|Year : 2018 | Volume
| Issue : 4 | Page : 157-160
Chasing perfection: Body dysmorphic disorder and its significance in dentistry
Shruti S Kumar1, Vishal Shrishail Kudagi2, Gurvinder Kaur3
1 Department of Pedodontics and Preventive Dentistry, JSS Dental College and Hospital, JSS University, Mysore, Karnataka, India
2 Department of Orthodontics, JSS Dental College and Hospital, JSS University, Mysore, Karnataka, India
3 Department of Consultant Pediatric Dentist, Fortis Memorial Research Institute, Gurgaon, Haryana, India
|Date of Web Publication||28-Aug-2018|
Dr. Shruti S Kumar
Department of Pedodontics and Preventive Dentistry, JSS Dental College and Hospital, SS Nagar, Bannimantap, Mysore, Karnataka
Source of Support: None, Conflict of Interest: None
Body dysmorphic disorder (BDD) is a type of mental illness, a somatoform disorder, wherein the affected person is concerned with body image, manifested as excessive concern about, and preoccupation with a perceived defect of their physical features. The individual may perceive a defect in either one feature or several features of their body, which causes psychological distress that impairs occupational or social functioning. Considerable numbers of these patients are obsessed with the appearance of their dentition and the shape of their jaws. Usually, the dentist can be the first to diagnose this condition which may otherwise pass unnoticed. This problem can sometimes interfere to a large extent in rendering appropriate dental treatment. BDD has remained an elusive topic for both researchers and clinicians likewise. This condition needs further research which can greatly help in intercepting and preventing its myriad lethal manifestations.
Keywords: Body dysmorphic disorder, eating disorders, physical appearance, selective serotonin reuptake inhibitors
|How to cite this article:|
Kumar SS, Kudagi VS, Kaur G. Chasing perfection: Body dysmorphic disorder and its significance in dentistry. J Int Oral Health 2018;10:157-60
|How to cite this URL:|
Kumar SS, Kudagi VS, Kaur G. Chasing perfection: Body dysmorphic disorder and its significance in dentistry. J Int Oral Health [serial online] 2018 [cited 2019 Jan 16];10:157-60. Available from: http://www.jioh.org/text.asp?2018/10/4/157/240016
| Introduction|| |
Man's obsession with physical appearance can be dated back to thousands of years. However, today, this preoccupation has risen to new heights, thanks to popular media, which has been playing a very important role in molding one's psyche. Every second of every day, people are being bombarded with images of impossibly flawless models with immaculate facial features and physique, which influences a person with average physical traits in a negative way. This ever-increasing frenzy about beauty has given rise to a myriad number of psychological disorders such as “body dysmorphic syndrome,” “anorexia nervosa,” and “bulimia nervosa.”
Body dysmorphic disorder (BDD) is defined by Diagnostic and Statistical Manual of Mental Disorders (DSM)-1V-TR as a condition marked by excessive occupation with an imaginary or minor defect in a facial feature or localized part of the body. The diagnostic criteria mentioned for this condition in the DSM, Fourth Edition, Text Revision are as follows: (1) a preoccupation with an imagined or slight defect in appearance (if a slight physical defect is present, the person's degree of concern is extreme); (2) marked distress or impairment in social, occupational, or other areas of functioning resulting from the appearance preoccupation; and (3) the preoccupation is not attributable to the presence of another psychiatric disorder (e.g., anorexia nervosa). This condition was archaically known as dysmorphophobia or body dysmorphia.
BDD is recognizable by damage to self-esteem, fear toward social situations, depression, suicidal tendencies, and an obsession to seek nonpsychiatric medical or surgical treatment to improve imagined flaw in their appearance. Although BDD is a psychiatric disorder, most patients visit cosmetic surgeons seeking to meliorate their perceived defect. Unfortunately, such remedies prove futile to the patient and the practitioner.
Given the increasing prevalence of psychiatric disorders, dentists may be confronted with behaviors that may interfere with the safe and efficient delivery of dental care. Although a few case descriptions of BDD have been reported in dental practices,, the prevalence rate of BDD patients, who seek esthetically motivated dental treatment, is still unclear.
Most people who present themselves for cosmetic treatment are likely to have underlying psychological conditions that need to be addressed. BDD, a disorder characterized by extreme appearance preoccupation, may be of particular relevance to orthodontists and other dental specialists who offer cosmetic procedures. This review focuses on some key issues pertaining to BDD and its implications in dentistry. The article also emphasizes on the need for further research in the field. Knowledge and awareness about this condition can aid the dentist to recognize and alleviate the problem at the earliest.
| History|| |
BDD was first documented in 1886 by an Italian psychopathologist named Enrique Morselli as “Dysmorphophobia.” Dysmorphophobia comes from a Greek word “dysmorfia,” meaning ugliness, especially of the face, which first appeared in the “Histories of Heroditus.” It refers to a myth of the “ugliest girl in Sparta,” who on being touched by a goddess transforms into a beautiful woman. This condition was not published in the DSMs until 1987. There was a consensus to call the disorder BDD and not “Dysmorphophobia” as it was perceived that the term implied to the presence of a behavioral pattern of public avoidance. In the fourth edition of the DSM, it was eventually renamed BDD.
There is an interesting situation documented by the psychologist Sigmund Freud about a patient in his practice who was so preoccupied with the appearance of his nose that it was hardly possible for him to go through his routine life due to the obsession. The patient's name was Sergei Pankejeff, who was also referred to by the nickname “the Wolf Man.” It would seem Sergei Pankejeff had all the classic symptoms of BDD.
| Prevalence|| |
BDD has been studied for more than a century. However, the exact prevalence rate of it in the general demographics is not well defined. Studies of the prevalence of this disorder in psychiatric patients and the general population suggest that BDD is relatively common, affecting up to 2% of the general population, and up to 12% of the psychiatric patients. A recent study reported a 7.5% incidence in an orthodontic patient sample compared with a 2.9% incidence in a general public sample. This study suggested that a higher percentage of the general population affected with BDD could be seeking orthodontic treatment. Furthermore, there is a higher prevalence of BDD in women.
| Onset and Course|| |
The onset of symptoms generally occurs in adolescence or early adulthood, where most personal criticism of one's own appearance usually begins. This condition might worsen with age. Often, if a person struggles with image concerns at a young age, they become more unhappy as they struggle with the physical changes that come with age (gray hair, loss of hair, wrinkles, and weight gain). BDD is considered to be continuous rather than intermittent. Signs and severity change consistently. Cure in totality relating to symptoms appears to be uncommon, even after the treatment.
| Etiology|| |
The factors that play a vital role in the development of this disorder are categorized under neurobiological, psychological, and sociocultural.
Impaired serotonin and dopamine activity have an effect in the etiology of BDD, as demonstrated by the fact that individuals positively respond to medications that alter levels of these neurotransmitters. Many studies imply that BDD may be triggered by conditions involving inflammatory pathways that can interfere in the process of serotonin synthesis. Neural injury to the frontotemporal region of the brain could also result in BDD symptoms as reported by a case study.
Justifications from the psychoanalysis point of view suggest deep-rooted conflicts in subconscious relating to sexuality and emotions, the projection of feelings of guilt, and inferiority to certain body parts. There have also been justifications that this disorder develops from a complex interaction of cognitive, emotional, and behavioral factors. Cognitive elements that appear to be monumental in the development and persistence of BDD include irrational attitudes about body image pertaining to perfection and symmetry, obsessive self-analyzing for the presence of physical flaws, and relating the facial expressions of others as being critical to one's appearance. From a behavioral perspective, BDD is thought to emerge from the positive reinforcement of appearance characteristics and social learning.
Individual raised in a household that is rejecting, neglectful, abusive, or critical as related to issues of esthetics and outwardly appearances, may be associated with BDD. Another important factor for an individual to suffer from this condition is excessive bullying in school and play areas. The ever-increasing obsession on physical perfection in the media is yet another force in the etiology of both general body image dissatisfaction and the appearance preoccupations among persons with BDD.
| Dental Implications of Body Dysmorphic Disorder|| |
Neziroglu et al. found that 86% of their BDD sample mentioned some aspect of their face. Common preoccupations include different physical aspects of the head, nose, teeth, ears, lips, mouth, and jaws. Therefore, dentists especially orthodontists and maxillofacial surgeons come across such patients often in their practice. Such patients are extremely concerned about minute dental defects, such as minimal crowding or proclination of anterior teeth, dental rotations, interdental spacing, and other imperfections. The patient's chief complaint needs to be thoroughly evaluated for any exaggerated perceptions of the defect and the actual need for the dental treatment should be analyzed. The key is to take a detailed history and ensure complete awareness of the patient's expectations and whether they are within the realms of reality. Patients suspected of having BDD should be referred to a psychiatrist for definitive diagnosis and management.
| Treatment|| |
The treatment of BDD consists of pharmacotherapy and behavioral therapy. Sometimes, performing the esthetic procedure requested might be an integral part of the patient's treatment; however, this should always be based on the recommendation of the treating psychiatrist. The primary treatment modalities for BDD include the use of selective serotonin reuptake inhibitors (SSRIs). Evidence for SSRIs in the treatment of BDD supports the use of SSRIs such as “fluoxetine,” fluvoxamine, escitalopram, and citalopram. Cognitive behavioral therapy is another common treatment approach. Cognitive behavioral therapy pertains to diagnosing and modification of appearance-related cognitions and behaviors. Methods used in this approach are self-monitoring of thoughts and behaviors related to appearance (e.g., analyzing of time spent mirror gazing); cognitive techniques (e.g., challenging distorted thoughts about one's appearance); and behavioral exercises (e.g., exposing the patient to a feared situation and preventing involvement in obsessive behaviors). Various studies justify the use of cognitive behavioral therapy an effective treatment modality for BDD.
According to Neziroglu et al., BDD is common in some psychiatric and cosmetic settings but is poorly identified. In another study, BDD was identified mainly in those with depression, substance abuse, or an anxiety disorder. The authors emphasize on diagnosis if missed could lead to an inappropriate treatment which might cause exacerbation of the existing condition. Yet, its prevalence and correlates are poorly understood in younger age groups.,, Many authors have also correlated BDD with the occurrence of obsessive–compulsive disorder.,,,, Furthermore, eating disorders have to be ruled out before diagnosing BDD.
Although there have been various studies, there is still need for future research which should include measurements of clinical severity in surveys of BDD. Measurement tools need to be updated with changing times.,
| Conclusion|| |
Much more research is needed on all aspects of BDD. Advances in knowledge will likely lead to the future refinements of this disorder's diagnostic criteria and an increased understanding of the BDD's relationship to other medical and psychiatric disorders. The stress of BDD can be very severe. The stress can lead to an unending search of unnecessary medical and surgical procedures, avoiding daily activities, avoiding job duties, avoiding social situations, and suicidal thoughts and attempts. The additional research is required to investigate further BDD among patients who present for various dental treatments. Awareness among the dentists about various dimensions and magnitude of this disorder can help in the identification of the condition and prevent the devastating consequences, it can have on the individual's mental and physical well-being.,,,
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th
ed. Text Revision. Washington. DC: American Psychiatric Association; 2000.
Veale D. Body dysmorphic disorder. Postgrad Med J 2004;80:67-71.
Rief W, Buhlmann U, Wilhelm S, Borkenhagen A, Brähler E. The prevalence of body dysmorphic disorder: A population-based survey. Psychol Med 2006;36:877-85.
Mackley CL. Body dysmorphic disorder. Dermatol Surg 2005;31:553-8.
de Jongh A, Adair P. Mental disorders in dental practice: A case report of body dysmorphic disorder. Spec Care Dentist 2004;24:61-4.
Cunningham SJ, Bryant CJ, Manisali M, Hunt NP, Feinmann C. Dysmorphophobia: Recent developments of interest to the maxillofacial surgeon. Br J Oral Maxillofac Surg 1996;34:368-74.
Phillips KA. The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder. New York, NY: Oxford University Press; 2005.
Phillips KA, Castle DJ. Body dysmorphic disorder. In: Castle DJ, Phillips KA, editors. Disorders of Body Image. Hampshire, England: Wrighton Biomedical; 2002. p. 101-20.
Otto MW, Wilhelm S, Cohen LS, Harlow BL. Prevalence of body dysmorphic disorder in a community sample of women. Am J Psychiatry 2001;158:2061-3.
Grant JE, Kim SW, Crow SJ. Prevalence and clinical features of body dysmorphic disorder in adolescent and adult psychiatric inpatients. J Clin Psychiatry 2001;62:517-22.
Hepburn S, Cunningham S. Body dysmorphic disorder in adult orthodontic patients. Am J Orthod Dentofacial Orthop 2006;130:569-74.
Veale D, Boocock A, Gournay K, Dryden W, Shah F, Willson R, et al.
Body dysmorphic disorder. A survey of fifty cases. Br J Psychiatry 1996;169:196-201.
Phillips KA, Menard W, Fay C, Weisberg R. Demographic characteristics, phenomenology, comorbidity, and family history in 200 individuals with body dysmorphic disorder. Psychosomatics 2005;46:317-25.
Hadley SJ, Newcorn JH, Hollander E. Body dysmorphic disorder: neurobiology and psychopharmacology. In: Castle DJ, Phillips KA, editors. Disorders of Body Image. Hampshire, England: Wrighton Biomedical; 2002. p. 139-55.
Gabbay V, O'Dowd MA, Weiss AJ, Asnis GM. Body dysmorphic disorder triggered by medical illness? Am J Psychiatry 2002;159:493.
Gabbay V, Asnis GM, Bello JA, Alonso CM, Serras SJ, O'Dowd MA, et al.
New onset of body dysmorphic disorder following frontotemporal lesion. Neurology 2003;61:123-5.
Phillips KA. Body dysmorphic disorder: The distress of imagined ugliness. Am J Psychiatry 1991;148:1138-49.
Rosen JC, Reiter J, Orosan P. Cognitive-behavioral body image therapy for body dysmorphic disorder. J Consult Clin Psychol 1995;63:263-9.
Veale D. Advances in a cognitive behavioural model of body dysmorphic disorder. Body Image 2004;1:113-25.
Neziroglu F, Roberts M, Yaryura-Tobias JA. A behavioral model for body dysmorphic disorder. Psychiat Ann 2004;34:915.
Veale D, Gournay K, Dryden W, Boocock A, Shah F, Willson R, et al.
Body dysmorphic disorder: A cognitive behavioural model and pilot randomised controlled trial. Behav Res Ther 1996;34:717-29.
Hollander E, Liebowitz MR, Winchel R, Klumker A, Klein DF. Treatment of body-dysmorphic disorder with serotonin reuptake blockers. Am J Psychiatry 1989;146:768-70.
Sarwer, D. B., Gibbons, L. M., and Crerand, C. E. Treating body dysmorphic disorder with cognitive-behavior therapy. Psychiatr Ann 2004;34:934.
Neziroglu FA, Yaryura-Tobias JA. Exposure, response prevention, and cognitive therapy in the treatment of body dysmorphic disorder. Behav Ther 1993;24:431.
Veale D, Gledhill LJ, Christodoulou P, Hodsoll J. Body dysmorphic disorder in different settings: A systematic review and estimated weighted prevalence. Body Image 2016;18:168-86.
Veale D, Akyüz EU, Hodsoll J. Prevalence of body dysmorphic disorder on a psychiatric inpatient ward and the value of a screening question. Psychiatry Res 2015;230:383-6.
Mastro S, Zimmer-Gembeck MJ, Webb HJ, Farrell L, Waters A. Young adolescents' appearance anxiety and body dysmorphic symptoms: Social problems, self-perceptions and comorbidities. J Obsessive Compuls Relat Disord 2016;8:50-5.
Kelly MM, Zhang J, Phillips KA. The prevalence of body dysmorphic disorder and its clinical correlates in a VA primary care behavioral health clinic. Psychiatry Res 2015;228:162-5.
Veale D, Bewley A. Body dysmorphic disorder. BMJ 2015;350:h2278.
Weingarden H, Renshaw KD, Wilhelm S, Tangney JP, DiMauro J. Anxiety and shame as risk factors for depression, suicidality, and functional impairment in body dysmorphic disorder and obsessive compulsive disorder. J Nerv Ment Dis 2016;204:832-9.
Spragg M, Cahill S. 'Life just kind of sparkles': Clients' experiences of being in cognitive behavioural group therapy and its impact on reducing shame in obsessive compulsive disorder. Cogn Behav Ther 2015;8:e6.
McKnight PE, Monfort SS, Kashdan TB, Blalock DV, Calton JM. Anxiety symptoms and functional impairment: A systematic review of the correlation between the two measures. Clin Psychol Rev 2016;45:115-30.
Singh S, Wetterneck CT, Williams MT, Knott LE. The role of shame and symptom severity on quality of life in obsessive-compulsive and related disorders. J Obsessive Compuls Relat Disord 2016;11:49-55.
Vizin G, Urbán R, Unoka Z. Shame, trauma, temperament and psychopathology: Construct validity of the experience of shame scale. Psychiatry Res 2016;246:62-9.
Mihout MF. Body dysmorphic disorder. In: Cosmetic Medicine and Surgery. 5 Howick Place, London: CRC Press 2016. p. 7-10.
Brohede S, Wyon Y, Wingren G, Wijma B, Wijma k. Body Dysmorphic Disorder; Int J Dermatol 2017;56:1387-94.
Klatte J, Vulink N, Kemperman P. Body dysmorphic disorder. Huisarts en wetenschap. 2016;59:20-3.
Dey JK, Ishii M, Phillis M, Byrne PJ, Boahene KD, Ishii LE, et al.
Body dysmorphic disorder in a facial plastic and reconstructive surgery clinic: Measuring prevalence, assessing comorbidities, and validating a feasible screening instrument. JAMA Facial Plast Surg 2015;17:137-43.
Naraghi M, Atari M, Asadollahi H. When aesthetics, surgery, and psychology meet: Aesthetic nasal proportions in patients having rhinoplasty and normal adults. Surg J (N Y) 2016;2:e44-8.