General Information (including ICD-9/-10 Codes)

Description :

• somatoform disorder, imagined nondelusional belief that body part is misshapen or defective, can acknowledge possibility of exaggerating

Also called :

• dysmorphophobia, atypical somatoform disorder

ICD-9 Codes :

• 300.7 hypochondriasis

ICD-10 Codes :

• F45.2 hypochondriacal disorder

Who is most affected :

• mean age 30, onset teen or young adult, males and females equally affected
• editorial discussion of body dysmorphic disorder in men can be found in BMJ 2001 Nov 3;323(7320):1015, commentary can be found in BMJ 2002 Mar 16;324(7338):678

Incidence/Prevalence :

• 14 (8.8%) of 159 Turkish patients with mild acne presenting to dermatologist had body dysmorphic disorder (Compr Psychiatry 2003 Sep-Oct;44(5):415)
• 7% of patients seeking elective cosmetic surgery had body dysmorphic disorder (Journal of Plastic, Reconstructive & Aesthetic Surgery 2006 Jan;59(1):54 in BMJ 2006 Jan 21;332(7534):186)

Causes and Risk Factors

Causes :

• unknown, consider unconscious conflict

Pathogenesis :

• repression, distortion and symbolization, projection (believe others see defect)

Complications and Associated Conditions

Complications :

• may progress to delusional belief

Associated conditions :

• anorexia nervosa, psychosocial stress, avoidant or obsessive-compulsive personality disorders
• in study of 50 patients (3/4 female), 26% mood disorder, 16% social phobia, 6% obsessive-compulsive disorder, 24% had attempted suicide (Br J Psych 1996 Aug;169(2):196 in J Watch Women's Health 1996 Oct;1(7):55)

History

Chief Concern (CC) :

• defect (e.g. wrinkles, hair loss, too small breasts/penis, age spots, stature) out of proportion to any minor objective physical abnormality

History of Present Illness (HPI) :

• pervasive bodily concerns

Past Medical History (PMH) :

• history of doctor visits regarding complaint, plastic surgery, dermatology

Physical

General Physical :

• minor physical/body deficits

Diagnosis

Making the diagnosis :

• DSM-IV-TR criteria
  • preoccupation with imagined defect in appearance in normal-appearing person or grossly excessive concern over slight anomaly
  • distress or impaired functioning
  • occurrence not only during anorexia nervosa or transsexualism

Rule out :

• schizophrenia, depression, obsessive-compulsive disorder, organic mental syndrome (e.g. temporal lobe epilepsy), somatization disorder, anorexia nervosa, bulimia nervosa

Other diagnostic testing :

• Draw-A-Person (DAP) test may show exaggeration/diminution/absence of affected body part

Prognosis

Prognosis :

• improvement (usually partial) common in one cohort (level 2 [mid-level] evidence)
  • based on retrospective study of 95 outpatients with body dysmorphic disorder
  • full remission achieved by 25% at 6-12 months and 58% at 4 years
  • partial or full remission achieved by 58% at 6-12 months and 84% at 4 years
  • 29% relapse rate after partial or full remission
  • Reference - Compr Psychiatry 2005 Sep-Oct;46(5):315
• poor prognosis reported in 2 cohorts (level 2 [mid-level] evidence)
  • markedly poor functioning and quality of life in study of 176 patients meeting DSM-IV criteria for body dysmorphic disorder (Compr Psychiatry 2005 Jul-Aug;46(4):254 full-text)
  • in chart review of 20 patients with clinically significant body dysmorphic disorder in Brazil
    • 11 (55%) were female
    • 18 (90%) were single or divorced
    • 17 (85%) were economically unproductive
    • mean 2.5 current imagined defects per patient
    • 13 (65%) had chronic condition
    • 12 (60%) kept same concerns during course of disorder
    • all patients had compulsive behaviors
    • 6 (30%) had no insight over dysmorphic beliefs
    • most patients had psychiatric comorbidities, mostly obsessive-compulsive disorder (70%) and major depressive disorder (55%)
    • only 5 (25%) responded favorably to treatment
    • Reference - Int J Psychiatry Med 2006;36(2):243

Treatment

Counseling :

• individual psychotherapy is most useful approach, uncover conflicts relating to symptom, feelings of inadequacy

Medications :

• benzodiazepines of limited use
• fluoxetine effective; 74 patients with delusional or nondelusional body dysmorphic disorder were entered into 1-week placebo run-in, 67 were randomized to fluoxetine (mean dose 78 mg/day) vs. placebo for 12 weeks, 93% vs. 85% completed the trial; fluoxetine significantly more effective than placebo for symptoms of body dysmorphic disorder during weeks 8-12, 53% vs. 18% responded (NNT 3), response of depressive symptoms did not predict response of body dysmorphic disorder; side effects were sedation and abdominal discomfort (Arch Gen Psychiatry 2002 Apr;59(4):381 in QuickScan Reviews in Fam Pract 2002 Sep;27(9):18)
• clomipramine more effective than desipramine in randomized crossover trial of 29 patients (Arch Gen Psychiatry 1999 Nov;56(11):1033 in Am Fam Physician 2000 Mar 15;61(6):1837)

Prevention and Screening

• not applicable

References including Reviews and Guidelines

General references used :

• related articles
  • Cororve MB, Gleaves DH. Body dysmorphic disorder: a review of conceptualizations, assessment, and treatment strategies. Clin Psychol Rev. 2001 Aug;21(6):949-70.
  • Grant JE, Kim SW, Crow SJ. Prevalence and clinical features of body dysmorphic disorder in adolescent and adult psychiatric inpatients. J Clin Psychiatry. 2001 Jul;62(7):517-22.
  • Arnold LM, Auchenbach MB, McElroy SL. Psychogenic excoriation. Clinical features, proposed diagnostic criteria, epidemiology and approaches to treatment. CNS Drugs. 2001;15(5):351-9.
  • Harth W, Linse R. Body dysmorphic disorder and life-style drugs. Overview and case report with finasteride. Int J Clin Pharmacol Ther. 2001 Jul;39(7):284-7.

Reviews :

• review can be found in Am Fam Physician 1999 Oct 15;60(6):1738
• review of somatoform disorders in primary care can be found in Adv Stud Med 2003 Sep;3(8):438 PDF

Patient Information

Patient information :

• handout from National Women's Health Information Center
• handout from Mayo Clinic
• handout from PsychNet-UK
• handout on body image problems from KidsHealth