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==Overview==
__NOTOC__
Factors that increase the chance of developing cancer are called risk factors.  There are 2 types of risk factors: Modifiable and Non-modifiable.  Modifiable risk factors are attitudes or circumstances that people can avoid, for example smoking. Non-modifiable risk factors are conditions that can't be changed, for example genetic predisposition to certain diseases.  Factors that decrease the chance of developing cancer are called protective factors.
{{CMG}}; {{AE}} {{Alonso}}


Many other factors in our environment, diet, and lifestyle may cause or prevent cancer.  This summary reviews only the major cancer risk factors and protective factors that can be controlled or changed to reduce the risk of cancer.  Risk factors that are not described in the summary include certain sexual behaviors, the use of estrogen, and being exposed to certain substances or chemicals.
Infobox goes here


==Factors That are Known to Increase the Risk of Cancer==
<nowiki>{{SI}}</nowiki>


===Tobacco===
'''''Synonyms and keywords:'''''


* Tobacco use is strongly linked to an increased risk for many kinds of cancer. [[Cigarette smoking]] is the leading cause of the following types of cancer:
== Overview ==
:* [[Acute myelogenous leukemia]] (AML)
'''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.
:* [[Bladder cancer]]
:* [[Esophageal cancer]]
:* [[Kidney cancer]]
:* [[Lung cancer]]
:* [[Oral cancer]]
:* [[Pancreatic cancer]]
:* [[Stomach cancer]]
* Not [[smoking]] or quitting [[smoking]] lowers the risk of getting cancer and dying from cancer.
* [[Cigarette smoking]] causes about 30% of all cancer deaths in the United States.
* [[Cigarette smoking]] causes an estimated 443,000 deaths each year, including approximately 49,000 deaths due to exposure to [[secondhand smoke]].
* [[Lung cancer]] is the leading cause of cancer death among both men and women in the United States, and 90% of [[lung cancer]] deaths among men and approximately 80% of [[lung cancer]] deaths among women are due to [[smoking]].


===Infections===
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.


Certain [[viral]] and [[bacterial]] infections are able to cause cancer. Infection as a cancer cause is more common in developing countries (about 1 in 4 cases of cancer) than in developed countries (less than 1 in 10 cases of cancer). Examples of infection caused cancers:
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.  
* [[Human papillomavirus]] (HPV):
:* [[Cervical cancer]]
:* [[Penis cancer]]
:* [[Vaginal cancer]]
:* [[Anal cancer]]
:* Oropharyngeal cancer
* [[Hepatitis B virus|Hepatitis B]] and [[Hepatitis C virus|hepatitis C]] viruses increase the risk for liver cancer
* [[Epstein-Barr virus]] increases the risk for [[Burkitt lymphoma]]
* [[Helicobacter pylori]] increases the risk for [[gastric cancer]]


Two [[vaccines]] to prevent infection by cancer-causing agents have already been developed and approved by the U.S. Food and Drug Administration (FDA):
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.
* [[Hepatitis B vaccine]]
* [[Human papillomavirus prevention#Vaccine|Human papillomavirus vaccine]]


===Radiation===
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./].


There are two main types of radiation linked with an increased risk for cancer:
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>.
* Ultraviolet radiation from sunlight: This is the main cause of nonmelanoma skin cancers.
* Ionizing radiation including:
:* Medical radiation from tests such as [[x-rays]], [[CT scans]], [[fluoroscopy]], and [[Nuclear medicine#Diagnostic testing|nuclear medicine scans]].
:* Radon gas found in homes.
* Radiation exposure from diagnostic [[X-rays]] increases the risk of cancer in patients and [[X-ray]] technicians.
* The growing use of [[CT scans]] over the last 20 years has increased exposure to ionizing radiation. The risk of cancer also increases with the number of [[CT scans]] a patient has and the radiation dose used each time.


Ionizing radiation has been associated with:
==Historical Perspective==
* [[Leukemia]]
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]].
* [[Thyroid cancer]]
* [[Breast cancer]]
* [[Myeloma]]
* [[Lung cancer]]
* [[Gastric cancer]]
* [[Colon cancer]]
* [[Esophageal cancer]]
* [[Bladder cancer]]
* [[Ovarian cancer]]


===Immunosuppressive Medicines===
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.


Immunosuppressive medicines are linked to an increased risk of cancer because these medications lower the immune system's ability to stop cancer from forming.
==Classification==


===Asbestos exposure===
==Pathophysiology==
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.


* [[Asbestos]] has been classified as a known human [[carcinogen]] by the U.S. Department of Health and Human Services, the EPA, and the International Agency for Research on Cancer.
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:
* Studies have shown that exposure to [[asbestos]] may increase the risk of [[lung cancer]] and [[mesothelioma]].
* [[Mesothelioma]] is the most common form of cancer associated with [[asbestos]] exposure.
* Though inconclusive, studies have shown an association between [[asbestos]] and other cancers:
:* [[Gastric cancer]]
:* [[Colorectal cancer]]
:* Throat cancer
:* [[Kidney cancer]]
:* [[Esophageal cancer]]
:* [[Gallbladder cancer]]
* [[Smokers]] who are also exposed to [[asbestos]] have a risk of developing [[lung cancer]] that is greater than the individual risks from [[asbestos]] and [[smoking]] added together.


===Formaldehyde===
'''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.
'''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.


* The International Agency for Research on Cancer (IARC) and the National Toxicology Program classify [[formaldehyde]] as a human [[carcinogen]].
'''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.
* Several National Cancer Institute (NCI) surveys suggested that professionals who are potentially exposed to [[formaldehyde]] in their work, such as anatomists and embalmers, have an increased risk of [[leukemia]] (particularly [[myeloid leukemia]]) and [[brain cancer]] compared with the general population.
* Several epidemiologic studies have shown the risk of [[formaldehyde]] exposure and cancer. This risk was associated with increasing peak, average levels and duration of exposure, but it was not associated with cumulative exposure.
* A 10-year follow-up study showed the risk of [[leukemia]] was highest earlier in the follow-up period.  Risks declined steadily over time, such that the cumulative excess risk of [[myeloid leukemia]] was no longer statistically significant at the end of the follow-up period.
* Several case-control studies, as well as analysis of the large NCI industrial cohort, found an association between [[formaldehyde]] exposure and nasopharyngeal cancer.
* Data from extended follow-up of the NCI cohort found that the excess of nasopharyngeal cancer observed in the earlier report persisted.


===Hair dye===
==Causes==


* Studies have shown that professional hairdressers have an increased risk of [[bladder cancer]] that may be due to occupational exposure to hair dye.  However, the information is inconclusive.
==Differentiating type page name here from other Diseases==
* A review of 14 studies of female [[breast cancer]] and hair dye published between 1977 and 2002 found that dye users had no increase in the risk of [[breast cancer]] compared with nonusers.
* Studies of the association between personal hair dye use and the risk of leukemia have had conflicting results.


===Acrylamide===
== Epidemiology and Demographics ==
''According to Dr Katharine Phillips (2004) :''


* The National Toxicology Program and the International Agency for Research on Cancer consider [[acrylamide]] to be a “probable human carcinogen,” based on studies in laboratory animals.
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).
* One study showed that women with higher levels of [[acrylamide]] bound to the [[hemoglobin]] in their blood, had a statistically significant increase in risk of [[estrogen]] receptor-positive [[breast cancer]].
* A questionnaire-based cohort study performed the Netherlands found an excess of [[Endometrial cancer|endometrial]] and [[ovarian cancer]] associated with higher levels of [[acrylamide]] exposure


===Artificial sweeteners===
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.


* '''[[Saccharin]]:'''
== Risk Factors ==
:* Studies in rats showed an increased incidence of [[bladder cancer]] at high doses of [[saccharin]], especially in male rats. However, mechanistic studies have shown that these results apply only to rats.
:* Human epidemiology studies have shown no consistent evidence that [[saccharin]] is associated with [[bladder cancer]] incidence.
* '''[[Aspartame]]:''' NCI examined human data from the NIH-AARP Diet and Health Study of over half a million retirees. Increasing consumption of [[aspartame]]-containing beverages was not associated with the development of [[lymphoma]], [[leukemia]], or [[brain cancer]].
* '''Acesulfame potassium, [[Sucralose]] and Neotame:''' These three artificial sweeteners are currently permitted for use in food in the United States.  Before approving these sweeteners, the FDA reviewed more than 100 safety studies that were conducted on each sweetener, including studies to assess cancer risk. The results of these studies showed no evidence that these sweeteners cause cancer or pose any other threat to human health.
* '''[[Cyclamate]]:''' Early studies showed that [[cyclamate]] in combination with [[saccharin]] caused [[bladder cancer]] in laboratory animals.
:* Results from subsequent studies of [[Cycalmate|cyclamate’s]] carcinogenicity and the evaluation of additional data, it was concluded that [[cyclamate]] was not a [[carcinogen]] or a co-carcinogen.
:* A food additive petition was filed with the FDA for the reapproval of [[cyclamate]], but this petition is currently being held in abeyance.  The FDA’s concerns about [[cyclamate]] are not cancer related.


==Factors That May Affect the Risk of Cancer==
== Screening ==


===Diet===
== Natural History, Complications, and Prognosis==


* Diet is being studied as a risk factor for cancer. 
== Diagnosis ==
* Some studies show that fruits and non-starchy vegetables may protect against [[oral cancer]], [[esophageal cancer]], [[gastric cancer]] and [[lung cancer]]
* Results from studies on the effect of a diet high in [[fat]], [[proteins]], [[calories]], and red meat as a risk factor for [[colorectal cancer]] are controversial.  There are studies that have showed a clear relationship and studies that haven't.
:* It is not known if a diet low in [[fat]] and high in [[fiber]], fruits, and vegetables lowers the risk of [[colorectal cancer]].


===Alcohol===
=== Symptoms ===
*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-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.


* Based on extensive reviews of research studies, there is a strong consensus about the association between alcohol drinking and several types of cancer.
===Location of imagined defects===
* The National Toxicology Program of the US Department of Health and Human Services lists consumption of alcoholic beverages as a known human [[carcinogen]].
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:
* Evidence indicates that the more alcohol a person drinks -particularly the more alcohol a person drinks regularly over time- the higher his or her risk of developing an alcohol-associated cancer.
{{col-begin}}
*Drinking alcohol is related with an increased risk of the following types of cancers:
{{col-break}}
:* [[Head and neck cancer]]: Alcohol consumption is a major risk factor for certain head and neck cancers, particularly cancers of the [[Oral cancer|oral cavity]], pharynx, and larynx.
*skin (73%)
::* People who consume 50 or more grams of alcohol per day (approximately 3.5 or more drinks per day) have at least a two to three times greater risk of developing these cancers than nondrinkers.
*hair (56%)
::* The risks of these cancers are substantially higher among persons who consume this amount of alcohol and also use tobacco.
*nose (37%)
:* [[Esophageal cancer]]: Alcohol consumption is a major risk factor for esophageal [[squamous cell carcinoma]]. People who inherit a deficiency or polymorphisms in ALDH2 (an enzyme that metabolizes alcohol) have been found to have substantially increased risks of alcohol-related esophageal squamous cell carcinoma.<ref name="pmid21157980">{{cite journal| author=Zhang GH, Mai RQ, Huang B| title=Meta-analysis of ADH1B and ALDH2 polymorphisms and esophageal cancer risk in China. | journal=World J Gastroenterol | year= 2010 | volume= 16 | issue= 47 | pages= 6020-5 | pmid=21157980 | doi= | pmc=PMC3007115 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21157980  }} </ref><ref name="pmid19320537">{{cite journal| author=Brooks PJ, Enoch MA, Goldman D, Li TK, Yokoyama A| title=The alcohol flushing response: an unrecognized risk factor for esophageal cancer from alcohol consumption. | journal=PLoS Med | year= 2009 | volume= 6 | issue= 3 | pages= e50 | pmid=19320537 | doi=10.1371/journal.pmed.1000050 | pmc=PMC2659709 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19320537  }} </ref>
*weight (22%)
:* [[Breast cancer]]: More than 100 epidemiologic studies have looked at the association between alcohol consumption and the risk of [[breast cancer]] in women. ::* These studies have consistently found an increased risk of breast cancer associated with increasing alcohol intake.  A meta-analysis of 53 of these studies (which included a total of 58,000 women with [[breast cancer]]) showed that women who drank more than 45 grams of alcohol per day (approximately three drinks) had 1.5 times more risk of developing [[breast cancer]] as nondrinkers.
*stomach (22%)
::* The risk of [[breast cancer]] was higher across all levels of alcohol intake: The Million Women Study in the United Kingdom showed an estimate of [[breast cancer]] risk at low to moderate levels of alcohol consumption: every 10 grams of alcohol consumed per day was associated with a 12 percent increase in the risk of [[breast cancer]].
*breasts/chest/nipples (21%)
:* [[Colorectal cancer]]: Alcohol consumption is associated with a modestly increased risk of cancers of the colon and rectum.
*eyes (20%)
::* A meta-analysis of 57 cohort and case-control studies that examined the association between alcohol consumption and [[colorectal cancer]] risk showed that people who regularly drank 50 grams or more of alcohol per day (approximately 3.5 drinks) had 1.5 times the risk of developing [[colorectal cancer]] as nondrinkers or occasional drinkers.
*thighs (20%)
::* For every 10 grams of alcohol consumed per day, there was a small 7% increase in the risk of [[colorectal cancer]].
*teeth (20%)
:* [[Liver cancer]]: Alcohol consumption is an independent risk factor for and a primary cause of [[liver cancer]].
*legs (overall) (18%)
* Multiple studies have shown that increased alcohol consumption is associated with a decreased risk [[renal cell carcinoma]] and [[Non-Hodgkin's Lymphoma]] (NHL).  A meta-analysis of the [[NHL]] studies found a 15% lower risk of [[NHL]] among alcohol drinkers compared with nondrinkers. The mechanisms by which alcohol consumption would decrease the risks of either [[renal cell carcinoma]] or [[NHL]] are not understood.
*body build / bone structure (16%)
*ugly face (general) (14%)
*lips (12%)
*buttocks (12%)
*chin (11%)
*fingers
*eyebrows (11%)


===Physical Activity===
''source: '''The Broken Mirror''', Katharine A Philips, Oxford University Press, 2005 ed, p56 ''


Studies have shown that physically active people have a lower risk of certain cancers than those who are not. It is not known if physical activity itself is the reason for this.  Physical activity has been associated with a lower risk of the following cancers:
People with BDD often have more than one area of concern.
* [[Colorectal cancer]]
* Postmenopausal [[breast cancer]]
* [[Endometrial cancer]]


===Obesity===
==The Disabling Effects of BDD==
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]].


* Studies show that obesity is linked to a higher risk of the following types of cancer:
==Prognosis==
:* Postmenopausal [[breast cancer]]
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.
:* [[Colorectal cancer]]
:* [[Endometrial cancer]]
:* [[Esophageal cancer]]
:* [[Kidney cancer]]
:* [[Pancreatic cancer]]
:* Some studies have shown obesity a risk factor for [[gallblader cancer]]
* It is not known if losing weight lowers the risk of cancer


===Environmental Risk Factors===
== Treatment ==
Typically the [[psychodynamic]] approach to therapy does not seem to be effective in battling BDD while in some patients it may even be countereffective.


Being exposed to chemicals and other substances in the environment has been linked to some cancers:
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]].
* [[Air pollution]] as a cancer risk factor has been demonstrated. These includes:
 
:* Association between lung cancer and [[secondhand smoke]], outdoor air pollution, and asbestos
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.
:* Association between drinking water that contains a large amount of [[arsenic]] and [[skin cancer]], [[bladder cancer]], and [[lung cancer]]
 
:* There are inconclusive results from studies performed to see if [[pesticides]] and other pollutants increase the risk of cancer. The results of those studies have been unclear because other factors can change the results of the studies.
==References==
{{reflist|2}}
 
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[[Category:Disease]]
[[Category:FLK]]

Latest revision as of 01:53, 14 October 2014

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Alonso Alvarado, M.D. [2]

Infobox goes here

{{SI}}

Synonyms and keywords:

Overview

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.

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.

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.

BDD combines obsessive and compulsive aspects, which links it to the 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.

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[3].

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[1]. There has also been a suggested link between undiagnosed BDD and a higher than average suicide rate among people who have undergone cosmetic surgery[2].

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.

Classification

Pathophysiology

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.

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:

A chemical imbalance in the brain. An insufficient level of serotonin, one of the brain's neurotransmitters involved in mood and pain, may contribute to body dysmorphic disorder. Although such an imbalance in the brain is unexplained, it may be hereditary.

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 genetic 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.

Causes

Differentiating type page name here from other Diseases

Epidemiology and Demographics

According to Dr Katharine Phillips (2004) :

Although large 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).

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.

Risk Factors

Screening

Natural History, Complications, and Prognosis

Diagnosis

Symptoms

  • 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-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.

Location 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:

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