Body dysmorphic disorder-is reflection your worst enemy: a review

INTRODUCTION

Body dysmorphic disorder (BDD), a diagnostic and statistical manual of mental disorders, fourth edition (DSM-IV) disorder, is a fairly common and disabling mental health condition characterized by excessive and persistent preoccupation with perceived imperfections or flaws in one's appearance that are imperceptible to others, as well as compulsive, repetitive behaviors that go along with it such as mirror checking and skin pricking.¹ Safety behaviors such as hiding unattractive body parts, with a hat, makeup, or sunglasses follow.¹ The disorder typically manifests throughout puberty, although it is extremely underdiagnosed and frequently goes unnoticed.² There is a need for a greater understanding of BDD across many specialties because it frequently results in significant suffering and functioning impairment.³ Moreover, BDD frequently worsens and creates clear functional impairment in several domains if left untreated.²

BODY DYSMORPHIC DISORDER

BDD seems to be rather frequent as point prevalence estimates from epidemiologic research range from 0.7% to 2.4% in the general population, making it more prevalent than disorders like schizophrenia or anorexia nervosa.⁴ These estimates, however, might underestimate its occurrence.⁵ Many BDD sufferers are ashamed of how they look and are so preoccupied with it that they might find it difficult to confide in doctors about their symptoms.⁵ Only 15.1% of psychiatric inpatients in one study had disclosed their body image concerns to their mental health providers, with embarrassment being the main deterrent in 31.3% of cases.⁵

The disorder is more common in women than men and has been documented to affect infants as young as 5 and individuals as old as 80.⁶ There are different foci of concern in patients with BDD. According to Cansever et al., the most frequently mentioned problem locations were the hips and head/face area.⁷ Skin blemishes (64.2%) and hair problems (42.3%) were the defects that caused the most concern in the study by al Saidan et al.⁸ Ahamed et al deduced that the condition affected skin (75%) and fat (68.8%) more frequently than other body aspects in female medical students.^9,10 Taqui et al reported the top three body-related concerns among male BDD sufferers were head hair (34.3%), being obese (32.8%), skin (14.9%), and nose (14.9%), whereas the top three among female sufferers were being fat (40.4%), skin (24.7%), and teeth (18%).¹⁰ Figure 1 shows common areas of concerns in patients with BDD.

DISCUSSION

BDD has a detrimental impact on the quality of life and mental health.¹¹ According to two population-based studies, people with the disorder are more likely to be divorced and less likely to get married than people without BDD.¹¹ Literature suggests that much more people with the illness are unemployed than the overall population.^11,12 A sample of 200 BDD patients revealed that 37.6% of them were unemployed, demonstrating the gravity of the problem.^11,12

BDD could be triggered by numerous factors, but the two most common ones are spending excessive time on social media and childhood abuse. There is mounting evidence that suggests spending more time on social media is linked to perception of a negative body image.⁸ A cross-sectional study by Al Saidan in Saudi Arabia comprising 1010 participants revealed that 42 (4.2%) of them fit the BDD criteria, with younger participants having a higher prevalence of the disorder.⁸ The results highlighted that BDD was substantially correlated with more time spent on Instagram, Snapchat, and decreased interest in religious subjects.⁸ In addition, patients with BDD experienced greater harassment and psychiatric history, and were more likely to compare their appearance to popular social media users.⁸ Another study found that numerous individuals with the disorder reported being abused or neglected as children. The severity of BDD symptoms, as well as gender, suicidality, and specific disorders, seem to be slightly correlated with specific forms of abuse and neglect.¹³

As symptoms of BDD typically manifest during adolescence, it is apparent that the disorder is common among college students. A 2003 study by Cansever et al conducted in Turkey sought to determine the prevalence and clinical characteristics of BDD among 420 Turkish female college students.⁷ The self-report questionnaire was utilized to gauge the individuals' obsessive tendencies and physical dissatisfactions. A DSM-IV diagnosis of BDD was made.⁷ A whopping 43.8% of the participants in this study felt unsatisfied with their appearance, and 4.8% of them had BDD.⁷ In a different study, conducted by Philips et al, 200 BDD individuals (164 adults and 36 adolescents) completed interviewer-administered and self-report assessments. Teenagers were concerned about several different parts of their appearance, most frequently their skin, hair, and stomach.¹⁴ Of the teenagers, 94.3% indicated moderate, severe, or great distress due to BDD, 80.6% had previously experienced suicidal thoughts, and 44.4% had attempted. High rates and levels of impairment in academics, employment, and other facets of psychosocial functioning were seen in teenagers.¹⁴

An online literature search carried out on pakMediNet and PubMed revealed that there is a dearth of evidence addressing BDD in medical students of Pakistan, demonstrating the lack of attention given to this phenomenon. The field of medicine is a highly competitive one and medical students are more likely to exhibit signs of BDD due to high levels of stress and self-doubt.¹⁵ Research has shown that stress is negatively linked to hair loss and obesity/anorexia.^16,17 Scott et al deduced that stress was linked to changes in dietary preferences, weight gain and fat accrual. Hair loss for males and obesity for both genders is a grave area of concern for patients suffering from BDD, which are likely to be exhibited by medical students.¹⁷

Only in 2008, did Taqui et al. set out to determine the prevalence of body dysmorphia among Pakistani medical students.¹⁰ The survey's findings were worrisome. 5.8% of the students fulfilled the DSM-IV criteria for BDD and 78.8% of the students overall expressed dissatisfaction with some aspect of their looks. Women expressed much more anxiety about being overweight (p=0.005). Male students were substantially more anxious about having head hair (p=0.012) and being skinny (p=0.01) than female students.¹⁰

Despite being a relatively common disorder, there are few effective treatments for BDD. Diagnosis is made through a medical evaluation which consists of a psychological evaluation, a review of patient's medical history and the onset of signs and symptoms.¹⁸ Once a diagnosis of BDD is reached, the patient is recommended to undergo cognitive behavioral therapy to help them better manage their emotions and train their brains to react to stressful situations or distressing ideas.¹⁸ However, CBT has minimal scientific backing and some patients reject CBT or stop it too soon, which demerits its use.¹⁸ Hence, there is a pressing need for more treatment options and anti-depressant medications such as Selective serotonin reuptake inhibitors (SSRIs) seem a viable option as it helps control negative thoughts and repetitive behaviors. Other treatment options include interpersonal psychotherapy (IPT).¹⁸ IPT is preferable to CBT as it helps patients develop more effective coping mechanisms to minimize interpersonal distress, low self-esteem, and depressed mood, all of which are known to contribute to body image disorders BDD patients frequently have a history of emotional abuse and protracted interpersonal conflicts and may experience debilitating social anxiety and interpersonal issues. IPT is better suited to address these concerns in patients because it focuses on managing acute mood symptoms, improving interpersonal skills, and addressing aspects of life that might be fueling the condition.¹³ The findings of a short open pilot experiment demonstrate the preliminary efficacy of IPT for BDD is encouraging.¹⁹ However, additional large, multi-center studies are required to determine the effectiveness of IPT in the treatment of BDD.

BDD is a relatively common phenomenon among medical students, resulting in a sharp decline in productivity, quality of life, and confidence. However, this disorder has not garnered much attention from the majority of the populace. The need of the hour is to conduct studies regarding Body dysmorphia in medical schools throughout Pakistan and raise awareness about it through social media platforms, and health professionals. There is a dire need to adopt the concept of body positivity at a national level as it promotes acceptance of all bodies, regardless of size, shape, skin tone, gender, and physical abilities. This will make people accept themselves as they are.

CONCLUSION

Moreover, it is crucial for healthcare organizations to develop and launch initiatives that give healthcare professionals the tools they need to identify and treat this issue. Medical students should have easy access to therapy and resources must be utilized to make therapies such as ‘Cognitive-behavioral therapy’ and ‘interpersonal psychotherapy’ available for BDD sufferers. This will improve their overall mental health and help to reduce cases of psychological illness and social isolation. The involvement of parents is also essential; they need to be made aware of this disorder so they may recognize the potential symptoms of the disorder. Encouraging body positivity amongst medical students and taking stern action against bullying will promote a healthier social and academic lifestyle.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

REFERENCES

1. 1. Phillips KA. Understanding Body Dysmorphic Disorder. OUP USA. 2009.
2. 2. Phillips KA, Didie ER, Menard W, Pagano ME, Fay C, Weisberg RB. Clinical features of body dysmorphic disorder in adolescents and adults. Psychiatry Res. 2006;141(3):305-14.
3. 3. Thompson CM, Durrani AJ. An increasing need for early detection of body dysmorphic disorder by all specialties. J R Soc Med. 2007;100(2):61-2.
4. 4. Bjornsson AS, Didie ER, Phillips KA. Body dysmorphic disorder. Dialogues Clin Neurosci. 2010;12(2):221.
5. 5. Conroy M, Menard W, Fleming-Ives K, Modha P, Cerullo H, Phillips KA. Prevalence and clinical characteristics of body dysmorphic disorder in an adult inpatient setting. Gen Hosp Psychiatry. 2008;30(1):67.
6. 6. Phillips KA, Menard W, Fay C. Gender similarities and differences in 200 individuals with body dysmorphic disorder. Compr Psychiatry. 2006;47(2):77-87.
7. 7. Cansever A, Uzun Ö, Dönmez E, Ozşahin A. The prevalence and clinical features of body dysmorphic disorder in college students: A study in a Turkish sample. Compr Psychiatry. 2003;44(1):60-4.
8. 8. Alsaidan MS, Altayar NS, Alshmmari SH, Alshammari MM, Alqahtani FT, Mohajer KA. The prevalence and determinants of body dysmorphic disorder among young social media users: A cross-sectional study. Dermatol Rep. 2020;12(3):70-6.
9. 9. Ahamed SS, Enani J, Alfaraidi L, Sannari L, Algain R, Alsawah Z, et al. Prevalence of Body Dysmorphic Disorder and its Association With Body Features in Female Medical Students. Iran J Psychiatry Behav Sci. 2016;10(2).
10. 10. Taqui AM, Shaikh M, Gowani SA, Shahid F, Khan A, Tayyeb SM, et al. Body Dysmorphic Disorder: Gender differences and prevalence in a Pakistani medical student population. BMC Psychiatry. 2008;8(1):1-10.
11. 11. Koran LM, Abujaoude E, Large MD, Serpe RT. The prevalence of body dysmorphic disorder in the United States adult population. CNS Spectr. 2008;13(4):316-22.
12. 12. Rief W, Buhlmann U, Wilhelm S, Borkenhagen A, Brähler E. The prevalence of body dysmorphic disorder: a population-based survey. Psychol Med. 2006;36(6):877-85.
13. 13. Didie ER, Tortolani CC, Pope CG, Menard W, Fay C, Phillips KA. Childhood abuse and neglect in body dysmorphic disorder. Child Abuse Negl. 2006;30(10):1105.
14. 14. Phillips KA, Didie ER, Menard W, Pagano ME, Fay C, Weisberg RB. Clinical features of body dysmorphic disorder in adolescents and adults. Psychiatry Res. 2006;141(3):305.
15. 15. MacArthur KR, Sikorski J. A qualitative analysis of the coping reservoir model of pre-clinical medical student well-being: Human connection as making it “worth it.” BMC Med Educ. 2020;20(1):1-11.
16. 16. Perera MH, Ahmed NK, Korrapati NH, Edpuganti S, Bhowmik P, Govindan AK, et al. Hair Loss In Medical Students: A Global Approach. Int J Progress Sci Technol. 2021;28(2):608-18.
17. 17. Scott KA, Melhorn SJ, Sakai RR. Effects of Chronic Social Stress on Obesity. Curr Obes Rep. 2012;1(1):16.
18. 18. Wilhelm S, Phillips KA, Didie E, Buhlmann U, Greenberg JL, Fama JM, et al. Modular cognitive-behavioral therapy for body dysmorphic disorder: a randomized controlled trial. Behav Ther. 2014;45(3):314-27.
19. 19. Bjornsson AS, Didie ER, Phillips KA. Body dysmorphic disorder. Dialogues in Clin Neurosci. 2010;12(2):221-32.