Brief overview
- Diagnosis: Psychological test questionnaire, exclusion of possible actual disfiguring diseases
- Symptoms: Constant mental preoccupation with the perceived physical deficiency, behavioral changes, psychological distress
- Causes and risk factors: Psychosocial and biological factors, childhood experiences, risk factors are abuse, neglect, bullying; disturbed brain chemistry (serotonin metabolism) is assumed
- Treatment: Cognitive behavioral therapy, drug treatment with antidepressants (selective serotonin reuptake inhibitors SSRI, )
- Prognosis: If left untreated, body dysmorphic disorder often develops chronically to the point of delusion; high risk of suicide; therapies show good results
What is dysmorphophobia?
People with dysmorphophobia, also known as body dysmorphic disorder, constantly think about their appearance. Those affected feel disfigured, even though there is no objective reason for this. Even if a part of the body actually does not correspond to the usual ideal of beauty, those affected perceive this to be much worse than it really is.
Dysmorphophobia has far-reaching consequences for social and professional life. Those affected withdraw from friends and family because they are ashamed of their appearance. They neglect their work. More than half of those affected have suicidal thoughts. Dysmorphophobia therefore also increases the risk of suicide.
Body dysmorphic disorder (BDD) is included in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as an obsessive-compulsive disorder. This is because people with dysmorphophobia exhibit similar behaviors to people with obsessive-compulsive disorder.
In the “International Statistical Classification of Diseases and Related Health Problems” (ICD-10) of the World Health Organization (WHO), non-delusional dysmorphophobia is classified as a “somatoform disorder” as a variant of hypochondriasis. If delusional thinking and behavior are added, it is classified as a “delusional disorder”.
How many people are affected by dysmorphophobia?
Muscle dysmorphia, muscle dysmorphic disorder
A special variant of dysmorphophobia is muscle dysmorphia or “muscle dysmorphic disorder”, which mainly affects men. They perceive their body as not muscular enough or feel too small. Even if their body already resembles that of a professional athlete, they still dislike it. Some therefore begin to train excessively. Muscle addiction is also known as the Adonis complex or inverse anorexia (reverse anorexia).
Similar to an anorexic person, men have a distorted perception of their body. However, instead of avoiding calories, they focus on eating protein-rich foods. Some, in desperation, turn to anabolic steroids to build muscle mass as quickly as possible.
It is unclear how many people are affected by muscle dysmorphia. Among bodybuilders, it is estimated to be around ten percent. Experts assume that the number of people affected will continue to increase. The reason for this is that men are now also under pressure to conform to an ideal of beauty.
How can dysmorphophobia be tested or diagnosed?
There are a number of self-tests on the internet that allow an initial assessment of dysmorphophobia. However, such a self-administered dysmorphophobia test does not replace a diagnosis by a psychiatrist or psychologist. The questions of such a test are similar to those asked by the practitioner (see below) and are weighted using a point system.
To diagnose dysmorphophobia, the psychiatrist or psychotherapist conducts a detailed medical history interview. Using questions based on the diagnostic criteria, the experts try to obtain a comprehensive picture of the symptoms. The therapists usually use special psychological questionnaires as a guide.
The psychiatrist or psychologist may ask the following questions to diagnose dysmorphophobia:
- Do you feel disfigured by your appearance?
- How much time a day do you spend dealing with external flaws?
- Do you spend a lot of time each day looking in the mirror?
- Do you avoid contact with other people because you are ashamed of your appearance?
- Do you feel burdened by thoughts about your appearance?
After the consultation, the therapist will discuss treatment options and the next steps with you.
When making a diagnosis, the therapist will usually also rule out the possibility that a disfiguring illness is actually present.
Symptoms
Others shy away from looking in the mirror and no longer dare to go out in public. As a rule, people with dysmorphophobia try to hide their imagined beauty flaws. Some regularly undergo cosmetic surgery or try to change their appearance themselves. But none of this solves the problem – they continue to feel ashamed of their appearance. Dysmorphophobia is often accompanied by depressive symptoms such as depression and hopelessness.
According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the following symptoms must apply for a diagnosis of dysmorphophobia:
- Those affected are excessively preoccupied with supposed beauty flaws that are not recognizable to others or are only minor.
- The supposed beauty flaw repeatedly drives those affected to certain behaviors or mental actions. They constantly check their appearance in the mirror, engage in excessive grooming, ask others to confirm that they are not ugly (reassurance behavior) or compare themselves with other people.
- Those affected suffer from excessive preoccupation with their external appearance, and it affects them in social, professional or other important areas of life.
In some cases, dysmorphophobia occurs in combination with delusions. The person affected is then completely sure that their perception of their own body corresponds to reality. Other sufferers, on the other hand, are aware that their self-perception does not correspond to reality.
Causes and risk factors
Experts believe that dysmorphophobia is caused by a combination of biological and psychosocial factors. The values that are conveyed in society also have an important influence. Beauty is highly valued. The media reinforce the importance of appearance by conveying the impression that beauty makes people happy.
Doctors refer to body dysmorphic disorder as a “disorder of intrapsychic body representation”; the perceived body image does not match the objective body image.
Psychosocial factors
There are indications that experiences in childhood play a decisive role. Experiences of abuse and neglect in childhood are risk factors for the development of dysmorphophobia. Children who grow up overprotected and whose parents avoid conflict are also at risk.
Teasing and bullying, which severely damage self-esteem, in some cases contribute to those affected questioning their appearance more and more. People who have low self-esteem and tend to be shy and anxious are particularly susceptible.
Biological factors
Experts believe that biological factors also influence the development of the condition. They suspect a disruption in the balance of the neurotransmitter serotonin. This assumption is supported by the fact that treatment with selective serotonin reuptake inhibitors (SSRIs, a psychotropic drug from the antidepressant group) often helps with dysmorphophobia.
Maintaining factors
Certain thoughts and behaviors perpetuate the symptoms of dysmorphophobia. Those affected often have a perfectionist and unattainable standard for their appearance. They focus a great deal of attention on their appearance and are therefore more aware of changes or deviations from their ideal. Their appearance always appears unattractive to them in comparison to their desired ideal.
Social withdrawal and constantly looking in the mirror reinforce the feeling of being ugly. This security behavior reinforces the person’s conviction that there is a good reason not to show themselves in public.
Treatment
For successful treatment, experts recommend cognitive behavioral therapy and medication. The therapy takes place either on an outpatient or inpatient basis.
Cognitive behavioral therapy
Cognitive behavioral therapy focuses on distorted thoughts and safety behavior. At the beginning of therapy, the therapist first explains the causes, symptoms and treatment of dysmorphophobia to the patient in detail. The more familiar those affected are with the disorder, the easier it is for them to recognize the symptoms in themselves.
An important part of therapy is also to identify possible causes of the disorder. When the causes come to the surface, many patients realize that the concern about their appearance is only an expression of a deeper problem.
In therapy, those affected learn to recognize and change stressful thoughts. The perfectionist demands are countered with realistic and achievable demands. In addition to thoughts, specific behaviors play an important role in the treatment. Many people no longer dare to go out in public because they are afraid of being judged by others.
When confronted with their fears, those affected experience that their fears are not true. The experience of other people not noticing their flaws changes their thoughts. With repeated confrontations with the feared situation, the uncertainty recedes and the fears diminish.
During inpatient treatment, patients are prepared for possible relapses before they are discharged. This is because many sufferers fall back into old patterns of behavior in their familiar environment. Ultimately, the aim of the therapy is for patients to use the techniques they have learned without outside help.
Drug treatment
A number of antidepressants have proven effective as medication for the treatment of dysmorphophobia. In combination with psychotherapeutic treatment, the practitioners therefore often additionally administer selective serotonin reuptake inhibitors (SSRIs).
They increase the level of the mood-boosting neurotransmitter serotonin in the brain and often contribute to an improvement in symptoms. SSRIs are not addictive, but they sometimes lead to nausea, restlessness and sexual dysfunction as an adverse effect.
Course of the disease and prognosis
The risk of a suicide attempt increases with the duration and severity of dysmorphophobia. Early detection and treatment of dysmorphophobia therefore increases the chances of successful therapy.