Body Dysmorphic Disorder. A Male Concern

TABLE OF CONTENTS

1. What is Body Dysmorphic Disorder?

2. How do I know if I have Body Dysmorphic Disorder?

3. Different forms of Body Dysmorphic Disorder…
3.1 Muscle Dysmorphia
3.2 BDD by proxy

4. Obsessions and BDD

5. Compulsions and BDD

6. Cases of males with BDD – examples

7. Causes of BDD

8. BDD and gender – a male slant

9. How does BDD affect the male sufferer?

10. Treatment options for BDD sufferers…
10.1 Medication
10.2 Cognitive-Behavioural Therapy
10.3 Cosmetic treatments

11. BDD and other disorders…
11.1 Obsessive-Compulsive Disorder
11.2 Depression
11.3 Eating Disorders
11.4 Social Phobia

12. Family assistance for the sufferer

13. Where to get help for the sufferer
13.1 Organizations
13.2 Books and Websites for further reading

14. References

15. APPENDICES
15.1 Appendix A – Definition of BDD (DSM-IV)
15.2 Appendix B – Do I Have BDD? (Anna Paterson)
15.3 Appendix C - Location of imagined defects in 30 patients with BDD
15.4 Appendix D - Have I got BDD? (Veale, Willson & Clarke)
15.5 Appendix E - Clues to the Adonis Complex in Boys (Pope et al.)
15.6 Appendix F - Common Compulsive Behaviours (Rituals) in BDD (Phillips)

1. What is Body Dysmorphic Disorder?

Body Dysmorphic Disorder (BDD) is ‘a psychiatric illness in which patients become obsessively preoccupied with perceived flaws in their appearance’ (Luciano 2002: p175). Martin & Costello (2008) view it is a severe dislike and concern about some slight or imagined aspect of their appearance, that causes them significant emotional distress and difficulties. Cash (2008) maintains that sufferers have ‘a grossly distorted view of what they look like’ and Phillips (2005) coins BDD as ‘the disorder of imagined ugliness’ (p5).

Body Dysmorphic Disorder is classified as a somatoform disorder because the primary focus is a psychological preoccupation with a somatic issue. (Barlow & Durand: 2005) Thompson (2000) explains that the term that preceded Body Dysmorphic Disorder was ‘dysmorphophobia’ which was used by Morselli in 1886 (Morselli, 1886) which literally meant a ‘fear of ugliness’. In 1903, Janet’s description referred to an ‘obsession with shame of the body’; for decades BDD was thought to represent a ‘psychotic delusional state’ (Barlow & Durand: 2005, p183). The first English language paper on dysmorphophobia was not published until 1970 (Hay: 1970) focusing on the fear of other people’s reactions to the imagined flaw in appearance. BDD gained official status in 1987 when it was first published in the DSM-III-R

Jim was convinced that everyone, even his good friends, was staring at a part of his body that he himself found absolutely grotesque. He reported that strangers would never mention his deformity and his friends felt too sorry for him to mention it. Jim thought his head was square! Jim could not imagine people getting past the fact that his head was square. To hide his condition as well as he could, Jim wore soft floppy hats and was most comfortable in winter, when he could all but completely cover his head with a large stocking cap. To us, Jim looked perfectly normal. (Barlow & Durand: 2005)

In the article ‘Body Dysmorphic Disorder in men, psychiatric treatments are usually effective’, Katharine Phillips notes that BDD is an underrecognised yet relatively common and severe psychiatric disorder. Many doctors…do not recognize the condition as yet and simply see it as low self-esteem’ (Paterson: 2008, p51) Claiborn & Pedrick (2002) focus their attention on the two predominant features of BDD; the preoccupation with the [imagined] defect and the actions taken to reduce the feelings of distress. (p12)

2. How do I know if I have Body Dysmorphic Disorder?

It is important to realize that people who do suffer with BDD usually look ‘normal’, but they are preoccupied with an idea that their appearance is abnormal or defective. The preoccupation causes them severe distress and interferes with their daily functioning. (Phillips: 2009).

If we look at the DSM-IV criteria for Body Dysmorphic Disorder, there are two main components in BDD (see Appendix A); namely a preoccupation, and distress or impairment of functioning. Luciano (2002) notes that the preoccupation with appearance is ‘obsessive’, and Paterson (2008) has ‘sufferers admitting to spending up to 99% of their time focusing on their perceived flaws.(p51) Many people with this disorder become fixated on mirrors (Veale & Riley: 2001) and others will avoid mirrors completely. The preoccupation will be time consuming, distressing and [interfere] (Thompson: 2000) with your normal functions of the day.

Barlow & Durand (2005) found that up to 70% of college students reported some level of dissatisfaction with their bodies and up to 28% of these met the criteria for BDD diagnosis. In ‘Fit to Die’, Anna Paterson gives 26 questions to ask yourself if you feel that you may be suffering with BDD (see Appendix B); if you find that you answer ‘yes’ to a number of these questions you may well be suffering with BDD.

Thompson (2000) finds that patients often have a rather vague complaint of ‘being ugly, misshapen, or odd looking and cannot locate or specify the nature of the defect. In contrast, others localize their concern exactly to features or blemishes, such as a big nose, crooked mouth, asymmetrical breasts, fleshy thighs, protruding buttocks, small penis, birthmark, hairline, acne, scars, and so forth’ (p150). Yet, it is also quite common for people with BDD to have little or no insight what so ever into the degree of exaggeration of their responses to intrusive thoughts of flawed looks. (Claiborn & Pedrick: 2002). Barlow & Durand (2005) outline the location of the imagined defects in 30 patients that suffer with BDD (see Appendix C); interestingly the most common area of preoccupation is the hair (63% of patients), followed by the nose and skin at 50% and noteworthy is the fact that most patients have preoccupations with more than one area.

In ‘Overcoming Body Image Problems’, Veale, Willson & Clarke (2009) developed the “Have I got BDD?-Questionnaire (see Appendix D) which highlights the key characteristics of BDD. If you complete this questionnaire and answer ‘yes’ to the first three questions and one other from questions four to seven it is likely that you may have BDD. The fact that children as young as five experience feelings of body image dissatisfaction and the fact that body image perceptions of 5-6 year-old boys have been under reported and not regarded as an issue of concern (18), I feel it necessary to add the work of Pope et al. in the form of their ‘Clues to the Adonis Complex in Boys-questionnaire’, (see Appendix E), this questionnaire can be completed by parents or educators as they note behaviour of the child. If the child displays some of these behaviours he may have BDD.

3. Different forms of Body Dysmorphic Disorder…

People suffering with Body Dysmorphic Disorder can dislike virtually any area of the body and Phillips (2009) notes that on average people report that they are excessively concerned with an average of five different parts of their body over a period of time. In an attempt to cope with their body concerns they perform a number of behaviours, such as mirror checking, excessive grooming, skin picking and reassurance seeking.

In ‘Understanding Body Dysmorphic Disorder’, Katharine Phillips worked with 500 people with BDD and found that the most frequent area of perceived defect was the skin (73%), followed by the hair and nose. Tyrone was one patient in the study, his appearance concerns were: his penis was too small, his wrists and body build was too small and he had a pot belly. The associated behaviours and consequences of these imagined defects were: he believed that others took special notice of his appearance, he checked mirrors excessively, he constantly compared himself with others, avoided gym showers, avoided dating and sex, he wears long bulky clothes to cover his crotch area, lifts weights excessively and consulted a urologist for penis enlargement surgery.

Phillips (2009) found that two-thirds of people with skin concerns obsessed about their acne or scarring. One-quarter of men with BDD are preoccupied with their overall body build, referred to as muscle dysmorphia. The specific body areas of concern can be present simultaneously or sequentially. Approximately 30% of people are concerned with one body part-or one set of body parts-over time. Approximately 40% are concerned with one body part and then add new parts as time progresses. The remaining 30% is a little more complex, their concern over a particular body or parts will disappear completely and be replaced with a deficit in another, new area.

3.1 Muscle Dysmorphia

One of the most important and common forms of BDD, according to Phillips (2009) is Muscle Dysmorphia. Cash (2008) describes it as a ‘subtype of BDD’. (p5). Muscle Dysmorphia occurs almost exclusively in males (Andersen et al: 2000, 82). Veale, Willson & Clarke (2009) describe it as a variation, in which a man is usually worried about being too small or too skinny or not muscular enough. The main concern for sufferers seem to be hair loss, the size of their nose, genitals or muscles, any scars they might have, their skin condition and their height or weight.

In the studies of Pope et al. (2000), body areas that caused distress among the men with BDD were hair (57%), nose (38%) and body build (25%). In a recent study of 268 patients seeking care from a dermatologist, Phillips, Dufresne, Wilkel & Vittorio (2000) found that 11,9% met the criteria for BDD, with as many as 2% of all patients requesting plastic surgery having BDD (Andersen & Bardach: 1977) and perhaps up to 25% (Barnard: 2000). The most common procedures were rhinoplasties (nose-jobs), face-lifts, eyebrow elevations, liposuction, breast augmentation, and surgery to alter the jaw line.

In ‘Body Image and Perceived Health in Adolescence’, the body dissatisfaction that occurs is defined as the discrepancy between an individual’s perceived current body size and perceived ideal body size. As a result, the person suffering with Muscle Dysmorphia will ‘engage in compulsive behaviours to try to increase muscle mass…weightlifting, taking diet supplements, and sometimes ingesting dangerous substances (Claiborn & Pedrich: 2002, p37)

Phillips (2009) found that 71% of men with Muscle Dysmorphia (MD) lifted weights excessively, 64% exercised excessively and 71% dieted. MD sufferers will often take anabolic steroids, protein powders and creatine, human growth hormones, diuretics and ephedrine in order to ‘bulk-up’. Muscle Dysmorphia may lead to potentially dangerous abuse of anabolic steroids, and studies in Phillips (2001) indicate that 6-7% of high school boys have used these drugs.

3.2 BDD by proxy

A different form of Body Dysmorphic Disorder is BDD by proxy. These sufferers worry about the appearance of someone else. These people will obsess about a defect in another person to the point of distraction, when in fact the person looks perfectly fine. This can be a dangerous disorder as well, as children of sufferers may be pushed into getting surgery for a defect that is not present at all.

Phillips (2009) notes the case of a father in his 50s was convinced that his daughter was going bald and he was the cause. His daughter looked perfectly normal, but his despair was so severe that he ended up killing himself.

4. Obsessions and BDD…

One-third of people with body dysmorphic disorder think about their appearance flaws for 1 to 3 hours a day, nearly 40% for 3 to 8 hours a day, and about a quarter for more than 8 hours a day (Phillips: 2009, 57). Most people living with BDD know that they spend too much time thinking (obsessing) about their perceived flaws, but for others the intrusive thoughts are such a part of their lives that they do not realize that they are worrying too much. These intrusive thoughts are difficult to control and resist; some people try to divert the focus of their attention but others find it too difficult and give in to the thoughts.

Some people have both BDD and health anxiety; these individuals have usually misinterpreted normal blemishes or sensations as evidence of an illness (Veale et al. 2009). BDD sufferers experience emotions such as ‘depression, sadness, hopelessness, anxiety, worry fear, shame, embarrassment, disappointment, self-disgust, anger, frustration, and guilt (Phillips: 2009, 59) The thought process in BDD varies on a continuum of insight from fair to delusional (Thompson: 2000), and the majority of people with BDD also experience negative recurrent appearance-related images, which are often very visual in nature. These delusional beliefs are found in the cases with more severe BDD symptoms.

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