Body Dysmorphic Disorder

Epidemiology and Etiology

• Worldwide prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency: 2%–4%
• Girls > boys
• Onset typically in adolescence (65% by the age of 18 years)
• 90% of patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship have comorbid depression.
• 70% have comorbid anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder.
• 30% have comorbid psychotic disorder.
• Incidence Incidence The number of new cases of a given disease during a given period in a specified population. It also is used for the rate at which new events occur in a defined population. It is differentiated from prevalence, which refers to all cases in the population at a given time. Measures of Disease Frequency is highest in dermatologic and cosmetic surgery patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship.

Etiology

• Etiology is unknown.
• Predisposing factors thought to include:
  • Genetics Genetics Genetics is the study of genes and their functions and behaviors. Basic Terms of Genetics: 43% heritability noted in monozygotic twins Monozygotic twins Result from the division of a single zygote; share the same genetic material Multiple Pregnancy
  • Frontal lobe dysfunction Frontal lobe dysfunction Heterogeneous group of neurodegenerative disorders characterized by frontal and temporal lobe atrophy associated with neuronal loss, gliosis, and dementia. Patients exhibit progressive changes in social, behavioral, and/or language function. Multiple subtypes or forms are recognized based on presence or absence of tau protein inclusions. Ftld includes three clinical syndromes: frontotemporal dementia, semantic dementia, and primary progressive nonfluent aphasia. Amyotrophic Lateral Sclerosis → deficits in executive function → focus on specific details of body rather than entirety of appearance
  • History of neglect Neglect Child Abuse or abuse
• Some studies suggest genetic predisposition along with OCD OCD Obsessive-compulsive disorder (OCD) is a condition characterized by obsessions (recurring and intrusive thoughts, urges, or images) and/or compulsions (repetitive actions the person is compelled to perform) that are time-consuming and associated with functional impairment. Obsessive-compulsive Disorder (OCD).

Clinical Presentation

General

• Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship don’t usually disclose the preoccupation.
• Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship have varying degrees of insight Insight Psychiatric Assessment into symptoms and must be asked specifically.
• Often present to dermatology or plastic surgery for correction of perceived imperfection
• May present with:
  • Social anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder and avoidance
  • Emotional distress
  • Poor psychosocial functioning and quality Quality Activities and programs intended to assure or improve the quality of care in either a defined medical setting or a program. The concept includes the assessment or evaluation of the quality of care; identification of problems or shortcomings in the delivery of care; designing activities to overcome these deficiencies; and follow-up monitoring to ensure effectiveness of corrective steps. Quality Measurement and Improvement of life
  • Suicidal ideation Suicidal ideation A risk factor for suicide attempts and completions, it is the most common of all suicidal behavior, but only a minority of ideators engage in overt self-harm. Suicide and behavior:
    • 4 times more likely to develop ideas
    • 2 times more likely to carry it out
  • Aggressive behavior

Muscle dysmorphia

• Subtype of body dysmorphic disorder (BDD)
• Preoccupied with idea that body build is too small or insufficiently muscular
• Commonly seen in men
• Usually associated with steroid abuse

Comorbidities Comorbidities The presence of co-existing or additional diseases with reference to an initial diagnosis or with reference to the index condition that is the subject of study. Comorbidity may affect the ability of affected individuals to function and also their survival; it may be used as a prognostic indicator for length of hospital stay, cost factors, and outcome or survival. St. Louis Encephalitis Virus

• Major depression
• Social anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder disorder
• Personality disorders Personality Disorders A major deviation from normal patterns of behavior. Cluster A Personality Disorders 
• OCD OCD Obsessive-compulsive disorder (OCD) is a condition characterized by obsessions (recurring and intrusive thoughts, urges, or images) and/or compulsions (repetitive actions the person is compelled to perform) that are time-consuming and associated with functional impairment. Obsessive-compulsive Disorder (OCD)
• Eating disorders
• Substance use disorders

Diagnosis

Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship exhibit:

• Preoccupation with 1 or more perceived defects or flaws in physical appearance that are not observable or appear slight to others:
  • Thought is difficult to resist or control.
  • Occurs for an average of 3–8 hours/day
• Repetitive behaviors or mental acts in response to concern with appearance:
  • Comparing features with those of others
  • Mirror checking
  • Excessive grooming
  • Seeking reassurance Reassurance Clinician–Patient Relationship from others
  • Camouflaging
• Clinically significant distress or impairment in social, occupational, or other areas of functioning due to preoccupation/compulsion
• Meeting the diagnostic criteria for eating disorders supersedes a diagnosis of BDD.

Management and Prognosis

• Psychoeducation Psychoeducation Psychotherapy is important, as many patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship lack insight Insight Psychiatric Assessment into the condition.
• Treatment includes psychological and pharmacological interventions:
  • Psychological interventions:
    • CBT
    • Metacognitive therapy
    • Address co-morbidities.
  • Pharmacological interventions:
    • Selective serotonin reuptake inhibitors Selective Serotonin Reuptake Inhibitors Serotonin Reuptake Inhibitors and Similar Antidepressants ( SSRIs SSRIs Serotonin Reuptake Inhibitors and Similar Antidepressants; fluoxetine Fluoxetine The first highly specific serotonin uptake inhibitor. It is used as an antidepressant and often has a more acceptable side-effects profile than traditional antidepressants. Serotonin Reuptake Inhibitors and Similar Antidepressants)
    • Clomipramine Clomipramine A tricyclic antidepressant similar to imipramine that selectively inhibits the uptake of serotonin in the brain. It is readily absorbed from the gastrointestinal tract and demethylated in the liver to form its primary active metabolite, desmethylclomipramine. Tricyclic Antidepressants

Prognosis Prognosis A prediction of the probable outcome of a disease based on a individual’s condition and the usual course of the disease as seen in similar situations. Non-Hodgkin Lymphomas

• Chronic illness
• Response to treatment requires ≤ 16 weeks of therapy.
• Response rate of 50%–80% with pharmacological treatment
• Relapses are common; maintenance SSRI therapy recommended.

Differential Diagnosis

• Generalized anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder disorder: marked by chronic, multiple worries that are irrational and uncontrollable. Associated with fatigue Fatigue The state of weariness following a period of exertion, mental or physical, characterized by a decreased capacity for work and reduced efficiency to respond to stimuli. Fibromyalgia, low concentration, restlessness, irritability, and sleep Sleep A readily reversible suspension of sensorimotor interaction with the environment, usually associated with recumbency and immobility. Physiology of Sleep disturbance. Symptoms last for more than 6 months and cause significant decline in functioning. Treatment includes psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy and medications (e.g., SSRI or serotonin-norepinephrine reuptake inhibitor (SNRI) antidepressants). 
• Social anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder disorder: disorder or social phobia Social phobia Anxiety disorder characterized by the persistent and irrational fear, anxiety, or avoidance of social or performance situations. Social Anxiety Disorder marked by fear and avoidance of social interactions due to concerns about embarrassment. Usually occurs in more than 1 social situation for more than 6 months and leads to a significant decline in function. Performance subtype occurs only in performance-related situations (e.g., giving a speech in front of others). Treatment includes CBT, antidepressants (SSRI, SNRI), and beta-blockers Beta-blockers Drugs that bind to but do not activate beta-adrenergic receptors thereby blocking the actions of beta-adrenergic agonists. Adrenergic beta-antagonists are used for treatment of hypertension, cardiac arrhythmias, angina pectoris, glaucoma, migraine headaches, and anxiety. Class 2 Antiarrhythmic Drugs (Beta Blockers) or benzodiazepines Benzodiazepines Benzodiazepines work on the gamma-aminobutyric acid type A (GABAA) receptor to produce inhibitory effects on the CNS. Benzodiazepines do not mimic GABA, the main inhibitory neurotransmitter in humans, but instead potentiate GABA activity. Benzodiazepines for performance-only subtype. 
• OCD OCD Obsessive-compulsive disorder (OCD) is a condition characterized by obsessions (recurring and intrusive thoughts, urges, or images) and/or compulsions (repetitive actions the person is compelled to perform) that are time-consuming and associated with functional impairment. Obsessive-compulsive Disorder (OCD): characterized by obsessions Obsessions Recurrent thoughts, images, or urges that are intrusive and recognized as unwanted, causing significant anxiety and distress . Obsessive-compulsive Disorder (OCD) (recurring senseless and intrusive thoughts, feelings, or sensations) that cause severe distress. Obsessions Obsessions Recurrent thoughts, images, or urges that are intrusive and recognized as unwanted, causing significant anxiety and distress . Obsessive-compulsive Disorder (OCD) are neutralized partly by compulsions Compulsions Repetitive behaviors or mental acts that the individual is driven to perform in relation to an obsession. Obsessive-compulsive Disorder (OCD) (repetitive actions), which are time-consuming and affect patient quality Quality Activities and programs intended to assure or improve the quality of care in either a defined medical setting or a program. The concept includes the assessment or evaluation of the quality of care; identification of problems or shortcomings in the delivery of care; designing activities to overcome these deficiencies; and follow-up monitoring to ensure effectiveness of corrective steps. Quality Measurement and Improvement of life. Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship may experience either obsessions Obsessions Recurrent thoughts, images, or urges that are intrusive and recognized as unwanted, causing significant anxiety and distress . Obsessive-compulsive Disorder (OCD) alone or a combination of obsessions Obsessions Recurrent thoughts, images, or urges that are intrusive and recognized as unwanted, causing significant anxiety and distress . Obsessive-compulsive Disorder (OCD) and compulsions Compulsions Repetitive behaviors or mental acts that the individual is driven to perform in relation to an obsession. Obsessive-compulsive Disorder (OCD). Treatment is monotherapy with antidepressants, which may be augmented by CBT and antipsychotic Antipsychotic Antipsychotics, also called neuroleptics, are used to treat psychotic disorders and alleviate agitation, mania, and aggression. Antipsychotics are notable for their use in treating schizophrenia and bipolar disorder and are divided into 1st-generation antipsychotics (FGAs) and atypical or 2nd-generation antipsychotics. First-Generation Antipsychotics medication.
• Anorexia Anorexia The lack or loss of appetite accompanied by an aversion to food and the inability to eat. It is the defining characteristic of the disorder anorexia nervosa. Anorexia Nervosa nervosa: eating disorder marked by self-imposed starvation and inappropriate dietary habits due to morbid fear of weight gain and disturbed perception Perception The process by which the nature and meaning of sensory stimuli are recognized and interpreted. Psychiatric Assessment of body shape and weight. Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship have strikingly low body weight (≤ 18.5 kg) and diverse physiological and psychological complications. Most commonly seen in adolescent girls. Treatment mainly consists of psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy (CBT) and patient hospitalization Hospitalization The confinement of a patient in a hospital. Delirium for optimization of nutritional deficiencies.