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BDD effects approximately 0.7% to 2.4% of general population. Specifically, in the United States, 2.2% of men and 2.5% of women suffer from BDD. <ref name="Koran">Koran LM, Abujaoude E, Large MD, Serpe RT. The prevalence of bodyfckLRdysmorphic disorder in the United States adult population. CNS Spectr.fckLR2008;13(4):316-322.</ref> Typically patients present in adolescence with an average age of sixteen years. Increased prevelance of BDD is seen in dermatological and cosmetic surgery practices.<ref name="Gupta" /><br>
BDD effects approximately 0.7% to 2.4% of general population. Specifically, in the United States, 2.2% of men and 2.5% of women suffer from BDD. <ref name="Koran">Koran LM, Abujaoude E, Large MD, Serpe RT. The prevalence of bodyfckLRdysmorphic disorder in the United States adult population. CNS Spectr.fckLR2008;13(4):316-322.</ref> Typically patients present in adolescence with an average age of sixteen years. Increased prevelance of BDD is seen in dermatological and cosmetic surgery practices.<ref name="Gupta" /><br>
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In spite of early onset of disease, most afflicted persons defer seeking treatment until early thirties. BDD seems to effect men and women equally, however some studies report a slightly higher frequency in women.<ref name="Crerand" />
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In spite of early onset of disease, most afflicted persons defer seeking treatment until early thirties. BDD seems to effect men and women equally, however some studies report a slightly higher frequency in women.<ref name="Crerand" /
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[[Image:BDD onset.gif|center]]<ref name="Healthy Living">Healthy vs Living. Body Image. https://mrkhealth.pbworks.com/w/page/64690414/Body%20Image%20-%20Aaron,%20Siddharth,%20Kyler,%20Ben (accessed 3 March 2014).</ref
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== Characteristics/Clinical Presentation <ref name="Crerand" /><ref name="Bjornsson" /><ref name="Gupta" /><ref name="WebMD" /><ref name="Ross">Ross J, Gowers S. Body dysmorphic disorder. Advances in Psychiatric Treatment. 17(2):142-149.</ref> ==
== Characteristics/Clinical Presentation <ref name="Crerand" /><ref name="Bjornsson" /><ref name="Gupta" /><ref name="WebMD" /><ref name="Ross">Ross J, Gowers S. Body dysmorphic disorder. Advances in Psychiatric Treatment. 17(2):142-149.</ref> ==
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[[Image:BDD chart.gif|center|361x455px]]
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[[Image:BDD chart.gif|center|361x455px]]
<ref name="Phillips 2" />
== Medications ==
== Medications ==
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Selective Serotonin Reuptake Inhibitors (SSRI) may help alleviate the symptom severity, and is the current medication of choice for treating BDD. There is some evidence that SSRI's are more effective than non-SSRI's in terms of pharmacological treatment. Additionally, SSRI's are frequently used in treatment of many of the co-morbid conditions associated with BDD, including depression, social phobia, bulimia, hypochondriasis, and anxiety. In the United States, the most common brand names of SSRI's are Celexa, Lexapro, Prozac, Zoloft, Luvox, Paxil, and Anafranil. Though SSRI's have been well studied for the treatment of BDD, there are currently no FDA approved pharmacologic interventions for this disorder.<ref name="Bjornsson" /><ref name="Phillips 3">Phillips KA, Hollander E. Treating body dysmorphic disorder with medication: evidence, misconceptions, and a suggested approach. Body Image. 2008;5(1):13-27.</ref>
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SSRI's can be used in conjunction with non-pharmacologic therapy (such as cognitive behavioral therapy). Caution must be taken when discontinuing an SSRI abruptly.<ref name="Phillips 3" />
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Other pharmacologic treatment options for BDD include anti-psychotics, benzodiazepines, lithium, serotonin-norepinephrine re-uptake inhibitors (SNRI), anti-epileptics, monoamine oxidase inhibitors (MAOI), and tricyclic antidepressants (TCA). These medications have only been studied in small trials, with a result of TCA's and SNRI's demonstrating the greatest potential.<ref name="Gupta" /
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== Diagnostic Tests/Lab Tests/Lab Values ==
== Diagnostic Tests/Lab Tests/Lab Values ==
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There are currently 3 diagnostic criteria for BDD:<ref name="APA">American Psychiatric Association. Diagnostic and StatisticalfckLRManual of Mental Disorders, Fourth Edition, Text Revision.fckLRWashington, D.C.: American Psychiatric Association, 2000.</ref><br>
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#A preoccupation with an imagined or slight defect in appearance
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#marked distress or impairment in social, occupational, or other areas of functioning resulting from the appearance preoccupation
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#the preoccupation is not attributable to the presence of another psychiatric disorder
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Diagnosis is difficult because of the accompaning shame that goes along with BDD, making a person with BDD reluctant to seek medical attention. More frequently plastic surgeons or dermatologists may suspect such a disorder based on frequent complaints and seeking surgical intervention. If a healthcare practitioner suspects BDD, then a referral to a psychiatrist or psychologist is recommended and should be followed through by the patient.<ref name="Crerand" /><ref name="WebMD" />
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== Etiology/Causes ==
== Etiology/Causes ==
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Multifactorial contributions are thought to play a role in the development in BDD, and they include:<ref name="Crerand" /><ref name="Ross" /><br>
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*neurobiological: there is some evidence to suggest a genetic component related to BDD. Studies have estimated that approximately 20% of BDD sufferers have a first degree relative with the disorder.<ref name="Ross" /> Other hypothesis have theorized an abnormal release and uptake of serotonin and dopamine, inflammatory processes interfering with serotonin production, and brain asymmetries of the caudate nucleus, or injury to the frontotemporal region.
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*psychological factors: "psychoanalytic explanations suggest that body dysmorphic disorder arises from an unconscious displacement of sexual or emotional conflist, or feelings of inferiority, guilt, or poor self image on to a body part."<ref name="Phillips 4">Phillips, K. A. Body dysmorphic disorder: The distress of imagined ugliness. Am. J. Psychiatry 148: 1138, 1991.</ref> A cognitive behavioral therapeutic approach suggests that emotional, cognitive, and behavioral factors combine to produce this disorder. Cognitive factors include an unrealistic perfect body image, emphasis on attention to perceived defect, or a misinterpretation of others responses to their perceived defect. Behavioral factors are thought to stem from positive or negative reinforcment of certain physical characteristics, and is related to social learning.
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*sociocultural factors: physical and psychological changes due to reinforcement during adolescence (e.g. neglectful, rejecting, critical) may contribute to image dissatisfaction.<ref name="Crerand" /> Traumatic life events such as physical or sexual abuse may predispose a person to developing BDD. Even seemingly benign forms of teasing, if chronic in nature, have been proposed as contributing factors to development of this disorder - up to 60% of people with BDD report this.<ref name="Ross" />
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== Systemic Involvement ==
== Systemic Involvement ==
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Systemic manifestations of the disease are associated primarily with the comorbid conditions, as listed above. In particular, depression has been correlated with many systemic disorders, including:<ref name="Goodman">Goodman CC, Snyder TE. Differential Diagnosis for Physical Therapists, Screening for Referral. Saunders; 2012.</ref><br>
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*cardiovascular: chest pain, palpatations, tachycardia
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*gastrointestional: irritable bowel syndrome, GERD, ulcers
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*neurological: parasthesias, dizziness, memory lapses
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*musculoskeletal: weakness, fatigue, chronic low back pain, fibromyalgia
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*immune: autoimmunity, recurrent infections, environmental hypersensativities
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*other: insomnia, headaches
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Additionally, substance abuse may disrupt many organ systems, including:<ref name="Goodman" />
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*liver
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*kidneys
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*heart
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*pancreas
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*skeletal
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Eating disorders are known to have deleterious effects on entire body systems, and are unique to each specific case and disorder.
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== Medical Management (current best evidence) <ref name="Crerand" /><ref name="Gupta" /><ref name="Ross" /> ==
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As outlined above, pharmacologic intervention is almost always utilized for the treatment of BDD despite the limited studies proving it efficacy. In addition to pharmacological treatment, psychological intervention is warranted. Currently cognitive behavioral therapy (CBT) is considered the gold standard treatment with BDD.<ref name="Ross" /> CBT treatments may include elimination of body checking, cognitive techniques to modify thoughts, exposure to avoided situations, and coping mechanisms for their preoccupation. Ultimately the goal of CBT is to help the person to change their innacurate perception of their physical self, and to place less emphasis on their physical appearance. Metacognitive therapy, which seeks to modify how a person thinks, has recently been used with limited success in the treatment of BDD.<ref name="Rabiei">Rabiei M, Mulkens S, Kalantari M, et al. Metacognitive therapy for body dysmorphic disorder patients in Iran: acceptability and proof of concept. J Behav Ther Exp Psychiatry. 2012;43:724-729.</ref><br>
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= Medical Management
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current best evidence
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In 2005, the United Kingdom added the NICE guidelines for treatment of BDD and OCD. These guidelines suggest a step-wise approach to treating these disorders. <ref name
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"NCCMH">National Collaborating Centre for Mental Health
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UK
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. Obsessive-Compulsive Disorder: Core Interventions in the Treatment of Obsessive-Compulsive Disorder and Body Dysmorphic Disorder. Leicester (UK): British Psychological Society; 2006. (NICE Clinical Guidelines, No. 31.) Available from: http://www.ncbi.nlm.nih.gov/books/NBK56458/</ref>
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*mild disorders (recommend a guided self-help book)
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*moderate disorders (SSRI or CBT)
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*severe disorders (combination of SSRI and CBT)
== Physical Therapy Management (current best evidence) ==
== Physical Therapy Management (current best evidence) ==
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Persons with BDD are primarily treated by physicans, and thus, specific treatment for BDD falls outside the scope of physical therapy practice. It is crucial for physical therapists to be aware of BDD in patients, as it relates to patient education, interpersonal interaction, personal wellness, and quality of life. Physical therapists are often the healthcare practitioner with which patients may feel comfortable confiding in, due to the nature of the profession. Recognition of the potential for BDD and appropriate refferal is essential for physical therapy practice. Physical activity has been proven to provide positive psychological benefits, in addition to the physical wellness it provides, and thus may be an appropriate adjunct therapy for persons participating in traditional BDD therapy.<br>
== Alternative/Holistic Management (current best evidence) ==
== Alternative/Holistic Management (current best evidence) ==
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At this time, studies have demonstrated no efficacy for the use of non-pharmacological and non-psychiatric treatment of BDD. <ref name="Crerand" /> Other forms of treatment sought most often include dermatology and surgical repair of perceived defect. Surgery is not recommnended for the treatment of BDD, due to concerns that psychological dysfunction may project to another part of the body.<ref name="Crerand" /><ref name="Ross" />
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= Differential Diagnosis ==
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One study determined 30% of surgeons surveyed consider BDD an absolute contraindication for surgery.<ref name
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"Sarwer">Sarwer, D. B. Awareness and identification of body dysmorphic disorder by aesthetic surgeons: Results of a survey of American Society for Aesthetic Plastic Surgery members. Aesthetic Surg. J. 22: 531, 2002.</ref>
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== Differential Diagnosis <ref name="Goodman" /> ==
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*Major depressive disorder
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*Anxiety <br>
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*Obsessive compulsive disorder
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*Social phobia<br>
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*Eating disorders: Anorexia and bulimia
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*Personality disorder
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*Bipolar disorder
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*Seasonal affective disorder<br>
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== Case Reports/ Case Studies ==
== Case Reports/ Case Studies ==
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== Resources <br> ==
== Resources <br> ==
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[http://www.adaa.org/understanding-anxiety/related-illnesses/other-related-conditions/body-dysmorphic-disorder-bdd <span style="text-decoration: underline;">Anxiety and Depression Association of America</span>]<br>
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[http://www.amazon.com/Overcoming-Problems-Including-Dysmorphic-Disorder/dp/1845292790 Overcoming Body Image Problems Including Body Dysmorphic Disorder (book)]
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed]) ==
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed]) ==