key features
Morselli first described BDD in 1886 as ‘dysmorphophobia,’ and
its symptoms have since been categorized under various nomenclatures in the psychiatric, dermatologic and cosmetic surgery
literature [5] . However, dysmorphophobia did not receive diagnostic recognition until DSM-III [6] , and its new name, body dysmorphic disorder, until DSM-III-Revised [7] . Since 1980, BDD
has been classified in the DSM as a somatoform disorder.
The DSM-IV-Text Revision (TR) defines BDD as an excessive preoccupation with an imagined or minor flaw in appearance
[2] . The appearance concerns must be distressing and/or interfering with social, occupational or other areas of functioning.
The preoccupations can involve any part of the body but most
often focuses on the skin, hair or the nose. The preoccupation
should not be better accounted for by another mental disorder
1210
(e.g., dissatisfaction with body shape and size in anorexia nervosa).
Individuals with BDD frequently describe the thoughts about
their presumed defects as difficult to control and often spend many
hours a day ruminating about imperfections in their appearance.
Most individuals with BDD engage in repetitive behaviors, usually
done to check on, hide or improve the perceived appearance flaws.
They may check mirrors and other reflecting surfaces, spend an
inordinate amount of time grooming, ask others for reassurance,
attempt to camouflage, compare their appearance to that of others
around them or in the media, or exercise excessively [8] .
Because of their appearance concerns, many individuals with
BDD will avoid social and public situations. This can restrict
educational and vocational options. Some individuals with BDD
become extremely socially isolated or housebound [9] . Individuals
with BDD may look for medical solutions to their appearance
concerns, such as dermatological, surgical and dental procedures
[10] . These procedures may or may not alleviate the concern, and
some individuals will have repeated surgeries on the same area.
Individuals with BDD have a relatively high rate of suicidal ideation, suicide attempts and completed suicide [11] , with as many as
25% of individuals with BDD reporting having attempted suicide
at least once [11,12] . In a direct comparison of suicidal ideation in
OCD and BDD, individuals with BDD were significantly more
likely than individuals with OCD to experience lifetime suicidal
ideation (77.8 vs 54.8%), although in this particular sample the
OCD group were as likely as the BDD group to have attempted suicide (13.3% for BDD vs 15.9% for OCD) [13] . Earlier reports (e.g.,
[14]) had shown higher levels of suicidal ideation in a BDD sample
compared with an OCD sample (70 vs 47%) and a higher rate of
suicide attempts (22 vs 8%) in the BDD sample compared with the
OCD sample. Only one study has reported on completed suicide
in BDD, but the annual rate appears to be extremely high (0.3%),
and much higher than for almost all other mental disorders [15,16] .
Suicidality in BDD underscores its high morbidity, the importance
of identifying and treating the disorder, and represents one clear
difference from the clinical presentation of OCD.
Level of insight in individuals with BDD is frequently poor in
contrast to OCD, where the majority (∼90%) of those affected
have insight [3,17] . The delusional and nondelusional variants of
BDD are classified as separate disorders in DSM-IV; that is, a
patient who has BDD with complete lack of insight will meet
DSM-IV-TR criteria for two disorders, BDD and delusional disorder, somatic type. However, a growing body of research suggests that delusional and nondelusional variants may reflect varying degrees of insight within a single disorder [18] . For example,
available data suggest no significant differences between BDD
and its delusional disorder variant with regard to demographics, phenomenology, course, associated psychopathology, family
history or treatment response [18] . Individuals with delusional
BDD tend to report more impairment and poorer quality of life
than those with the nondelusional variant, which may suggest the
delusional variant to be a more severe form of the disorder [18] .
Individuals who meet criteria for BDD frequently meet criteria
for depressive disorders, OCD, substance use, social phobia and
personality disorders [10] .
Expert Rev. Neurother. 8(8), (2008)
Body dysmorphic disorder & obsessive–compulsive disorder
Several prevalence studies have examined BDD, but their
obtained rates vary widely, which may be due to methodological differences. The largest study so far has been completed
in Germany and found a prevalence rate of 1.7% [19] . Rates of
BDD are high in dermatology settings, cosmetic surgery settings
and other psychiatric groups [20] . BDD may be present at a very
high rate among general inpatients [21] . One recent report found
BDD to be present in 15% of severely ill (residential) patients
with OCD [22] . In another study of psychiatric inpatients, BDD
was identified in half the inpatients with borderline personality
disorder [23] . Despite its prevalence and severity, BDD is often
missed in clinical settings. Often individuals with BDD are too
ashamed of their symptoms to report them, even to their own
providers [21] . Currently, few clinicians are experienced with the
diagnosis and treatment of BDD, so many cases may be missed.
Patients may receive medical treatment, such as surgery, rather
than seek psychiatric help. However, surgical interventions rarely
lead to a sufficiently satisfying outcome [24] .
The onset of BDD tends to be in adolescence, although, like
OCD, it can have a childhood onset. BDD is sometimes found
to be more common in women than in men (e.g., 60% in [19]) ,
although other studies suggest approximately equivalent prevalence in men and women [10] . Like OCD, BDD is a chronic disorder although the specific concerns and severity may vary over
the lifespan [13] .
Clinical presentation of OCD & BDD
Individuals with OCD tend to have distorted beliefs that are
consistent with their specific OCD symptoms, but there are also
some cognitive themes that are common to many individuals
with OCD. The cognitive themes that tend to be similar are
beliefs about the importance of thoughts and the importance of
controlling thoughts, perfectionism, intolerance of uncertainty,
over-responsibility and overestimations of danger [25] . Such beliefs
may contribute to the maintenance of OCD patterns.
Like people with OCD, many individuals with BDD show
evidence of distorted beliefs that may play a role in maintaining
their disorder. However, unlike OCD, BDD beliefs are seldom
experienced as intrusive and senseless [26] . Some researchers
(e.g., [27]) have found it useful to look at BDD from the perspective of overvalued ideation (excessive preoccupation around a certain fi xed and overvalued notion), also found in hypochondriasis
and anorexia. Some of the cognitive themes in BDD are similar to
those in individuals with OCD, such as overvaluing perfectionism
and symmetry [28] . Other cognitive themes appear more specific
to the BDD pathology, such as an over-focus on the importance
of, and meaning ascribed to, thoughts about appearance. For
instance, one woman with BDD reported believing that the
age lines around her eyes and mouth made her ‘hideous’, and
that because of these lines she was not only unattractive but also
unlovable and unworthy. Because of this belief she would avoid
leaving the house for days at a time, was unable to work and
completely avoided dating. Unlike OCD beliefs, BDD beliefs
frequently involve shame or inferiority, similar to beliefs seen in
social phobia [29] .
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In BDD, but not in OCD, appearance is a central component
in the individual’s valuation of self worth. Individuals with BDD
are apt to think that others notice and judge appearance flaws
harshly, or are laughing at or mocking them. Depending on how
strongly these erroneous beliefs are held, they may be classified as
ideas of reference or delusions of reference. Individuals who have
delusional ideas of reference related to their appearance, and are
completely convinced that others are taking special notice of (e.g.,
laughing about or staring at) their perceived flaw, may in fact be
diagnosed with a delusional disorder, somatic type. With respect
to beliefs, the delusional aspect of BDD (including delusional
appearance-related beliefs and delusions of reference) is markedly
different from the clinical presentation of OCD [8,30] ; although
individuals with OCD may also have low insight and some are
delusional, a higher proportion of people with OCD have at least
some insight into the reasonableness of their concerns. In a direct
comparison of individuals with BDD to individuals with OCD,
those with BDD were three times as likely as those with OCD
to meet the delusional criterion [13] .
Behavioral patterns and compulsions in OCD are highly varied. Even two individuals with the same general OCD concerns
may exhibit quite different compulsions. One person with contamination concerns may wash his hands with scalding water for
a certain number of times; another may feel ‘decontaminated’
after wiping his hands with a tissue or moistened wipe or saying
a particular prayer silently. In general, the compulsions and avoidance habits are designed to satisfy an urge or to decrease anxiety
generated by contact with OCD triggers. At times the compulsions are successful with regard to reducing anxiety in the short
term; at other times a person with OCD may get caught up in
an episode in which their compulsions trigger further doubt and
a need to perform even more compulsions, which may increase
rather than decrease anxiety.
People with BDD may engage in some repetitive behaviors similar or identical to those in OCD, but there are also a number of
behavioral patterns that are specific to BDD. Individuals with
BDD may repeatedly check the specific aspect(s) of their appearance they consider problematic, seek out and/or avoid mirrors or
other reflective surfaces, seek reassurance, dress to camouflage,
pick skin and groom excessively [8,10] . These behaviors may take
hours each day. Many individuals with BDD are hyperaware of the
effect of lighting arrangements and will seek out or avoid particular types of lighting (most prefer to avoid strong or harsh lighting).
Most individuals with BDD compare aspects of their appearance
to others they know, or to celebrities or actors. Dietary restrictions
and excessive exercise are also common in this population. As
noted previously, some individuals with BDD pursue dermatological, dental and surgical interventions, and some will perform
self-surgery in an attempt to remedy the supposed defect.
Avoidance is a key behavioral component of most types of
OCD. Individuals with OCD will avoid subtle and obvious triggers, and opportunities for triggers. For example, a contamination
phobic person might well avoid touching surfaces, shaking hands
and using public restrooms. She/he might avoid crowds or public transportation. More subtle contamination-related avoidance
1211
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Chosak, Marques, Greenberg, Jenike, Dougherty & Wilhelm
could include standing a certain distance from another person
or averting the head rather than facing the person to whom she/
he is speaking. Some OCD patients will avoid or cancel social or
professional obligations if there is word of a virus going around. A
parent with intrusive thoughts of causing harm may avoid spending time alone with the child, avoid using sharp implements such
as a knife or even avoid certain aspects of caring for the child
(such as changing diapers) out of the irrational fear she/he might
molest the infant.
Individuals with BDD tend to avoid triggering situations, as do
those with OCD, but again there are differences in the type of
avoidance patterns in the two disorders. Individuals with BDD
characteristically dread and feel a need to avoid many social and
public situations so as to avoid any attention directed towards
the perceived imperfections. People with BDD will often avoid
intimate contact, for example, potential romantic partners, parties and city streets, in their efforts to minimize distress due to
appearance concerns. Individuals with BDD may even avoid contact (so as to avoid scrutiny) with close family members. Social
avoidance is part of the reason so many individuals with BDD
are impaired in their vocational and social lives. In their excessive
concerns about being judged by others and avoidance of social
situations, individuals with BDD are more similar to individuals with social phobia than they are to individuals with OCD.
This intense avoidance and social isolation may be part of the
reason why depression and suicidal ideations are so common in
this group.
Biological factors in OCD & BDD
OCD is a familial condition and the presence of OCD in the
family increases the risk for OCD and other putative OCSDs (see
‘Classification debate’ section). One early study demonstrated that
first-degree relatives of OCD probands have a significantly greater
risk of developing OCD or of experiencing subthreshold OCD
symptoms (10.3 and 7.9%) than controls (1.9 and 2.0%) [31] .
Similar results have been found in BDD, where 5.8% of the
first-degree relatives of 200 BDD probands were found …
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