By the way, doctor: What is body dysmorphic disorder?

Q. My niece has been diagnosed with body dysmorphic disorder. I've heard of it, but I'm not sure what it is exactly.

A. Concern about appearance is usually normal, and a sign of healthy self-esteem. But being overly self-conscious about looks may be a problem, and it's extremely distressing when it takes the form of body dysmorphic disorder (BDD). People who have this condition are preoccupied with what they regard as physical defects. In many cases, this concern reaches delusional proportions: they see bodily flaws that aren't there and have little to no awareness that their worries are irrational. Some with the disorder know that they're unreasonably hung up on some aspect of their appearance, but this only makes them feel ashamed and causes them to keep their painful symptoms a secret.

Often people with BDD become preoccupied with checking their appearance in the mirror or they spend an inordinate amount of time grooming. The shame they feel may cause them to avoid socializing. They may focus on their appearance to the exclusion of everything else, including work or personal relationships. BDD increases the risk for suicide and half of those with the disorder develop alcohol or drug problems.

Although public awareness of the problem has increased in recent years, BDD is still more common than many realize, perhaps because many people manage to conceal their symptoms from families and doctors. Some researchers estimate the prevalence may be as high as 2% of Americans.

Similar numbers of men and women have BDD, despite the stereotype that women are more concerned with their appearance. Men often have a variation called muscle dysmorphia. Someone with this problem believes his body is too small or not muscular enough — he may get compulsive about working out, be prone to eating disorders, and abuse anabolic steroids.

People with BDD often get cosmetic surgery or dermatology treatments in pursuit of fixes for perceived flaws. Sadly, their unrealistic expectations can lead them to feel worse, not better, and the disappointment can be devastating. A group from the University of Pennsylvania reviewed studies linking cosmetic breast augmentation and suicide. The authors noted that among patients with BDD who receive this surgery, more than 90% had similar or worse symptoms of BDD after the procedure.

Research has shown that the severity of the BDD symptoms correlates to certain patterns of activity in two areas of the brain — the visual processing center in the orbitofrontal cortex, and the frontostriatal system, which affects emotional reactions and behaviors. This suggests that people with BDD are processing visual information differently in their brains and may help to explain why their perceptions differ from those of other people.

The American Psychiatric Association is revising its diagnostic system. Rather than classifying BDD with disorders like hypochondriasis, research suggests that the disorder has more in common with the anxiety and obsessive-compulsive spectrum disorders. The new proposal also includes a way to record a dimension that is relevant for planning treatment — how much insight a person has into his or her condition.

Regarding treatment, the first big step is helping the person recognize she has a problem: your niece may already have jumped that hurdle. The degree of a person's self-awareness can be elicited through a short questionnaire. Education about the condition can help a person see the value of mental health treatment. A handful of studies have shown that antidepressants like fluoxetine (Prozac) can help, although they seem to be effective only about half the time. Other classes of drugs have not been proved effective for BDD, but theoretically they could be helpful for symptoms that are common in the illness, such as delusions. Psychotherapy is helpful for those with milder (non-delusional) symptoms. Above all, the goal is to help the BDD sufferer turn away from a preoccupation with appearance and engage in treatment for underlying problems. A very difficult task to be sure, but probably the only way to achieve relief.

— Michael Craig Miller, M.D.
Harvard Health Letter Editorial Board