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'''For patient information, click [[Body dysmorphic disorder (patient information)|here]]'''
{{SI}}
{{SI}}
{{CMG}}; {{AE}} {{Chelsea}} {{Alonso}}
{{SK}} BDD
==Overview==
Body dysmorphic disorder (BDD) is a [[mental disorder]] that involves a disturbed [[body image]] where there is an excessive preoccupation with the physical appearance despite the fact there may be no noticeable [[disfigurement]] or [[defect]]. Common areas of concern in most people suffering from BDD include perceived flaws relating to the [[face]], [[nose]], [[eyes]], [[skin]], and [[hair]]. BDD combines [[obsessive]] and [[compulsive]] aspects, which links it to the [[Obsessive-compulsive disorder|OCD]] spectrum disorders. People with BDD may engage in [[compulsive]] mirror checking behaviors or mirror avoidance, typically think about their appearance for more than one hour a day, and in severe cases may drop all social contact and responsibilities as they become homebound. The [[disorder]] is linked to an unusually high [[suicide]] rate among all [[mental disorders]].


{{CMG}}
==Historical Perspective==
BDD was first documented in 1886 by the researcher [[Morselli]], who called the condition simply "'''Dysmorphophobia'''". BDD was first recorded/formally recognized in 1997 as a disorder in the [[Diagnostic and Statistical Manual of Mental Disorders|DSM]]; however, in 1987 it was first truly recognized by the [[American Psychiatric Association]].


{{EH}}
In his practice, [[Sigmund Freud|Freud]] eventually had a patient who would today be diagnosed with the disorder; Russian [[aristocrat]] [[Sergei Pankejeff]], nicknamed "The Wolf Man" by [[Freud]] himself in order to protect Pankejeff's identity, had a preoccupation with his nose to an extent that greatly limited his functioning.


'''Body dysmorphic disorder (BDD)''' is a mental disorder that involves a disturbed [[body image]]. It is generally diagnosed in those who are extremely critical of their physique or self-image, despite the fact there may be no noticeable disfigurement or defect.
==Causes==
The exact etiology of BDD is unclear, but it is likely an interplay in [[social]], [[psychological]], and [[biological]] factors. <ref name="BuhlmannMarques2012">{{cite journal|last1=Buhlmann|first1=Ulrike|last2=Marques|first2=Luana M.|last3=Wilhelm|first3=Sabine|title=Traumatic Experiences in Individuals With Body Dysmorphic Disorder|journal=Journal of Nervous & Mental Disease|volume=200|issue=1|year=2012|pages=95–98|issn=0022-3018|doi=10.1097/NMD.0b013e31823f6775}}</ref>


Most people wish they could change or improve some aspect of their physical appearance, but people suffering from BDD, generally considered of normal appearance, believe that they are so unspeakably hideous that they are unable to interact with others or function normally for fear of ridicule and humiliation at their appearance. They tend to be very secretive and reluctant to seek help because they are afraid others will think them vanity|vain or they may feel too embarrassed to do so.
===Social Factors===
Individuals with BDD have suffered from some form of abuse in the past. These experiences comprised [[emotional]] [[neglect]] in 68%, [[emotional abuse]] in 56 %, [[physical abuse]] in 34.7%, and [[sexual abuse]] in 28% of patients. <ref name="BuhlmannMarques2012">{{cite journal|last1=Buhlmann|first1=Ulrike|last2=Marques|first2=Luana M.|last3=Wilhelm|first3=Sabine|title=Traumatic Experiences in Individuals With Body Dysmorphic Disorder|journal=Journal of Nervous & Mental Disease|volume=200|issue=1|year=2012|pages=95–98|issn=0022-3018|doi=10.1097/NMD.0b013e31823f6775}}</ref> <ref name="DidieTortolani2006">{{cite journal|last1=Didie|first1=Elizabeth R.|last2=Tortolani|first2=Christina C.|last3=Pope|first3=Courtney G.|last4=Menard|first4=William|last5=Fay|first5=Christina|last6=Phillips|first6=Katharine A.|title=Childhood abuse and neglect in body dysmorphic disorder|journal=Child Abuse & Neglect|volume=30|issue=10|year=2006|pages=1105–1115|issn=01452134|doi=10.1016/j.chiabu.2006.03.007}}</ref>
===Neurobiological Model for BDD===
====Detailed processing and visual processing streams====
A dysfunction in [[visual processing systems]] accounts for the heightened detail processing in BDD patients. This is due to the observed early travel of [[first-order visual information]] from V1 and V2 areas to [[temporal]] regions in the left hemisphere, where detail and structure are encoded. In addition, there is the faulty formation of holistic elements of visual information due to decreased use of the processing of [[second-order visual information]], as evidenced by decreased activity in the lateral [[occipital]] [[cortex]] and [[precuneus]]. These findings explain the enhanced awareness of perceived imperfections in BDD patients.<ref name="ArienzoLeow2013">{{cite journal|last1=Arienzo|first1=Donatello|last2=Leow|first2=Alex|last3=Brown|first3=Jesse A|last4=Zhan|first4=Liang|last5=GadElkarim|first5=Johnson|last6=Hovav|first6=Sarit|last7=Feusner|first7=Jamie D|title=Abnormal Brain Network Organization in Body Dysmorphic Disorder|journal=Neuropsychopharmacology|volume=38|issue=6|year=2013|pages=1130–1139|issn=0893-133X|doi=10.1038/npp.2013.18}}</ref> <ref name="FeusnerArienzo2013">{{cite journal|last1=Feusner|first1=Jamie D.|last2=Arienzo|first2=Donatello|last3=Li|first3=Wei|last4=Zhan|first4=Liang|last5=GadElkarim|first5=Johnson|last6=Thompson|first6=Paul M.|last7=Leow|first7=Alex D.|title=White matter microstructure in body dysmorphic disorder and its clinicalcorrelates|journal=Psychiatry Research: Neuroimaging|volume=211|issue=2|year=2013|pages=132–140|issn=09254927|doi=10.1016/j.pscychresns.2012.11.001}}</ref> <ref name="LeowZhan2012">{{cite journal|last1=Leow|first1=Alex D.|last2=Zhan|first2=Liang|last3=Arienzo|first3=Donatello|last4=GadElkarim|first4=Johnson J.|last5=Zhang|first5=Aifeng F.|last6=Ajilore|first6=Olusola|last7=Kumar|first7=Anand|last8=Thompson|first8=Paul M.|last9=Feusner|first9=Jamie D.|title=Hierarchical Structural Mapping for Globally Optimized Estimation of Functional Networks|volume=7511|year=2012|pages=228–236|issn=0302-9743|doi=10.1007/978-3-642-33418-4_29}}</ref> <ref name="LiArienzo2013">{{cite journal|last1=Li|first1=Wei|last2=Arienzo|first2=Donatello|last3=Feusner|first3=Jamie D.|title=Body Dysmorphic Disorder: Neurobiological Features and an Updated Model|journal=Zeitschrift für Klinische Psychologie und Psychotherapie|volume=42|issue=3|year=2013|pages=184–191|issn=1616-3443|doi=10.1026/1616-3443/a000213}}</ref> <ref name="GraceLabuschagne2017">{{cite journal|last1=Grace|first1=Sally A.|last2=Labuschagne|first2=Izelle|last3=Kaplan|first3=Ryan A.|last4=Rossell|first4=Susan L.|title=The neurobiology of body dysmorphic disorder: A systematic review and theoretical model|journal=Neuroscience & Biobehavioral Reviews|volume=83|year=2017|pages=83–96|issn=01497634|doi=10.1016/j.neubiorev.2017.10.003}}</ref>


Ironically, BDD is often misunderstood as a vanity driven obsession, whereas it is quite the opposite; people with BDD believe themselves to be irrevocably ugly or defective.  
====Frontostriatal systems====
Increased activity and reduced [[grey matter]] volumes in the [[frontostriatal]] and [[subcortical]] regions are linked to BDD patients' [[repetitive]] and [[compulsive]] behaviors, which is similarly observed in OCD patients.This is supported by abnormal [[circuitry]] seen in the inferior [[occipitofrontal fasciculus]], a pathway that connects the [[frontal]] and [[occipital]] lobes via the [[caudate]]. The caudate nucleus seems to play an essential role in inappropriately mediating motor inhibition. <ref name="SaxenaRauch2000">{{cite journal|last1=Saxena|first1=Sanjaya|last2=Rauch|first2=Scott L.|title=FUNCTIONAL NEUROIMAGING AND THE NEUROANATOMY OF OBSESSIVE-COMPULSIVE DISORDER|journal=Psychiatric Clinics of North America|volume=23|issue=3|year=2000|pages=563–586|issn=0193953X|doi=10.1016/S0193-953X(05)70181-7}}</ref> <ref name="BuchananRossell2013">{{cite journal|last1=Buchanan|first1=B. G.|last2=Rossell|first2=S. L.|last3=Maller|first3=J. J.|last4=Toh|first4=W. L.|last5=Brennan|first5=S.|last6=Castle|first6=D. J.|title=Brain connectivity in body dysmorphic disorder compared with controls: a diffusion tensor imaging study|journal=Psychological Medicine|volume=43|issue=12|year=2013|pages=2513–2521|issn=0033-2917|doi=10.1017/S0033291713000421}}</ref>
         
====Temporolimbic systems====
The [[limbic system]] is also involved in BDD. In particular, the right [[amygdala]] demonstrates [[hyperactivity]] during [[visual]] tasks and mediates the relationship between [[anxiety]] and ventral [[visual system]] activation. This results in heightened [[emotions]] to [[visual]] information.<ref name="BuhlmannWinter2013">{{cite journal|last1=Buhlmann|first1=Ulrike|last2=Winter|first2=Anna|last3=Kathmann|first3=Norbert|title=Emotion recognition in body dysmorphic disorder: Application of the Reading the Mind in the Eyes Task|journal=Body Image|volume=10|issue=2|year=2013|pages=247–250|issn=17401445|doi=10.1016/j.bodyim.2012.12.001}}</ref> <ref name="MonzaniRijsdijk2012">{{cite journal|last1=Monzani|first1=Benedetta|last2=Rijsdijk|first2=Fruhling|last3=Iervolino|first3=Alessandra C.|last4=Anson|first4=Martin|last5=Cherkas|first5=Lynn|last6=Mataix-Cols|first6=David|title=Evidence for a genetic overlap between body dysmorphic concerns and obsessive-compulsive symptoms in an adult female community twin sample|journal=American Journal of Medical Genetics Part B: Neuropsychiatric Genetics|volume=159B|issue=4|year=2012|pages=376–382|issn=15524841|doi=10.1002/ajmg.b.32040}}</ref>


BDD combines obsessive and compulsive aspects, which links it to the [[Obsessive-Compulsive Disorder|OCD]] spectrum disorders among psychologists. People with BDD may engage in compulsive mirror checking behaviors or mirror avoidance, typically think about their appearance for more than one hour a day, and in severe cases may drop all social contact and responsibilities as they become homebound. The disorder is linked to an unusually high [[suicide]] rate among all mental disorders.  
===Genetic Factors===
A [[genetic]] component may also be involved in BBD. Patients with BDD have a family member with a similar condition in 8% of patients, while 7% of BDD patients have first-degree family members with [[OCD]]. <ref name="BjornssonDidie2013">{{cite journal|last1=Bjornsson|first1=Andri S.|last2=Didie|first2=Elizabeth R.|last3=Grant|first3=Jon E.|last4=Menard|first4=William|last5=Stalker|first5=Emily|last6=Phillips|first6=Katharine A.|title=Age at onset and clinical correlates in body dysmorphic disorder|journal=Comprehensive Psychiatry|volume=54|issue=7|year=2013|pages=893–903|issn=0010440X|doi=10.1016/j.comppsych.2013.03.019}}</ref>


A German study has shown that 1-2% of the population meet all the diagnostic criteria of BDD, with a larger percentage showing milder symptoms of the disorder (''Psychological Medicine'', vol 36, p 877). Chronically low self-esteem is characteristic of those with BDD due to the value of oneself being so closely linked with their perceived appearance. The prevalence of BDD is equal in men and women, and causes chronic social [[anxiety]] for those suffering from the disorder[http://www.lipo.com/Health_Articles/Lifestyle_Articles/When_the_mirror_lies_-_Body_dysmorphic_disorder_(dysmorphophobia)_on_the_rise_and_taking_lives./].
==Differential Diagnosis==
Body dysmorphic disorder must be differentiated from: <ref name="DSMV">{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>


Phillips & Menard (2006) found the completed suicide rate in patients with BDD to be 45 times higher than in the general US population. This rate is more than double that of those with [[Clinical depression]] and three times as high as those with [[bipolar disorder]]<ref>http://ajp.psychiatryonline.org/cgi/content/full/163/7/1280</ref>. There has also been a suggested link between undiagnosed BDD and a higher than average suicide rate among people who have undergone cosmetic surgery<ref>http://www.newscientist.com/channel/health/mg19225745.200-cosmetic-surgery-special-when-looks-can-kill.html</ref>.
*[[Anxiety disorder]]


==History ==
*[[Eating disorders]]
BDD was first documented in 1886 by the researcher Morselli, who called the condition simply "'''Dysmorphophobia'''". BDD was first recorded/formally recognized in 1997 as a disorder in the [[Diagnostic and Statistical Manual of Mental Disorders|DSM]]; however, in 1987 it was first truly recognized by the [[American Psychiatric Association]].


In his practice, [[Sigmund Freud|Freud]] eventually had a patient who would today be diagnosed with the disorder; Russian [[aristocrat]] [[Sergei Pankejeff]], nicknamed "The Wolf Man" by Freud himself in order to protect Pankejeff's identity, had a preoccupation with his nose to an extent that greatly limited his functioning.
*[[Illness anxiety disorder]]


==Diagnoses ==
*[[Major depressive disorder]]
According to the DSM IV the following criteria must be met in order to receive a definite diagnosis for Body Dysmorphic Disorder.
*Other [[OCD|obsessive-compulsive disorders]]


*The patient is preoccupied with an imagined defect of appearance or is excessively concerned about a slight physical anomaly.
*[[Psychotic disorders]]
 
==Epidemiology and Demographics==
===Prevalence===
The prevalence of BDD is at 0.7-2.4% in the general population making it more common than other psychiatric disorders such as [[anorexia nervosa]] or [[schizophrenia]]. In clinical settings, BDD seems to have a prevalence of 9-13% in [[dermatology]] settings, 3-53% in [[cosmetic surgery]] settings and it coexists with [[OCD]] in 8-37% of patients.
Considering how common this condition is, many individuals don’t report their symptoms due to embarrassment. <ref name="pmid20623926">{{cite journal| author=Bjornsson AS, Didie ER, Phillips KA| title=Body dysmorphic disorder. | journal=Dialogues Clin Neurosci | year= 2010 | volume= 12 | issue= 2 | pages= 221-32 | pmid=20623926 | doi= | pmc=3181960 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20623926  }} </ref>
 
===Gender===
BDD affects more women than men (2.5% vs 2.2%) and the average onset is at 17 years old.<ref name="HongNezgovorova2019">{{cite journal|last1=Hong|first1=Kevin|last2=Nezgovorova|first2=Vera|last3=Uzunova|first3=Genoveva|last4=Schlussel|first4=Danya|last5=Hollander|first5=Eric|title=Pharmacological Treatment of Body Dysmorphic Disorder|journal=Current Neuropharmacology|volume=17|issue=8|year=2019|pages=697–702|issn=1570159X|doi=10.2174/1570159X16666180426153940}}</ref>
 
==Risk Factors==
 
Some of risk factors include: <ref name="DSMV">{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>


*This preoccupation causes clinically important distress or impairs work, social or personal functioning.
*First-degree relatives of patients with [[obsessive compulsive disorder]] ([[OCD]])
*History of childhood abuse


*Another mental disorder (such as [[Anorexia Nervosa]]) does not better explain the preoccupation.
==Natural History, Complications, and Prognosis==
===Natural History===
BDD usually develops in [[adolescence]], a time when people are generally most sensitive about their appearance. However, many patients suffer for years before seeking help. When they do seek help through mental health professionals, patients often complain of other symptoms such as [[depression]], [[social anxiety]] or [[obsessive-compulsive disorder]], but do not reveal their real concern over body image. Most patients cannot be convinced that they have a distorted view of their [[body image]], due to the very limited knowledge of the disorder as compared to OCD or others. 
Male patients have more risk of developing the obsession around the genitalia and females have higher risk of developing [[eating disorders]] associated with the BDD.<ref name="pmid17183412">{{cite journal| author=Phillips KA| title=The Presentation of Body Dysmorphic Disorder in Medical Settings. | journal=Prim psychiatry | year= 2006 | volume= 13 | issue= 7 | pages= 51-59 | pmid=17183412 | doi= | pmc=1712667 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17183412  }} </ref>


==Symptoms ==
===Complications===
*Compulsive mirror checking, glancing in reflective doors, windows and other reflective surfaces.
====Suicide Risk====
*Alternatively, an inability to look at one's own reflection or photographs of oneself; often the removal of mirrors from the home.
*Compulsive skin-touching, especially to measure or feel the perceived defect.
*Reassurance-seeking from loved ones.
*Social withdrawal and co-morbid depression.
*Obsessive viewing of favorite celebrities or models the person suffering from BDD may wish to resemble.
*Excessive grooming behaviors: combing hair, plucking eyebrows, shaving, etc.
*Obsession with [[plastic surgery]] or multiple plastic surgeries with little satisfactory results for the patient.
*In obscure cases patients have performed plastic surgery on themselves, including [[liposuction]] and various implants with disastrous results.


==Common locations of imagined defects==
*The [[suicide]] rates in patients with BDD are high at all ages, with a higher incidence in adolescent patients.
In research carried out by Dr. Katharine Philips, involving over 500 patients, the percentage of patients concerned with the most common locations were as follows:
*Risk factors associated with completed [[suicide]] in patients with BDD are [[suicide]] thoughts and previous attempts, association with [[major depressive syndrome]] and demographic locations associated with high rates of suicide.
{{col-begin}}
*Phillips & Menard (2006) found the completed [[suicide]] rate in patients with BDD to be 45 times higher than in the general US population. This rate is more than double that of those with [[Clinical depression]] and three times as high as those with [[bipolar disorder]]. There has also been a suggested link between undiagnosed BDD and a higher than average [[suicide]] rate among people who have undergone [[cosmetic surgery]]<ref>http://ajp.psychiatryonline.org/cgi/content/full/163/7/1280</ref><ref>http://www.newscientist.com/channel/health/mg19225745.200-cosmetic-surgery-special-when-looks-can-kill.html</ref>.
{{col-break}}
*skin (73%)
*hair (56%)
*nose (37%)
*weight (22%)
*stomach (22%)
*breasts/chest/nipples (21%)
*eyes (20%)
*thighs (20%)
*teeth (20%)
*legs (overall) (18%)
*body build / bone structure (16%)
*ugly face (general) (14%)
*lips (12%)
*buttocks (12%)
*chin (11%)
*fingers
*eyebrows (11%)


''source: '''The Broken Mirror''', Katharine A Philips, Oxford University Press, 2005 ed, p56 ''
====Functional Consequences of BDD====


People with BDD often have more than one area of concern.
*Impaired [[psychosocial]] development which can range from mild (the patient avoids [[social situations]]) to severe (the patient doesn't leave the house).
*The severity of the disorder is usually directly associated with the degree of [[psychosocial impairment]].
*Chronically low [[self-esteem]] is characteristic of those with BDD due to the value of oneself being so closely linked with their perceived appearance. BDD causes chronic social [[anxiety]] for those suffering from the disorder[http://www.lipo.com/Health_Articles/Lifestyle_Articles/When_the_mirror_lies_-_Body_dysmorphic_disorder_(dysmorphophobia)_on_the_rise_and_taking_lives./]


==Development ==
===Prognosis===
BDD usually develops in adolescence, a time when people are generally most sensitive about their appearance. However, many patients suffer for years before seeking help. When they do seek help through mental health professionals, patients often complain of other symptoms such as depression, social anxiety or obsessive compulsive disorder, but do not reveal their real concern over body image. Most patients cannot be convinced that they have a distorted view of their body image, due to the very limited knowledge of the disorder as compared to OCD or others.
Many individuals with BDD have repeatedly sought treatment from [[dermatologists]] or [[cosmetic surgeons]] with little satisfaction before finally accepting [[psychiatric]] or [[psychological]] help. Treatment can improve the outcome of the illness for most people. Other patients may function reasonably well for a time and then [[relapse]], while others may remain chronically ill. Research on outcomes without therapy is not known but it is thought the symptoms persist unless treated. <ref name="pmid29872676">{{cite journal| author=Higgins S, Wysong A| title=Cosmetic Surgery and Body Dysmorphic Disorder - An Update. | journal=Int J Womens Dermatol | year= 2018 | volume= 4 | issue= 1 | pages= 43-48 | pmid=29872676 | doi=10.1016/j.ijwd.2017.09.007 | pmc=5986110 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29872676  }} </ref>


An absolute cause of body dysmorphic disorder is unknown. However research shows that a number of factors may be involved and that they can occur in combination, including:
==Diagnosis==
===Diagnostic Criteria===
====DSM-V Diagnostic Criteria for Body Dysmorphic Disorder Body Dysmorphic Disorder====
{{cquote|
*The patient is preoccupied with an imagined defect of appearance or is excessively concerned about a slight physical anomaly.


'''A chemical imbalance in the brain.''' An insufficient level of [[serotonin]], one of the brain's [[neurotransmitter]]s involved in mood and pain, may contribute to body dysmorphic disorder. Although such an imbalance in the brain is unexplained, it may be hereditary.
'''AND'''
'''Obsessive-compulsive disorder.''' BDD often occurs with OCD, where the patient uncontrollably practices ritual behaviors that may literally take over their life. A history of, or [[gene]]tic predisposition to, OCD may make people more susceptible to BDD.


'''Generalized anxiety disorder.''' Body dysmorphic disorder may co-exist with generalized anxiety disorder. This condition involves excessive worrying that disrupts the patient's daily life, often causing exaggerated or unrealistic anxiety about life circumstances, such as a perceived flaw or defect in appearance, as in BDD.
*During the course of the disease the patient develops behaviors such as excessive mirror checking, grooming, seek for [[reassurance]] or compare his/her appearance with others.


==The Disabling Effects of BDD==
'''AND'''
BDD can be anywhere from slightly to severely debilitating. It can make normal employment or family life impossible. Those who are in regular employment or who have family responsibilities would almost certainly find life more productive and satisfying if they did not have the symptoms. The partners of sufferers of BDD may also become involved and suffer greatly, sometimes losing their loved one to [[suicide]].


==Prognosis==
*This preoccupation causes clinically important distress or impairs [[work]], [[social]] or [[personal]] functioning.
Many individuals with BDD have repeatedly sought treatment from dermatologists or cosmetic surgeons with little satisfaction before finally accepting psychiatric or psychological help. Treatment can improve the outcome of the illness for most people. Other patients may function reasonably well for a time and then relapse, while others may remain chronically ill. Research on outcome without therapy is not known but it is thought the symptoms persist unless treated.  


==Prevalence==
'''AND'''
''According to Dr Katharine Phillips (2004) :''


Although large [[epidemiology|epidemiologic]] surveys of BDD's prevalence have not been done, studies to date indicate that BDD is relatively common in both nonclinical and clinical settings (Phillips & Castle, 2002). Studies in community samples have reported current rates of 0.7% and 1.1%, and studies in nonclinical student samples have reported rates of 2.2%, 4%, and 13% (Phillips & Castle, 2002). A study in a general inpatient setting found that 13% of patients had BDD (Grant, Won Kim, Crow, 2001). Studies in outpatient settings have reported rates of 8%-37% in patients with OCD, 11%-13% in social phobia, 26% in trichotillomania, 8% in major depression, and 14%-42% in atypical major depression (Phillips & Castle, 2002). In one study of atypical depression, BDD was more than twice as common as OCD (Phillips, Nierenberg, Brendel et al 1996), and in another (Perugi, Akiskal, Lattanzi et al, 1998) it was more common than many other disorders, including OCD, social phobia, simple phobia, generalized anxiety disorder, [[bulimia nervosa]], and substance abuse or dependence. In a [[dermatology]] setting, 12% of patients screened positive for BDD, and in [[cosmetic surgery]] settings, rates of 6%-15% have been reported (Phillips & Castle, 2002).
*Another mental disorder (such as [[Anorexia Nervosa]]) does not better explain the preoccupation.
}}


BDD is underdiagnosed, however. Two studies of inpatients (Phillips, McElroy, Keck et al, 1993, and Grant, Won Kim, Crow, 2001), as well as studies in general outpatients (Zimmerman & Mattia, 1998) and depressed outpatients (Phillips, Nierenberg, Brendel et al 1996), systematically assessed a series of patients for the presence of BDD and then determined whether clinicians had made the diagnosis in the clinical record. All four studies found that BDD was missed by the clinician in every case in which it was present. Thus, underdiagnosis of BDD appears common.
*One must also specify if a patient with BDD has [[muscle dysmorphia]] where one seems to be preoccupied in a too small or insufficiently muscular physique even though they have a normal-looking build.


==Treatments==
*In addition, the degree of insight must also be evaluated <ref name="DSMV">{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>.
Typically the [[psychodynamic]] approach to therapy does not seem to be effective in battling BDD while in some patients it may even be countereffective.


CBT ([[Cognitive Behavioral Therapy]]) coupled with [[exposure therapy]] has been shown effective in the treatment of BDD. Low levels or insufficient use of serotonin in the brain has been implicated with the disorder and so [[SSRI]] drugs are commonly used, and with some success, in the treatment of Body Dysmorphic Disorder. Drug treatment will sometimes also include the use of an [[anxiolytic]].
===Symptoms===
[[Symptoms]] of body dysmorphic disorder include:<ref name="DSMV">{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>


BDD tends to be chronic; current information suggests that symptoms do not subside, but rather worsen through time. Indeed in most patients, the symptoms and concerns diversify and social contacts may further deteriorate. As so, treatment should be initiated as early as possible following the diagnoses.
*[[Compulsive]] mirror checking, glancing in reflective doors, windows, and other reflective surfaces
*Alternatively, an inability to look at one's own reflection or photographs of oneself; often the removal of mirrors from the home
*[[Compulsive]] [[skin]]-touching, especially to measure or feel the perceived defect
*[[Reassurance]]-seeking from loved ones
*[[Social withdrawal]] and co-[[Morbidity|morbid]] [[depression]].
*[[Obsessive viewing]] of favorite celebrities or models the person suffering from BDD may wish to resemble
*Excessive grooming behaviors: combing [[hair]], plucking [[eyebrows]], shaving, etc
*Obsession with [[plastic surgery]] or multiple [[plastic surgeries]] with few satisfactory results for the patient
*In obscure cases patients have performed [[plastic surgery]] on themselves, including [[liposuction]] and various [[implants]] with disastrous results


== See also ==
===Common Locations of imagined Defects===
* [[Clinical depression]]
In research carried out by Dr. Katharine Philips, involving over 500 patients, the percentage of patients concerned with the most common locations were as follows:
* Lookism
{{col-begin|width=80%}}
* [[Anxiety disorders]]
*[[Skin]] (73%)
* [[Obsessive-compulsive disorder]]
*[[Hair]] (56%)
* Audrey Hepburn, widely considered one of the most beautiful women in history, never considered herself very attractive.
*[[Nose]] (37%)
* Cycloponomia, a rarer and more extreme condition similar in some ways to BDD.
*[[Weight]] (22%)
* [[Scars]]
*[[Stomach]] (22%)
* [[Deformity]]
*[[Breasts]]/ [[Chest]]/ [[Nipples]] (21%)
* Michael Jackson, who is also thought to have BDD, but he doesn't admit it.
*[[Eyes]] (20%)
*[[Thighs]] (20%)
*[[Teeth]] (20%)
*[[Legs]] (Overall) (18%)
*Body Build/ [[Bone]] Structure (16%)
*Ugly [[Face]] (General) (14%)
*[[Lips]] (12%)
*[[Buttocks]] (12%)
*[[Chin]] (11%)
*[[Fingers]]  
*[[Eyebrows]] (11%)
{{col-end}}
People with BDD often have more than one area of concern.
''Source: ''' The Broken Mirror''', Katharine A Philips, Oxford University Press, 2005 ed, p56 ''


==References==
* Wilhelm, S. ''Feeling Good About the Way You Look''. New York: Guilford Press, 2006
* Phillips, K.A. ''The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder''. New York: Oxford University Press, 1996 (Revised and Expanded Edition, 2005)
* Barlow, David H., & Durand, V. Mark. ''Essentials of Abnormal Psychology''. Thomson Learning, Inc., 2006.
* Neziroglu, F.; Roberts, M.; Yayura-Tobias, J.A.A behavioral model for body dysmorphic disorder. ''Psychiatric Annals, 34'' (12): 915-920, 2004.
* Phillips, KA. Body dysmorphic disorder: the distress of imagined ugliness. American ''Psychiatric Association, 148'': 1138-1149, 1991.[http://ajp.psychiatryonline.org/cgi/content/abstract/148/9/1138]
* James Claiborn; Cherry Pedrick. (2004). ''The BDD Workbook''. New Harbinger Publications, U.S. Jan 2003
* Phillips, Katherine A. Body dysmorphic disorder: recognizing and treating imagined ugliness. ''World Psychiatry, 3''(1): 12–17.
* Phillips, K.A., & Castle, D.J. Body dysmorphic disorder. In: Castle DJ, Phillips KA., editors. ''Disorders of Body Image''. Hampshire: Wrightson Biomedical; 2002.
* Grant, J.E., Won Kim, S., & Crow, S.J. (2001). Prevalence and clinical features of body dysmorphic disorder in adolescent and adult psychiatric inpatients. ''J Clin Psychiatry, 62'':517–522.
* Phillips K.A., Nierenberg A.A., Brendel G., et al. (1996). Prevalence and clinical features of body dysmorphic disorder in atypical major depression. ''J Nerv Ment Dis. 184'':125–129.
* Perugi G, Akiskal HS, Lattanzi L, et al. (1998). The high prevalence of "soft" bipolar (II) features in atypical depression. ''Compr Psychiatry, 39'':63–71.
* Zimmerman M, Mattia JI. (1998). Body dysmorphic disorder in psychiatric outpatients: recognition, prevalence, comorbidity, demographic, and clinical correlates. ''Compr Psychiatry, 39'':265–270.
* Phillips KA, McElroy SL, Keck PE Jr, et al. (1993). Body dysmorphic disorder: 30 cases of imagined ugliness. ''Am J Psychiatry, 150'':302–308.


==Further reading==
==Treatment==
* Saville, Chris. "The Worried Well." Body Dysmorphic Disorder. Films for the Humanities & Sciences, Princeton, NJ. 1997. Video Archive. 2004.
*The combination of [[Cognitive Behavioral Therapy]] [[(CBT)]] and [[Selective Serotonin Reuptake Inhibitors]] [[(SSRIs)]] are the mainstay treatments for BDD.
* Walker, Pamela. "Everything You Need To Know About Body Dysmorphic Disorder." New York: The Rosen Publishing Group, Inc., 1999.
* Phillips, Dr Katharine A. "The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder", Oxford University Press, 1998
*[[CBT]] involves [[psychotherapy]] centered on developing [[coping mechanisms]] by altering [[repetitive]] [[behavior]] patterns and [[thoughts]]. Strategies involve gradual [[sensitization]] of fear-inducing circumstances and [[retraining]] of thoughts. They are administered for 12-22 weeks of weekly sessions.<ref name="HofmannAsmundson2013">{{cite journal|last1=Hofmann|first1=Stefan G.|last2=Asmundson|first2=Gordon J.G.|last3=Beck|first3=Aaron T.|title=The Science of Cognitive Therapy|journal=Behavior Therapy|volume=44|issue=2|year=2013|pages=199–212|issn=00057894|doi=10.1016/j.beth.2009.01.007}}</ref> <ref name="WilhelmPhillips2014">{{cite journal|last1=Wilhelm|first1=Sabine|last2=Phillips|first2=Katharine A.|last3=Didie|first3=Elizabeth|last4=Buhlmann|first4=Ulrike|last5=Greenberg|first5=Jennifer L.|last6=Fama|first6=Jeanne M.|last7=Keshaviah|first7=Aparna|last8=Steketee|first8=Gail|title=Modular Cognitive-Behavioral Therapy for Body Dysmorphic Disorder: A Randomized Controlled Trial|journal=Behavior Therapy|volume=45|issue=3|year=2014|pages=314–327|issn=00057894|doi=10.1016/j.beth.2013.12.007}}</ref>
* Thomas F. Cash Ph.D., "The Body Image Workbook", New Harbinger Publications, 1997
* Veale, David and Willson, Rob. "Overcoming Body Shame and Body Dysmorphic Disorder": Robinson, (forthcoming mid 2007)
* Westwood, S., "Suicide Junkie." A sufferers account of living and surviving BDD, Chipmunka Publishing, 2007


The film “Looks that Kill” features a patient who was treated at the Priory Hospital North London. The video is available from Films of Record tel.: +44(0)20 7286 0333
*[[SSRIs]], more commonly [[fluoxetine]] and [[escitalopram]], are used to treat BDD and its accompanying comorbidities such as [[major depressive disorder]], (social [[anxiety disorder]], and [[OCD]]. The incorporation of [[clomipramine]] is also initiated in some cases where [[SSRIs]] may not be of benefit. What should be noted with the use of [[SSRIs]] in the treatment of BDD is that they require higher doses compared to doses used to treat other psychiatric conditions. Typically, observed response to [[SSRI]] requires 12-16 weeks to determine response.<ref name="pmid29701157">{{cite journal| author=Hong K, Nezgovorova V, Uzunova G, Schlussel D, Hollander E| title=Pharmacological Treatment of Body Dysmorphic Disorder. | journal=Curr Neuropharmacol | year= 2019 | volume= 17 | issue= 8 | pages= 697-702 | pmid=29701157 | doi=10.2174/1570159X16666180426153940 | pmc=7059151 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29701157  }} </ref>


==External links==
==References==
*[http://www.bodyimageprogram.com/ Dr. Katharine Phillips Body Image Program at Butler Hospital]
{{reflist|2}}
*[http://www.massgeneral.org/bdd/ Massachusetts General Hospital BDD clinic]
*[http://www.mssm.edu/psychiatry/ciadp/ciadp_bdd.shtml BDD Research at New York City's Mount Sinai School of Medicine]
*[http://www.bddhelp.com/home BDDHelp.com UK site]
*[http://www.bddcentral.com/ BDD Central]
*[http://www.semel.ucla.edu/adc/researchstudies.html Body Dysmorphic Disorder and Obsessive Compulsive Disorder Research]
*[http://www.ocdaction.org.uk OCD Action UK]
*[http://www.bddclinic.com/ Los Angeles Body Dysmorphic Disorder Clinic]
*[http://www.bddstory.co.uk/ BDD and rhinoplasty story]
*http://www.ncpamd.com/body_dysmorphic_disorder.htm
*[http://www.bodydysmorphicdisorder.eu/ German Body Dysmorphic Disorder Website]
*[http://www.unipark.de/uc/bddsurvey/ Philipps Universität online survey for individuals with and without BDD]


[[Category:DSM-V Diagnostic Criteria]]
[[Category:Psychiatric Disease]]
[[Category:Psychiatry]]
[[Category:Somatoform disorders]]
[[Category:Somatoform disorders]]
{{SIB}}
[[de:Dysmorphophobie]]
[[es:Trastorno dismórfico corporal]]
[[fr:Dysmorphophobie]]
[[it:Dismorfofobia]]
[[he:BDD]]
[[nl:Stoornis van de lichaamsbeleving]]
[[ja:身体醜形障害]]
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Chelsea Mae Nobleza, M.D.[2] Alonso Alvarado, M.D. [3]

Synonyms and keywords: BDD

Overview

Body dysmorphic disorder (BDD) is a mental disorder that involves a disturbed body image where there is an excessive preoccupation with the physical appearance despite the fact there may be no noticeable disfigurement or defect. Common areas of concern in most people suffering from BDD include perceived flaws relating to the face, nose, eyes, skin, and hair. BDD combines obsessive and compulsive aspects, which links it to the OCD spectrum disorders. People with BDD may engage in compulsive mirror checking behaviors or mirror avoidance, typically think about their appearance for more than one hour a day, and in severe cases may drop all social contact and responsibilities as they become homebound. The disorder is linked to an unusually high suicide rate among all mental disorders.

Historical Perspective

BDD was first documented in 1886 by the researcher Morselli, who called the condition simply "Dysmorphophobia". BDD was first recorded/formally recognized in 1997 as a disorder in the DSM; however, in 1987 it was first truly recognized by the American Psychiatric Association.

In his practice, Freud eventually had a patient who would today be diagnosed with the disorder; Russian aristocrat Sergei Pankejeff, nicknamed "The Wolf Man" by Freud himself in order to protect Pankejeff's identity, had a preoccupation with his nose to an extent that greatly limited his functioning.

Causes

The exact etiology of BDD is unclear, but it is likely an interplay in social, psychological, and biological factors. [1]

Social Factors

Individuals with BDD have suffered from some form of abuse in the past. These experiences comprised emotional neglect in 68%, emotional abuse in 56 %, physical abuse in 34.7%, and sexual abuse in 28% of patients. [1] [2]

Neurobiological Model for BDD

Detailed processing and visual processing streams

A dysfunction in visual processing systems accounts for the heightened detail processing in BDD patients. This is due to the observed early travel of first-order visual information from V1 and V2 areas to temporal regions in the left hemisphere, where detail and structure are encoded. In addition, there is the faulty formation of holistic elements of visual information due to decreased use of the processing of second-order visual information, as evidenced by decreased activity in the lateral occipital cortex and precuneus. These findings explain the enhanced awareness of perceived imperfections in BDD patients.[3] [4] [5] [6] [7]

Frontostriatal systems

Increased activity and reduced grey matter volumes in the frontostriatal and subcortical regions are linked to BDD patients' repetitive and compulsive behaviors, which is similarly observed in OCD patients.This is supported by abnormal circuitry seen in the inferior occipitofrontal fasciculus, a pathway that connects the frontal and occipital lobes via the caudate. The caudate nucleus seems to play an essential role in inappropriately mediating motor inhibition. [8] [9]

Temporolimbic systems

The limbic system is also involved in BDD. In particular, the right amygdala demonstrates hyperactivity during visual tasks and mediates the relationship between anxiety and ventral visual system activation. This results in heightened emotions to visual information.[10] [11]

Genetic Factors

A genetic component may also be involved in BBD. Patients with BDD have a family member with a similar condition in 8% of patients, while 7% of BDD patients have first-degree family members with OCD. [12]

Differential Diagnosis

Body dysmorphic disorder must be differentiated from: [13]

Epidemiology and Demographics

Prevalence

The prevalence of BDD is at 0.7-2.4% in the general population making it more common than other psychiatric disorders such as anorexia nervosa or schizophrenia. In clinical settings, BDD seems to have a prevalence of 9-13% in dermatology settings, 3-53% in cosmetic surgery settings and it coexists with OCD in 8-37% of patients. Considering how common this condition is, many individuals don’t report their symptoms due to embarrassment. [14]

Gender

BDD affects more women than men (2.5% vs 2.2%) and the average onset is at 17 years old.[15]

Risk Factors

Some of risk factors include: [13]

Natural History, Complications, and Prognosis

Natural History

BDD usually develops in adolescence, a time when people are generally most sensitive about their appearance. However, many patients suffer for years before seeking help. When they do seek help through mental health professionals, patients often complain of other symptoms such as depression, social anxiety or obsessive-compulsive disorder, but do not reveal their real concern over body image. Most patients cannot be convinced that they have a distorted view of their body image, due to the very limited knowledge of the disorder as compared to OCD or others. Male patients have more risk of developing the obsession around the genitalia and females have higher risk of developing eating disorders associated with the BDD.[16]

Complications

Suicide Risk

  • The suicide rates in patients with BDD are high at all ages, with a higher incidence in adolescent patients.
  • Risk factors associated with completed suicide in patients with BDD are suicide thoughts and previous attempts, association with major depressive syndrome and demographic locations associated with high rates of suicide.
  • Phillips & Menard (2006) found the completed suicide rate in patients with BDD to be 45 times higher than in the general US population. This rate is more than double that of those with Clinical depression and three times as high as those with bipolar disorder. There has also been a suggested link between undiagnosed BDD and a higher than average suicide rate among people who have undergone cosmetic surgery[17][18].

Functional Consequences of BDD

  • Impaired psychosocial development which can range from mild (the patient avoids social situations) to severe (the patient doesn't leave the house).
  • The severity of the disorder is usually directly associated with the degree of psychosocial impairment.
  • Chronically low self-esteem is characteristic of those with BDD due to the value of oneself being so closely linked with their perceived appearance. BDD causes chronic social anxiety for those suffering from the disorder[4]

Prognosis

Many individuals with BDD have repeatedly sought treatment from dermatologists or cosmetic surgeons with little satisfaction before finally accepting psychiatric or psychological help. Treatment can improve the outcome of the illness for most people. Other patients may function reasonably well for a time and then relapse, while others may remain chronically ill. Research on outcomes without therapy is not known but it is thought the symptoms persist unless treated. [19]

Diagnosis

Diagnostic Criteria

DSM-V Diagnostic Criteria for Body Dysmorphic Disorder Body Dysmorphic Disorder

“
  • The patient is preoccupied with an imagined defect of appearance or is excessively concerned about a slight physical anomaly.

AND

  • During the course of the disease the patient develops behaviors such as excessive mirror checking, grooming, seek for reassurance or compare his/her appearance with others.

AND

  • This preoccupation causes clinically important distress or impairs work, social or personal functioning.

AND

  • Another mental disorder (such as Anorexia Nervosa) does not better explain the preoccupation.
 ”
  • One must also specify if a patient with BDD has muscle dysmorphia where one seems to be preoccupied in a too small or insufficiently muscular physique even though they have a normal-looking build.
  • In addition, the degree of insight must also be evaluated [13].

Symptoms

Symptoms of body dysmorphic disorder include:[13]

Common Locations of imagined Defects

In research carried out by Dr. Katharine Philips, involving over 500 patients, the percentage of patients concerned with the most common locations were as follows:

People with BDD often have more than one area of concern. Source: The Broken Mirror, Katharine A Philips, Oxford University Press, 2005 ed, p56


Treatment

  • SSRIs, more commonly fluoxetine and escitalopram, are used to treat BDD and its accompanying comorbidities such as major depressive disorder, (social anxiety disorder, and OCD. The incorporation of clomipramine is also initiated in some cases where SSRIs may not be of benefit. What should be noted with the use of SSRIs in the treatment of BDD is that they require higher doses compared to doses used to treat other psychiatric conditions. Typically, observed response to SSRI requires 12-16 weeks to determine response.[22]

References

  1. ↑ 1.0 1.1 Buhlmann, Ulrike; Marques, Luana M.; Wilhelm, Sabine (2012). "Traumatic Experiences in Individuals With Body Dysmorphic Disorder". Journal of Nervous & Mental Disease. 200 (1): 95–98. doi:10.1097/NMD.0b013e31823f6775. ISSN 0022-3018.
  2. ↑ Didie, Elizabeth R.; Tortolani, Christina C.; Pope, Courtney G.; Menard, William; Fay, Christina; Phillips, Katharine A. (2006). "Childhood abuse and neglect in body dysmorphic disorder". Child Abuse & Neglect. 30 (10): 1105–1115. doi:10.1016/j.chiabu.2006.03.007. ISSN 0145-2134.
  3. ↑ Arienzo, Donatello; Leow, Alex; Brown, Jesse A; Zhan, Liang; GadElkarim, Johnson; Hovav, Sarit; Feusner, Jamie D (2013). "Abnormal Brain Network Organization in Body Dysmorphic Disorder". Neuropsychopharmacology. 38 (6): 1130–1139. doi:10.1038/npp.2013.18. ISSN 0893-133X.
  4. ↑ Feusner, Jamie D.; Arienzo, Donatello; Li, Wei; Zhan, Liang; GadElkarim, Johnson; Thompson, Paul M.; Leow, Alex D. (2013). "White matter microstructure in body dysmorphic disorder and its clinicalcorrelates". Psychiatry Research: Neuroimaging. 211 (2): 132–140. doi:10.1016/j.pscychresns.2012.11.001. ISSN 0925-4927.
  5. ↑ Leow, Alex D.; Zhan, Liang; Arienzo, Donatello; GadElkarim, Johnson J.; Zhang, Aifeng F.; Ajilore, Olusola; Kumar, Anand; Thompson, Paul M.; Feusner, Jamie D. (2012). "Hierarchical Structural Mapping for Globally Optimized Estimation of Functional Networks". 7511: 228–236. doi:10.1007/978-3-642-33418-4_29. ISSN 0302-9743.
  6. ↑ Li, Wei; Arienzo, Donatello; Feusner, Jamie D. (2013). "Body Dysmorphic Disorder: Neurobiological Features and an Updated Model". Zeitschrift für Klinische Psychologie und Psychotherapie. 42 (3): 184–191. doi:10.1026/1616-3443/a000213. ISSN 1616-3443.
  7. ↑ Grace, Sally A.; Labuschagne, Izelle; Kaplan, Ryan A.; Rossell, Susan L. (2017). "The neurobiology of body dysmorphic disorder: A systematic review and theoretical model". Neuroscience & Biobehavioral Reviews. 83: 83–96. doi:10.1016/j.neubiorev.2017.10.003. ISSN 0149-7634.
  8. ↑ Saxena, Sanjaya; Rauch, Scott L. (2000). "FUNCTIONAL NEUROIMAGING AND THE NEUROANATOMY OF OBSESSIVE-COMPULSIVE DISORDER". Psychiatric Clinics of North America. 23 (3): 563–586. doi:10.1016/S0193-953X(05)70181-7. ISSN 0193-953X.
  9. ↑ Buchanan, B. G.; Rossell, S. L.; Maller, J. J.; Toh, W. L.; Brennan, S.; Castle, D. J. (2013). "Brain connectivity in body dysmorphic disorder compared with controls: a diffusion tensor imaging study". Psychological Medicine. 43 (12): 2513–2521. doi:10.1017/S0033291713000421. ISSN 0033-2917.
  10. ↑ Buhlmann, Ulrike; Winter, Anna; Kathmann, Norbert (2013). "Emotion recognition in body dysmorphic disorder: Application of the Reading the Mind in the Eyes Task". Body Image. 10 (2): 247–250. doi:10.1016/j.bodyim.2012.12.001. ISSN 1740-1445.
  11. ↑ Monzani, Benedetta; Rijsdijk, Fruhling; Iervolino, Alessandra C.; Anson, Martin; Cherkas, Lynn; Mataix-Cols, David (2012). "Evidence for a genetic overlap between body dysmorphic concerns and obsessive-compulsive symptoms in an adult female community twin sample". American Journal of Medical Genetics Part B: Neuropsychiatric Genetics. 159B (4): 376–382. doi:10.1002/ajmg.b.32040. ISSN 1552-4841.
  12. ↑ Bjornsson, Andri S.; Didie, Elizabeth R.; Grant, Jon E.; Menard, William; Stalker, Emily; Phillips, Katharine A. (2013). "Age at onset and clinical correlates in body dysmorphic disorder". Comprehensive Psychiatry. 54 (7): 893–903. doi:10.1016/j.comppsych.2013.03.019. ISSN 0010-440X.
  13. ↑ 13.0 13.1 13.2 13.3 Diagnostic and statistical manual of mental disorders : DSM-5. Washington, D.C: American Psychiatric Association. 2013. ISBN 0890425558.
  14. ↑ Bjornsson AS, Didie ER, Phillips KA (2010). "Body dysmorphic disorder". Dialogues Clin Neurosci. 12 (2): 221–32. PMC 3181960. PMID 20623926.
  15. ↑ Hong, Kevin; Nezgovorova, Vera; Uzunova, Genoveva; Schlussel, Danya; Hollander, Eric (2019). "Pharmacological Treatment of Body Dysmorphic Disorder". Current Neuropharmacology. 17 (8): 697–702. doi:10.2174/1570159X16666180426153940. ISSN 1570-159X.
  16. ↑ Phillips KA (2006). "The Presentation of Body Dysmorphic Disorder in Medical Settings". Prim psychiatry. 13 (7): 51–59. PMC 1712667. PMID 17183412.
  17. ↑ http://ajp.psychiatryonline.org/cgi/content/full/163/7/1280
  18. ↑ http://www.newscientist.com/channel/health/mg19225745.200-cosmetic-surgery-special-when-looks-can-kill.html
  19. ↑ Higgins S, Wysong A (2018). "Cosmetic Surgery and Body Dysmorphic Disorder - An Update". Int J Womens Dermatol. 4 (1): 43–48. doi:10.1016/j.ijwd.2017.09.007. PMC 5986110. PMID 29872676.
  20. ↑ Hofmann, Stefan G.; Asmundson, Gordon J.G.; Beck, Aaron T. (2013). "The Science of Cognitive Therapy". Behavior Therapy. 44 (2): 199–212. doi:10.1016/j.beth.2009.01.007. ISSN 0005-7894.
  21. ↑ Wilhelm, Sabine; Phillips, Katharine A.; Didie, Elizabeth; Buhlmann, Ulrike; Greenberg, Jennifer L.; Fama, Jeanne M.; Keshaviah, Aparna; Steketee, Gail (2014). "Modular Cognitive-Behavioral Therapy for Body Dysmorphic Disorder: A Randomized Controlled Trial". Behavior Therapy. 45 (3): 314–327. doi:10.1016/j.beth.2013.12.007. ISSN 0005-7894.
  22. ↑ Hong K, Nezgovorova V, Uzunova G, Schlussel D, Hollander E (2019). "Pharmacological Treatment of Body Dysmorphic Disorder". Curr Neuropharmacol. 17 (8): 697–702. doi:10.2174/1570159X16666180426153940. PMC 7059151 Check |pmc= value (help). PMID 29701157.
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