'Through a glass, darkly': Pediatric body dysmorphic disorder

Body dysmorphic disorder (BDD) can be a chronic and severe condition that often starts in adolescence. The telltale sign: children’s preoccupation with the idea that there’s something wrong with how they look, when in reality the imperfections they perceive in their appearance are slight or nonexistent.¹ In addition, to qualify for a diagnosis of BDD, the appearance preoccupations must cause clinically significant distress or impairment in functioning.

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To kids suffering with the disorder, the perceived flaws are often life altering and can threaten their education, socialization, and occupation. It’s alarming that about 80% of people with BDD report past or current suicidal ideation, and about one-quarter have attempted suicide. In a study of 33 children and adolescents with BDD, 39% had been psychiatrically hospitalized, and 21% had attempted suicide.^1,2

“[To describe what they see,] some use words like deformed, hideous. Some simply say unattractive. Ugly is the most common descriptor. Some will use very extreme terms, like they look like a monster,” says Katharine Phillips, MD, professor of psychiatry and human behavior at the Warren Alpert Medical School of Brown University, Providence, Rhode Island, and director of the body dysmorphic disorder program at Rhode Island Hospital, Providence.

Pediatric BDD

Research on BDD in children and adolescence is scarce, although BDD has been described since the 1800s.¹ “That’s really problematic, given how common and how severe it often is,” Phillips says.

Prevalence rates vary. In a survey of 2510 German adults, researchers found BDD’s current prevalence was 1.8%, or 45 people.³ A US study with 2048 participants found a point prevalence of 2.5% among women versus 2.2% among men. Gender-wise, clinical samples suggest BDD might be slightly more common among females, but males clearly are affected, too.¹

Body dysmorphic disorder, according to Phillips, seems to have both genetic and environmental contributions. “There are probably many, many risk factors,” she says. “I think it’s complex in terms of its etiology. Probably, being teased a lot is a risk factor, for example, but we don’t know very much about that at this point.”⁴

Although BDD has been reported in children aged as young as 5 years, it’s primarily a disorder of early to mid-adolescence.¹

“I have 2 big samples of individuals with BDD. One has 200 individuals and one has close to 300, mostly adults. In those samples we found that BDD onset had an average age of 16 to 17. That’s the mean. The most common age of onset is 12 or 13. And in those samples, we found that two-thirds of patients had onset of BDD before age 18,” Phillips says.

Prospective data suggest that, without adequate treatment, BDD is likely to be chronic.¹

NEXT: Looking for signs and symptoms

Signs, symptoms

Patients with BDD are not only preoccupied with perceived flaws, but they also tend to engage in repetitive behaviors (ie, compulsions or rituals).¹ “All aim to decrease the anxiety and distress that these appearance concerns cause, although [patients] often don’t experience that,” Phillips says.

The often time-consuming repetitive behaviors, according to Phillips, include: comparing one’s appearance to that of others; mirror checking; excessive grooming; frequent attempts to make little blemishes look better; and reassurance seeking, including such questions as “How do I look?”

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Although any part of the body can be a preoccupation for those with BDD, skin, hair, nose, and stomach appearance concerns are the most common among adolescent patients.⁵ Skin ranks first among all age groups and can include acne scarring, blemishes, or wrinkles. Those with hair concerns might think their hair is too thin, uneven, and/or falling out.

Patients with BDD have an average of 5 to 7 body parts that preoccupy them in their lifetimes, and about 40% of people with BDD spend from 3 to 8 hours a day focused on the body parts they dislike.¹

Not just a phase

In a sample of 200 persons, including 36 adolescents, with BDD, researchers found: 94.3% of the adolescents reported moderate, severe, or extreme distress because of BDD; 80.6% had a history of suicidal ideation; and 44.4% had attempted suicide. The researchers went on to report that adolescents in the study had high rates and levels of impairment in school, work, and other aspects of psychosocial functioning.

“Adolescents and adults were comparable on most variables, although adolescents had significantly more delusional BDD beliefs (ie, complete conviction that their view of the perceived abnormality was accurate) and a higher lifetime rate of suicide attempts. Thus, adolescents with BDD have high levels of distress and rates of functional impairment, suicidal ideation, and suicide attempts. BDD's clinical features in adolescents appear largely similar to those in adults,” according to the researchers.⁵

In typical cases, kids are late for school or refuse to go to school because they think that their skin is ugly; their hair doesn’t look right; their teeth are too yellow; and so on. The impaired social functioning that results from BDD can be so detrimental that children and adolescents may drop out of school. Studies suggest that from 20% to 25% of persons with BDD drop out of school because of the condition.¹

Adolescents often have coexisting substance abuse. Other conditions can exist along with BDD, including depression, anxiety and, sometimes, eating disorders.¹

Many with BDD feel rejected by others because of their perceived ugliness, according to Phillips. They tend to be rejection sensitive. They often socially isolate, withdraw, and feel alone, she says.

NEXT: Diagnosing BDD

Diagnosing BDD

Pediatricians should be aware of BDD symptoms, according to Phillips, but they’ll generally have to screen for BDD in order to diagnose it.

“These people tend to be very secretive about their concerns. They worry that they’ll be considered vain or that their concerns will be considered trivial. I think, sometimes, that if they do get the courage to talk about this with somebody, the adult may assume it’s a passing phase,” Phillips says.

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Phillips recommends that pediatricians ask adolescent patients--especially those with anxiety or depression or those struggling in school-specific questions related to BDD. Among those questions: Are you worried about how you look in any way? Are you unhappy with how you look?

Depending on the responses, pediatricians might then assess for BDD diagnostic criteria by saying: Tell me about these concerns. Do you think about it every day? How unhappy do these concerns make you? Are they getting in the way of your life in any way? Are they affecting school, sports, or your friendships?

NEXT: What are the next steps?

Next steps

Pediatricians who suspect BDD should educate parents and children about the disorder, informing patients and families that BDD is a known and common disorder that should be taken seriously.

“I think patients often benefit from hearing this is a known disorder, and that they’re not vain. I think just taking this seriously is a big step forward for them,” Phillips says.

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Pediatricians should ask about suicidality and try to determine if detected suicidality is related to BDD. Some questions include: How upset do you get over your appearance? Does it make you sad, nervous, worried? More probing questions would be: Does it ever make you feel like you just don’t want to get up in the morning? Do you ever feel like life’s not worth living? Have you ever thought of hurting yourself because of these concerns?

Pediatricians should also screen for coexisting conditions, including major depressive disorder. More than 80% of a sample of 36 adolescents with BDD had major depression. Obsessive-compulsive disorder occurred in more than a quarter of children in the sample; substance abuse in more than 44%; and eating disorders in 16.7%.⁵

One of the challenges associated with educating people with BDD about the disorder is they don’t think it’s a perception problem. They believe it’s an actual physical deformity. This is especially true with children and adolescents, Phillips says.¹

“Especially with kids, their insight tends to be very poor in the sense that they think their view is correct that they look horrible. They think they look like the ugliest kid in class. They don’t realize that their view of how they look is distorted,” Phillips says.

NEXT: Managing referrals

Treatment and referrals

Getting the right kind of treatment, including cognitive-behavioral therapy and/or serotonin reuptake inhibitors (SRIs), helps adolescents and adults with BDD, but getting access to appropriate treatment can be challenging, according to Phillips.

Cognitive-behavioral therapy that is tailored to BDD is the psychotherapy of choice in adults with BDD.

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“There are many more studies in adults than in adolescents,” says Phillips. “We published a treatment manual, with a very detailed, how-to guide for therapists to follow when treating BDD. Treatment of BDD is really different than that of other disorders, and I think it’s really hard to treat without using the therapist treatment manual,” she says.⁶

Another treatment manual is Body Dysmorphic Disorder: A Treatment Manual, by David Veale and Fugen Neziroglu, published in 2010.⁷

“There is a dearth of mental health professionals who are really trained in BDD,” Phillips says. “I encourage people to adapt the adult manual and modify it for adolescents.”

Medications-specifically SRIs-have been shown in case series to be an appropriate first-line medication for BDD in adolescents. They have been much better studied in adults in controlled trials, and are often efficacious. There is, however, no treatment approved by the US Food and Drug Administration for BDD in adults or adolescents.¹

“I recommend SRIs for adolescents who have more severe BDD symptoms-especially those who are really struggling in school or those with severe depression or other co-occurring disorders that might also benefit from an SRI, like social anxiety disorder or bulimia,” Phillips says.

Doses of SRIs for BDD tend to be higher than those generally recommended for depression, according to Phillips. Clinicians should prescribe an SRI trial of 12 to 16 weeks in duration to determine if the drugs are working.

A general recommendation is as follows: “[H]ighest SRI dose recommended by the manufacturer or tolerated by the patient should be reached if a lower dose is ineffective. If this fails, another SRI should be tried. If several SRIs fail, referral to a psychiatrist should again be considered. It appears that most patients who respond to an SRI will require longer-term treatment, as the risk of relapse appears high with SRI discontinuation,” according to a study published in 2007.⁸

NEXT: Resources for physicians

Ignorance is anything but bliss

Without treatment, the developmental trajectory of an adolescent with BDD can be severely disrupted, according to Phillips. “I’ve treated many adults who have dropped out of high school because of BDD. They stopped seeing their friends; they stopped playing sports; and they just stayed in their bedroom for 5 or 10 years. They may have never gone on a date. They may not have a job,” she says.

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Early recognition and treatment can get kids back on track with their education and more, Phillips says. “I think it’s very important for pediatricians to be aware of BDD-to be aware that it can range from mild to life-threatening,” she says. “Not all appearance concerns in adolescence are normal or a passing phase. When appearance concerns really start to become preoccupying-at least an hour or more a day, cause a lot of distress, are interfering with day-to-day functioning--that’s not normal, and it may be BDD.”

REFERENCES

1. Bjornsson AS, Didie ER, Phillips KA. Body dysmorphic disorder. Dialogues Clin Neurosci. 2010;12(2):221-232.

2. Albertini RS, Phillips KA. Thirty-three cases of body dysmorphic disorder in children and adolescents. J Am Acad Child Adolesc Psychiatry. 1999;38(4):453-459.

3. Buhlmann U, Glaesmer H, Mewes R, et al. Updates on the prevalence of body dysmorphic disorder: a population-based survey. Psychiatry Res. 2010;178(1):171-175.

4. Phillips KA. Understanding Body Dysmorphic Disorder. New York: Oxford University Press; 2009.

5. Phillips KA, Didie ER, Menard W, Pagano ME, Fay C, Weisberg RB. Clinical features of body dysmorphic disorder in adolescents and adults. Psychiatry Res. 2006;141(3):305-314.

6. Wilhelm S, Phillips KA, Steketee G. Cognitive-Behavioral Therapy for Body Dysmorphic Disorder: A Treatment Manual. New York: Guilford Press; 2013.

7. Veale D, Neziroglu F. Body Dysmorphic Disorder: A Treatment Manual. UK: John Wiley and Sons Ltd; 2010.

8. Phillips KA, Dufresne RG Jr. Body dysmorphic disorder: a guide for primary care physicians. Prim Care. 2002;29(1):99-111.

Find out more

Rhode Island Hospital Body Dysmorphic Disorder (BDD) Program

www.rhodeislandhospital.org/bdd/

Massachusetts General Hospital BDD Clinic

https://mghocd.org/clinical-services/bdd/

Feeling Good About the Way You Look: A Program for Overcoming Body Image Problems, by Sabine Wilhelm, PhD (New York: Guilford Press; 2006)

bit.ly/Wilhelm-body-image

The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder, by Katharine A. Phillips, MD (New York: Oxford University Press; 2005)

bit.ly/Phillips-broken-mirror

Understanding Body Dysmorphic Disorder, by Katharine A. Phillips, MD (New York: Oxford University Press; 2009)

bit.ly/Phillips-understanding-BDD

Ms Hilton is a medical writer who has covered health and medicine for 25 years. She resides in Boca Raton, Florida. She has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.