Body Dysmorphic Disorder
July 14, 2004, KidsHealth.org

To your dismay, your daughter has started to complain more and more about the appearance of her eyelids. She grudgingly compares them to those of her classmates. You frequently catch her standing before a mirror, scrutinizing her appearance. When you try to discuss your concerns, she becomes defensive. To make matters worse, you've observed her reading materials about cosmetic surgery.

How do you know if your daughter is simply experiencing a typical stage in adolescence or if she has a more complex problem? Teens seem to worry incessantly about their weight and appearance, but some may become obsessed with a specific flaw or perceived defect. Along with eating disorders, body dysmorphic disorder (BDD) has become a growing concern for young adults.

The severity of this disorder varies. Some are able to function and cope with daily life, whereas others experience paralyzing symptoms of depression, anxiety, and avoidance of social situations.

"These adolescents have a very distorted view of how they look, and it does not match how other youth see them," says Katharine Phillips, MD, director of the Body Image Program at Butler Hospital in Providence, Rhode Island.

What Is BDD?
Those who have BDD are abnormally preoccupied with a real or imagined defect in their physical appearance. For example, they may worry endlessly that their skin is pale, their hair is too curly, their nose is too long, or something else is wrong with the way they look. When others tell them they look fine or that the flaw isn't noticeable, people with this disorder don't hear or believe it. The person with BDD may also experience periods of depression, anxiety, and even suicidal thoughts because of their preoccupation with their perceived flaw. "Body dysmorphic disorder is a type of anxiety disorder. The disorder is different from eating disorders because it involves other factors besides one's weight or body size. Physical features or attributes are what provokes the person's anxiety and negative beliefs. Those with BDD have several 'cognitive distortions' about how they look. Cognitive distortions are distorted beliefs about a perceived flaw," explains Steven Pittman, PhD, a licensed clinical psychologist.

What Causes BDD?
BDD is thought to be associated with a chemical imbalance in the brain, which may be genetically based.

"A child who has a family with a history of generalized anxiety disorder or obsessive-compulsive disorder is more prone to developing this type of problem. Also, those coming from a family with an upward socioeconomic status seem to be more at risk for developing this disorder. I have also seen a trend in families that have unrealistically high expectations," Dr. Pittman says.

Signs and Symptoms of BDD
There are many ways to determine if your child is at risk for developing this disorder, or if she is already dealing with it. Dr. Phillips offers these clues:
o frequently comparing the appearance of the perceived defect with that of others
o frequently checking appearance of the specific body part in mirrors and other reflective surfaces
o camouflaging the perceived defect with clothing, makeup, hats, hands, or posture
o seeking surgery, dermatological treatment, or other medical treatment when doctors or other people have said that the flaws are minimal or nonexistent or that such treatment isn't necessary
o seeking reassurance about the flaw or attempting to convince others of its ugliness
o excessive grooming (for example, combing hair, shaving, removing or cutting hair, applying makeup)
o avoiding mirrors
o frequently touching the perceived defect
o picking one's skin
o measuring the disliked body part
o excessively reading about the defective body part
o avoiding social situations in which the perceived defect might be exposed
o feeling anxious and self-conscious around other people because of the perceived defect

Signs of BDD are often evident in a child's late teen years or early adulthood, but certain behaviors or other signs may be noticed earlier.

Diagnosing BDD
BDD seems to affect males and females equally. A person whose family has a high incidence of mood disorders and obsessive-compulsive disorders also seems to be at high risk. According to the American Psychiatric Association's Diagnostic and Statistical Manual - 4th Edition (DSM-IV), doctors use the following criteria to diagnose BDD:
o preoccupation with the perceived physical defect
o clinically significant distress or impairment in school, work, or social situations
o preoccupation is not better explained by another mental disorder, such as anorexia nervosa

Treating BDD
"Therapy and medication are the primary means of treatment of this disorder. Antidepressants such as sertaline and fluoxetine and others are used in conjunction with psychotherapy. Often, the medication may not cure the disorder, but it makes the person more amenable to therapy and hopefully more open to receiving ongoing treatment," Dr. Pittman says.

Katharine Phillips concurs: "The prescription-only SSRIs [selective serotonin reuptake inhibitors such as sertaline and fluoxetine] are not addictive and are usually well tolerated. They can significantly relieve BDD symptoms by diminishing bodily preoccupation, distress, depression, and anxiety and by significantly allowing increased control over the youth's thoughts and improving functioning. In some cases, these medications are lifesaving, especially for those who have attempted suicide in their despair over their appearance."

Cognitive-behavioral therapy may also be helpful. In this therapy, a therapist helps the person with BDD resist compulsive behaviors, such as mirror checking. It's important to determine whether a therapist has been specifically trained in cognitive-behavioral therapy because many other types of therapy do not appear to be effective in the treatment of BDD.

Helping Your Child Develop a Positive Self-Image
As a parent, you can help your child maintain a positive self-image and self-esteem. Here are some ways you can help:
o Always maintain an open door policy when it comes to problem solving. o If your child knows it's OK to approach you with problems or concerns, she's more likely to do so.
o Be aware of peer influence and the affects of media on your child. Is your child reading too many fashion magazines or spending time with a new crowd?
o Recognize the need for professional help. If you suspect your child has BDD, a doctor or professional therapist can help.
o Know the signs and symptoms of suicidal behavior. If you think your child is suicidal, get help immediately. Your child's doctor can refer you to a psychologist or psychiatrist, or you can contact your local hospital's department of psychiatry and ask for a referral. Your community mental health association or county medical society can also provide referrals.