Body Image and Body Dysmorphic Disorder

Athealth.com is pleased to welcome J. Kevin Thompson, PhD, co-author of Exacting Beauty: Theory, Assessment, and Treatment of Body Image Disturbance, who answers questions about body image and body dysmorphic disorder (BDD).

Athealth.com: Tell us about your professional background.

Dr. Thompson: I am a professor of psychology in the Department of Psychology at the University of South Florida, where I have been since 1985. I received my PhD in clinical psychology from the University of Georgia in 1982.

Athealth.com: How did you become interested in problems related to body image?

Dr. Thompson: My early work was in the treatment of obesity and in the development of strategies to increase participation in physical fitness programs. These interests evolved into a focus on eating disorders in the early 80s at a time when bulimia nervosa was just becoming recognized as a clinical disorder. My early work in eating disorders focused on body image, with findings that body dissatisfaction was not limited to individuals with anorexia nervosa and/or bulimia nervosa, but was, in fact, present in individuals without eating disorders. Since the mid-80s, my work has consisted of a variety of studies focused on body image in diverse samples, such as in athletes, plastic surgery patients, adolescents, adults, and individuals of different ethnicity and countries.

Athealth.com: How do you define body image? How does this relate to body image disturbances?

Dr. Thompson: Body image is an internal view of one's own appearance. It is, in effect, how we see ourselves. However, it is multifaceted and consists of several components. For instance, there is the issue of accuracy of body perception - Do you see what others see? Overestimating the size of certain body sites (such as waist and hip size) when compared to objective measurements has often been noted as a sign of body image disturbance. However, more often the perception is not truly distorted, but rather, some aspect of appearance is disliked, disparaged, or seen as unacceptable.

Indications of this subjective distress can be assessed with a wide variety of questionnaires or figural rating scales. These measures may indicate high levels of body dissatisfaction, negative thoughts, or cognitions associated with certain body parts, or even high levels of social avoidance due to negative feelings about the body. In our book, Exacting Beauty, my co-authors and I have reproduced over 30 of the most commonly used body image scales.

Body image may be seen as "disturbed" when one's self-evaluation of appearance is at such a level that it interferes with social and/or occupational functioning, or causes elevated levels of anxiety and depression in the individual.

Athealth.com: What are the features or characteristics of body dysmorphic disorder? How does BDD manifest itself?

Dr. Thompson: The primary feature is a person's extreme disparagement of some aspect of his/her appearance. Importantly, the individual's rating of the body feature does not fit with that of an objective observer, who may not see anything unattractive or unusual about the feature, or who may note some minimal problem (i.e., the nose or ears may be a bit larger than "average"). What is perhaps most important from a clinical viewpoint is that the individual is obsessively focused on the disliked body feature, and this obsession severely interferes with that person's existence.

BDD may occur for a variety of appearance features. However, prevalence studies indicate that the following sites are reported frequently: hair, nose, skin, eyes, thighs, abdomen, breast size or shape, chest size, lips, chin, scars, height, and teeth.

Athealth.com: Isn't it true that most people show at least some signs of dissatisfaction with one or more aspects of their appearance?

Dr. Thompson: Almost everyone has some body feature that they would like to modify. In the case of BDD, the individual will go to great lengths to modify the body site (via surgery, exercise, diet, etc.) or cover the feature (via make-up, clothing).

Athealth.com: What causes BDD? Are there factors that predispose a person to BDD?

Dr. Thompson: There is little definitive research on the causes of BDD and the factors that predispose a person to BDD. Much of the work in this area comes from an examination of case studies and the factors that patients relate to the onset of symptoms. In many of these cases, it seems that some event precipitates an initial selective focus on a specific body site. Often the event consists of a negative or teasing comment from someone directed at the appearance feature ("Hey, Dumbo"). Sexual abuse or harassment may also be a precipitant. In perhaps 70% cases, the onset of symptoms begins in adolescence.

Athealth.com: How severe is BDD?

Dr. Thompson: BDD may lead a person to engage in extreme avoidance behaviors, such as isolation from acquaintances and even loved ones. Suicidal behavior is not uncommon, and clinical depression may also eventuate. In some cases, multiple surgeries and body modification efforts (such as compulsive weightlifting) fail to improve the person's view of the appearance "defect."

Athealth.com: How prevalent is BDD? What populations are affected?

Dr. Thompson: Prevalence studies have not been conducted. However, it is likely that the disorder is rare, perhaps affecting between 1.0-2.0% of the general population and 10-15% of psychiatric outpatients. Some researchers believe that the prevalence is on the rise, as diagnostic methods become better at detecting the problem and as society becomes even more obsessed with appearance. Interestingly, studies suggest that BDD may be equally common in adult females and males. This is in sharp contrast with the data for eating disorders, which suggests that about 90% of the cases are females. However, in the only study to date of prevalence in adolescents, only 9% of the cases were boys. To date, we have little other information regarding prevalence in specific populations and whether or not there is a connection within families.

Athealth.com: How is body dysmorphic disorder distinguished from eating disorders and from obsessive-compulsive disorder (OCD)?

Dr. Thompson: Certainly, someone with an eating disorder may also show signs of body dysmorphia, especially if there are signs of body image disparagement for a weight-related body site (waist, hips, thighs). The presence of BDD with a site that is non-weight-related (nose, ears) usually indicates that there is no co-occurring eating disorder. However, if the BDD site of concern is a weight-related site, then an assessment for an eating disorder should be undertaken with a focus on the usual eating disordered symptoms of excessive dieting, weight loss, purging, and feelings of loss of control surrounding food.

It is very difficult to distinguish BDD from OCD, and some researchers and clinicians believe that BDD is an OCD "spectrum" disorder (i.e., it has the same core symptoms, but with the focus of the OCD cognitions and behaviors on an aspect of appearance). In fact, the psychological and pharmacological therapies are similar for both disorders.

Athealth.com: Are other psychiatric conditions associated with BDD?

Dr. Thompson: Disorders commonly found to be associated with BDD include depression and social anxiety problems (social phobia, avoidant personality disorder). However, once again, there is little real empirical work in this area.

Athealth.com: How is BDD diagnosed?

Dr. Thompson: There are two primary methods. First, because BDD is a specific DSM disorder, there are clearcut diagnostic criteria available. On p. 445 of the American Psychiatric Association's, Diagnostic and Statistical Manual for Mental Disorders (APA, 1994), criteria are provided. These criteria focus on the excessive preoccupation with an "imagined defect in appearance" or one where a "slight physical anomaly is present."

In addition, James Rosen of the University of Vermont has developed an interview scale specific to BDD, which he calls the Body Dysmorphic Disorder Examination. He has used this in several studies, and it is an excellent tool for cataloging BDD symptoms and facilitating an accurate diagnosis of the disorder. This interview scale contains 34 items that index the core symptoms and associated features of BDD, including the following:

How often the patient experiences upsetting preoccupation with appearance.
How often the patient thought other people were scrutinizing his/her defect.
How often the patient camouflages or hides his or her appearance defects with clothes, make-up, and so forth.

Athealth.com: How is BDD treated? How successful are the various forms of treatment?

Dr. Thompson: There are very few controlled outcome studies on the treatment of BDD. Encouraging results have been found with medication (serotonin reuptake inhibitors, i.e., clomipramine) and cognitive-behavioral treatment strategies (i.e., exposure and response prevention). The latter techniques focus on breaking compulsive patterns, such as checking in the mirror and asking others for reassurance. In addition, social avoidance is countered by helping patients learn to deal with social situations that promote appearance anxiety. Again, James Rosen of the University of Vermont has pioneered the use of these techniques for BDD. (See his chapter on BDD in my 1996 book, Body Image, Eating Disorders and Obesity.)

Athealth.com: Is it common for a person with BDD to go untreated?

Dr. Thompson: It is difficult to determine how many people are untreated. However, since many clinicians and family members may not yet recognize the warning signs of BDD, it is likely that a large number of those suffering have not received treatment.

Athealth.com: What should a person do if a friend or family member has BDD? How can friends and family help in the recovery process?

Dr. Thompson: The best option is to refer the individual to a mental health professional with expertise in BDD or, minimally, with expertise in eating disorders and/or OCD. The role of family or friends in the recovery process is a complicated one. The therapist may ask them to resist responding to reassurance-seeking behavior on the part of the patient regarding appearance concerns. Otherwise, it is best for the significant other to refrain from challenging the veracity of the patient's complaints ("But I don't see anything wrong with your hair.") because this invalidates the views of the patient. Conflict is liable to arise out of attempts at assistance. It is perhaps best that family and friends simply listen and offer support and defer any active modification attempts to the professional.

Dr. Thompson also authored of Body Image Disturbance: Assessment and Treatment (Pergamon Press, 1990) and edited Body Image, Eating Disorders, and Obesity : An Integrative Guide to Assessment and Treatment (American Psychological Association, 1996). He is on the editorial board of the International Journal of Eating Disorders.