Dysmorphophobia

What is dysmorphophobia?

Dysmorphophobia, also known as body dysmorphic disorder (BDD), is a psychiatric disorder characterised by fixation on an imaginary flaw in physical appearance. Although it is a psychiatric illness, most patients do not acknowledge this and seek help from cosmetic surgeons and dermatologists. In the dermatological setting the condition has been termed dermatological hypochondriasis.

Patients with dysmorphophobia may become distressed about any part of their body but most frequently complain about their skin, hair, and nose. Many have a preoccupation with wrinkles, acne, marks and large pores.

Who gets dysmorphophobia and what is the cause?

The cause of dysmorphophobia is unknown but a hereditary factor may be involved as the chance of dysmorphophobia is four times higher in first-degree relatives of people with the condition. It also appears to be related to obsessive–compulsive disorder (OCD) as it occurs frequently in people with OCD and their relatives.

More recent studies into brain function have suggested people with dysmorphophobia may have abnormalities in the area of visual processing, emotional processing and visual information transfer.

Dysmorphophobia affects males and females, although each sex tends to focus on different types of perceived defects. The condition usually starts to occur in adolescence, however the average age of those seeking dermatological care is around 33 years. It has been found that the incidence of dysmorphophobia is much higher among patients receiving dermatological care than in the general population.

What are the signs and symptoms of dysmorphophobia?

People suffering from dysmorphophobia often lack self-esteem, may be self-conscious around others, and seek medical reassurance about a particular physical feature that would not normally have been noticed until pointed out.

Characteristic symptoms include:

• Patient seeking numerous opinions from medical doctors, particularly dermatologists or cosmetic surgeons, then often displeased with being told the defect is non-existent or minor. Refusal to accept they have an underlying psychiatric illness.
• Agonise over perceived defects to the point they cannot function properly at work or socially.
• Often develop compulsive habits such as frequent mirror checking and extensive grooming.
• May develop skin picking to try and remove or disguise the defect, but only manage to worsen the situation.
• Disguise or conceal their defect using items such as wigs and hairpieces, hats and camouflage make-up.

What is the treatment for dysmorphophobia?

The management of patients with dysmorphophobia is often difficult as they often refuse psychiatric referral because of poor insight into the underlying psychiatric illness. In some cases even though patients may be aware that their concerns are excessive, they still continue to agonise over their perceived defect. Other patients may be delusional and have no insight into their unusual behaviour.

The following points should be taken into consideration when treating a patient.

• Considerable tact and repeated visits are needed to gain the patient's trust before broaching the fact they have no physical defect and noting that the problem is a psychiatric illness.
• Sufferers are often reluctant to seek psychiatric help, and if suggestions to do so by a doctor or dermatologist are not made carefully, the patient may not return for future visits.
• Behavioural modification therapy can help by stopping or reducing compulsive behaviours such as skin picking.
• Cognitive behavioural therapy can encourage self-esteem, modify distorted thoughts and formulate coping strategies.
• Antidepressant medication, in particular, the serotonin reuptake inhibitors (SRIs) in conjunction with cognitive behavioural therapy has proven effective in the treatment of dysmorphophobia.