**5. Prevalence, comorbidities, influencing factors, and association with other disorders**

is frequent enough to cause injuries or irreversible hair loss or diary. Normally, it is followed by the attempt of hiding the injuries. There is a female preponderance, and the average age of

There is an important trait of BDD, established by essays, which is the capability of these individuals of observing "irregularities and defects" in their own appearance. Any minimal asymmetry can be the starter for the development or worsening of the disease. Only patients with BDD may have such a powerful intensified selective attention able to find or imagine defects on their own face. Moreover, it also happens with another person's body's area, for example, the defect they imagine on him/her and they also observe too much in the others [33]. Indeed, the symmetry obsession is considered one of the most obvious traits of the BDD, and very often, it is found in OCD patients, who suffer from a chronic and disabling disorder characterized by uncontrollable, persistent, and repetitive obsessions and compulsions. Around 25% of BDD patients present this symptom, and it has a direct impact in the low qual-

BDD is also characterized by mental acts, in which the patient wastes most of his/her time thinking about his/her appearance or concerned about it; in addition to it, the person cannot stop comparing his/her appearance with the others [8]. Unwanted mental intrusions might be a transdiagnostic variable across different disorders such as OCD, BDD, eating disorders, and hypochondriasis, and they might contribute to explaining the phenomenological similarities among them. Unwanted mental intrusions in BDD have been defined as discrete, untimely, and unexpected conscious cognitive products that can be experienced as thoughts, images, sensations, or impulses. They interfere with the normal flow of thoughts, tend to be recurrent, and promote subjective resistance efforts, although they are highly uncontrollable [33].

Still regarding personality, individuals with BDD have been postulated to have schizoid, narcissistic, and obsessional personality traits and to be sensitive, introverted, perfectionist, and insecure. However, data on personality traits and disorders in BDD are limited. In one research involving patients diagnosed with BDD, 57% had one or more personality disorders, with avoidant personality disorder (43%) being most common, followed by dependent (15%), obsessive–compulsive (14%), and paranoid (14%) personality disorders [34, 35]. In another assessment in patients seeking cosmetic surgery and diagnosed with BDD, it was also found that the presence of a psychopathological reaction to imagined defects in appearance in subjects pursuing a surgical correction is associated with the severity of schizotypal and paranoid

In another trial, more recent, three groups of personality were verified in patients diagnosed with BDD. The first group includes pessimistic, shy, insecure subjects; people with fragile and immature personality and poor self-esteem; individuals concerned about the way they look and those who spend more time thinking about it. The second group includes subjects that are more confident, with a stronger personality and a greater self-esteem. A third, less differentiated group, includes subjects who are more impulsive and spend an intermediate amount of

onset of this syndrome varies between 30 and 50 years [29, 31].

ity of life of these individuals [27].

8 Pathophysiology - Altered Physiological States

personality disorders [36].

time thinking about the way they look [37].

The prevalence of BDD is increasing around the world. Prevalence in the general population may differ between countries, because of cultural differences and different health-care systems. Studies have found a BDD prevalence of 1.9 in German women [40]; 2.5% in American women [41]; 2.0% in American women in another time frame [42]; 4.4% in German women in another time frame [43]; 2.1% in Swedish women [8]. In mixed populations (both genders), the prevalence of BDD was 1.7% in English population and 2.4% in French population [44]; 0.7% in Italian population [45], and around 28% in the population of American college students [48]. In the worldwide population, the prevalence of BDD is around 1–2% [3, 14, 46]; it can reach 3% of global population [25]. In the dermatological patient population, the prevalence is predominantly higher, with 8.8% of Turkish dermatology patients [47]; 14% of US dermatology patients [8]; 6.7% of Brazilian dermatology patients [48]; 4.2% of Turkish dermatology patients in another time frame [49]; 4.9% of Swedish dermatology patients [8]; and from 2.9 to 24.9% in patients of multiple nationalities [3].

BDD affects each individual in a different way; so, its prevalence can be modified according to not only the population regarding its finding, but also regarding the original physical trait that the person assumed as a "defect." The prevalence of BDD in patients who underwent plastic surgery procedures is around 6–20%. In patients undergoing rhinoplasty, it raises to 20.7% [50]. An essay was conducted with patients seeking for plastic surgery, and 7.7% showed BDD. Most of these patients (85.7%) were diagnosed before surgery, and the remaining (14.3%) in the post-surgery period, after they have reported dissatisfaction with the surgical results [51].

According to different researches, the prevalence of BDD in plastic surgery is around 7–15% [29]; another study points to a prevalence of 16–24% [50], and there is another that points to about 53% [52]. In Iran, a research was conducted with patients who were seeking plastic surgery. It was noticed that 41% of them had shown mental disorder, of which 24.5% were diagnosed as BDD patients. Most of the subjects of the survey were seeking for rhinoplasty and 80% of them were women [53]. The rhinoplasty surgery, in special, is a common practice in BDD patients' community, and the diagnoses of severe cases of BBD before surgery are very frequently connected to the high level of dissatisfaction with the results after surgery [54, 55].

Among BDD patients, 76% have already considered plastic surgery as a "treatment" for their "defects," of which most of them, 64–66%, have previously undergone some plastic surgery [53]. Although the dissatisfaction level with the results is high, the idea of perfection is based on delusional thoughts about one's esthetics complaints, which are not reachable by cosmetic treatments or surgeries [50]. For this reason, a more comprehensive psychiatric evaluation is indicated for the patients who look for an esthetic procedure, because in the case of BDD patient, the psychological intervention is more indicated than a surgical procedure [53, 56].

The same happens to the work capability of the BDD patients: when the disorder starts earlier in life, the social and labor impairment usually is worse. BDD patients in which the disease started before 18 years old had more issues regarding work (65.8%) than patients in which the

Body Dysmorphic Disorder: Characteristics, Psychopathology, Clinical Associations, and…

http://dx.doi.org/10.5772/intechopen.76446

11

Among BDD patients in treatment, 57.5% were unemployed, only 38.5% were working full time, 22.5% were working half time, and 3% were removed from work due to Medical

More recently, another study showed that among OCD patients, less than half were in a full-time employment, and 27.2% was receiving work incapacity benefit [60]. Almost 39% of patients reported removal from work and 79.7% indicated some level of labor functional impairment because of the pathology. It is been noticed that patients who were removed from work because of the psychopathology of BDD presented more severe form of the disease and tended more to chronicity as well. The worse cases were usually composed by males with a lower scholarship, more severe depressive symptoms, higher rates of comorbidities, worse quality of life, worse social skills, higher rates of suicides, and higher propensity to psychiatric internment. One study concluded that being removed from work can worsen the outcome of the treatment for the patient, because it would intensify the tendency to self-isolation and depression [60]. It has to be considered, however, on the other hand, that some of these cases may be condemned to evolve badly since the onset of the disorder, due to possibly neuroanatomic lesions or malfunctions (already described earlier). The characteristics as lower scholarship, worse social skills, poverty, and worse quality of life may be associated to brain damage. We also know that male gender is more vulnerable to express this type of symptomatology. Therefore, it is possible that the same patients have to be removed from work with special care, because the removal is necessary at some point of the treatment, but the prolonged

Hispanics or "non whites" were considered the minority of patients (19.1%) with BDD comparing the prevalence of the disease among the different ethnic groups [59], or even less than that (9.1%) in another study [60]. The Caucasian was 87.9% of BDD population under treat-

Concerning the way of living, 44.8% of the BDD individuals live with a spouse, 28.4% with their parents, 25.4% alone, and 1.5% need home supervision because they have special needs

Although BDD is more often present in athletes than in regular people, the intensity of psychological problems usually is more severe in non-athletes. Therefore, the current practice of physical activity is very good for mental health. In both samples, the rate of satisfaction with

Regarding differences between genders in BDD, there are more points of similarities than differences, although much disparity can be found. Initially, the areas elected as central "loci" of BDD were different between genders, for example, men were obsessed about genitals, muscle mass amount, and hair loss. Women, on the other hand, were obsessively concerned about skin, breasts, buttocks, thighs, legs, hips, toes, and body hair, among many other parts of

disorder started after this age (58.1%) [58].

Certificate of Health related to BDD [38].

ment in another study [38].

removal without care will lead to psychological worsening [60].

or comorbidities that imply in additional risks [38].

body self-image presented equally low [61].

Regarding the prevalence of BDD between genders, different studies have shown that although seeking for surgical esthetic treatments is more frequent in feminine population (86.4%) than in masculine population (13.6%), BDD is more prevalent in masculine gender. Among men of the sample, 33.3% presented BDD, while only 14% of women presented the disorder [36]. Therefore, although men are the minority in the researches regarding esthetics treatments, they have presented always equal or larger prevalence of BDD than women. In a German study involving 133 college students, in which 71.4% were women, there were no differences of prevalence between genders; with 5.1% of women and 5.7% of men diagnosed with BDD [57]. In another population of patients with BDD clinically diagnosed, 89% of the sample was female [58]. There is another study, in which case 64.2% of the sample is composed of women [38]. In all these reports, the prevalence of BDD was larger among men.

Comparing prevalence between genders, considering patients of general dermatological clinics, women are the most frequent costumers (69.7%), against 30.3% of men. Considering individuals who look for treatment in dermatological clinic specialized in acne, the prevalence between genders do not change compared to the first case (general dermatologic clinic). Women were 66.7% of the patients and men were 33.3%. However, in the dermatological clinics with aesthetic purposes, an increase of women clients (85.2%) and a decrease of men clients (14.8%) can be noticed [25]. In general, the prevalence of BDD is larger in esthetics dermatological clinics (14%); compared to general dermatological clinics (6.7%) and in the control group (2%), the prevalence of BDD was almost equal to the general population [48].

Comparing the prevalence of BDD and considering the level of schooling of the subjects, it has been reported in most of the samples that the BDD patients usually were attending middle school (63.3%), followed by patients who were attending primary school (36.4%). In this sample, none of the patient with BDD was attending university education [36]. In another study where patients were clinically diagnosed with BDD, 72.4% of the sample [38] and 77% of another sample [58] had university education complete or incomplete.

Regarding the prevalence of BDD and marital status of the patients, BDD patients usually have emotional impairment, remaining single (56.3%) [59]. Some studies have shown a 72.7% rate that has never been married [60]. This scenery does not seem to be modified through the years, considering that in a precedent study, the rate of BDD patients that were never married was 60.4%, the married were 25.4%, the divorced were 13.4%, and the widowers were 0.7% [38]. The age of the onset of the symptoms seems to be related to the marital status. When it shows up before 18 years old, the prevalence of singles in the sample seems to be higher (77.9%) than if it begins after 18 years old, when the prevalence of singles is a little lower (64.5%) [58].

The same happens to the work capability of the BDD patients: when the disorder starts earlier in life, the social and labor impairment usually is worse. BDD patients in which the disease started before 18 years old had more issues regarding work (65.8%) than patients in which the disorder started after this age (58.1%) [58].

Among BDD patients, 76% have already considered plastic surgery as a "treatment" for their "defects," of which most of them, 64–66%, have previously undergone some plastic surgery [53]. Although the dissatisfaction level with the results is high, the idea of perfection is based on delusional thoughts about one's esthetics complaints, which are not reachable by cosmetic treatments or surgeries [50]. For this reason, a more comprehensive psychiatric evaluation is indicated for the patients who look for an esthetic procedure, because in the case of BDD patient, the psychological intervention is more indicated than a surgical procedure [53, 56].

10 Pathophysiology - Altered Physiological States

Regarding the prevalence of BDD between genders, different studies have shown that although seeking for surgical esthetic treatments is more frequent in feminine population (86.4%) than in masculine population (13.6%), BDD is more prevalent in masculine gender. Among men of the sample, 33.3% presented BDD, while only 14% of women presented the disorder [36]. Therefore, although men are the minority in the researches regarding esthetics treatments, they have presented always equal or larger prevalence of BDD than women. In a German study involving 133 college students, in which 71.4% were women, there were no differences of prevalence between genders; with 5.1% of women and 5.7% of men diagnosed with BDD [57]. In another population of patients with BDD clinically diagnosed, 89% of the sample was female [58]. There is another study, in which case 64.2% of the sample is composed of women [38]. In all these reports, the prevalence of BDD was larger among men.

Comparing prevalence between genders, considering patients of general dermatological clinics, women are the most frequent costumers (69.7%), against 30.3% of men. Considering individuals who look for treatment in dermatological clinic specialized in acne, the prevalence between genders do not change compared to the first case (general dermatologic clinic). Women were 66.7% of the patients and men were 33.3%. However, in the dermatological clinics with aesthetic purposes, an increase of women clients (85.2%) and a decrease of men clients (14.8%) can be noticed [25]. In general, the prevalence of BDD is larger in esthetics dermatological clinics (14%); compared to general dermatological clinics (6.7%) and in the control group (2%), the prevalence of BDD was almost equal to the general population [48]. Comparing the prevalence of BDD and considering the level of schooling of the subjects, it has been reported in most of the samples that the BDD patients usually were attending middle school (63.3%), followed by patients who were attending primary school (36.4%). In this sample, none of the patient with BDD was attending university education [36]. In another study where patients were clinically diagnosed with BDD, 72.4% of the sample [38] and 77%

Regarding the prevalence of BDD and marital status of the patients, BDD patients usually have emotional impairment, remaining single (56.3%) [59]. Some studies have shown a 72.7% rate that has never been married [60]. This scenery does not seem to be modified through the years, considering that in a precedent study, the rate of BDD patients that were never married was 60.4%, the married were 25.4%, the divorced were 13.4%, and the widowers were 0.7% [38]. The age of the onset of the symptoms seems to be related to the marital status. When it shows up before 18 years old, the prevalence of singles in the sample seems to be higher (77.9%) than if it begins after 18 years old, when the prevalence of singles is a little lower

of another sample [58] had university education complete or incomplete.

(64.5%) [58].

Among BDD patients in treatment, 57.5% were unemployed, only 38.5% were working full time, 22.5% were working half time, and 3% were removed from work due to Medical Certificate of Health related to BDD [38].

More recently, another study showed that among OCD patients, less than half were in a full-time employment, and 27.2% was receiving work incapacity benefit [60]. Almost 39% of patients reported removal from work and 79.7% indicated some level of labor functional impairment because of the pathology. It is been noticed that patients who were removed from work because of the psychopathology of BDD presented more severe form of the disease and tended more to chronicity as well. The worse cases were usually composed by males with a lower scholarship, more severe depressive symptoms, higher rates of comorbidities, worse quality of life, worse social skills, higher rates of suicides, and higher propensity to psychiatric internment. One study concluded that being removed from work can worsen the outcome of the treatment for the patient, because it would intensify the tendency to self-isolation and depression [60]. It has to be considered, however, on the other hand, that some of these cases may be condemned to evolve badly since the onset of the disorder, due to possibly neuroanatomic lesions or malfunctions (already described earlier). The characteristics as lower scholarship, worse social skills, poverty, and worse quality of life may be associated to brain damage. We also know that male gender is more vulnerable to express this type of symptomatology. Therefore, it is possible that the same patients have to be removed from work with special care, because the removal is necessary at some point of the treatment, but the prolonged removal without care will lead to psychological worsening [60].

Hispanics or "non whites" were considered the minority of patients (19.1%) with BDD comparing the prevalence of the disease among the different ethnic groups [59], or even less than that (9.1%) in another study [60]. The Caucasian was 87.9% of BDD population under treatment in another study [38].

Concerning the way of living, 44.8% of the BDD individuals live with a spouse, 28.4% with their parents, 25.4% alone, and 1.5% need home supervision because they have special needs or comorbidities that imply in additional risks [38].

Although BDD is more often present in athletes than in regular people, the intensity of psychological problems usually is more severe in non-athletes. Therefore, the current practice of physical activity is very good for mental health. In both samples, the rate of satisfaction with body self-image presented equally low [61].

Regarding differences between genders in BDD, there are more points of similarities than differences, although much disparity can be found. Initially, the areas elected as central "loci" of BDD were different between genders, for example, men were obsessed about genitals, muscle mass amount, and hair loss. Women, on the other hand, were obsessively concerned about skin, breasts, buttocks, thighs, legs, hips, toes, and body hair, among many other parts of the body. Women were also more predisposed to behave repetitively (compulsion), using resources like camouflage of the presumed defects and constant image check; they tend more to the neurotic excoriation and to eating disorder, as well [62].

of life or functional loss between patients in which the disorder started early or later in life [68]. Although, depending of the history of life of the individual, the outcome of the disorder can be suicidal or other comorbidity even more severe than BDD [58, 72], the majority of BDD patients have suicidal ideas (80%), and a considerable percentage of them have already presented suicidal attempts (24%) [60, 69]. Among American population, it has been noticed that suicide rates are 45 times larger in BDD patients when related to the rest of the population. It means there is a higher mortality rate in BDD than compared with what is observed in pathologies like "anorexia nervosa," severe depression, and bipolar disorder [29, 70]. Suicidal

Body Dysmorphic Disorder: Characteristics, Psychopathology, Clinical Associations, and…

http://dx.doi.org/10.5772/intechopen.76446

13

Comparing the existence of comorbidities in BDD with OCD, the rates were 27.5% and 10.4%. Both conditions presented SAD and severe depression (major depression) as the main comorbidities [72]. The association of BDD cases with psychiatric internment is estimated in 14% of the cases, while the suicide attempts are present in 22–27.5% of the cases [14, 70, 73]. Based on these possible comorbidities linked to BDD, there are studies showing that among patients with BDD, 76.4% present mood disorder, 1.8% present psychotic disorder, 70.9% present anxiety disorder, 16.4% present some type of drug abuse or addiction, 10.9% present eating disorders, 3.6% present somatoform disorder, 66.7% present some type of personality disorder,

Therefore, BDD at most of the time presents an important association with another psychiatric morbidity, and it can evolve to more severe conditions, like anorexia, vigorexia, bulimia, major depression, and a very high risk of suicide, besides leading to a low capability and quality of life [64, 74]. BDD is linked to other psychiatric symptoms: 80% of the cases are connected with depressive symptoms, 12% has SAD, 48.9% are linked with drug abuse, and 32.5% of the

There are some diseases more acknowledged and shared by media, characterized as eating disorder, but, actually, they are all derived from a primary BDD and ultimately evolve with very own traits which make easier to diagnose and to treat them. Anorexia, bulimia, and vigorexia are examples of such case [75–77]. In anorexia, BDD gets evident regarding body weight, in which case the patient's self-image is distorted and the person imagines herself/himself with lots more weight than actually has. Trying to compensate it, the patient seeks compulsively to lose these "imaginary" extra pounds by refusing to eat, exercising too much, taking pills (laxatives and diuretics), and/or self-inflicted vomiting episodes. In bulimia, BDD shows up just like anorexia, but there are previous episodes of binge eating followed by extreme regret, which leads the patient to the already described compulsive behavior to try to lose weight immediately. In vigorexia, BDD is related to body size and strength. Patient's self-image is small and weak, which makes the person eat and exercise compulsively, trying to get the maximum of possible muscle mass that one can reach, frequently using steroids to get bigger enough. There is a condition called plasticomania too, in which BDD is evident in one or multiple areas of the body, and the patient do not hesitate to undergo several plastic surgeries, trying to solve the frustration [76, 78, 79].

Although several researches have been concluded, BDD is still an underdiagnosed disease. Too many professionals that should be involved in this disorder recognition ignore the condition and its severity. In studies with patients diagnosed with depression, there are elevated rates of

rates are most frequently observed in patients with dermatological complaints [71].

and only 1.5% do not present any kind of comorbidity [60].

patients diagnosed with BDD have eating disorders as well [50].

BDD individuals usually have lower scores of self-evaluation regarding appearance and high levels of dissatisfaction to their own body compared with normal population, in both genders [4, 63]. It means that the disorder directly affects the self-body image of the patients and it is frequently associated with other disorder in which the individuals refer the fear of being negatively evaluated by other people, which is the same as what occur in the social phobia disorder (SAD). In fact, SAD is considered an outstanding feature of BDD [32, 60], even though there are remarkable differences between this theoretical constructs.

Some pathologies can be associated to BDD. A research involving BDD population sample found that the majority of the patients (71%) have not shown concerns related to body weight, but they have bigger concerns related to body parts, such as skin, hair, nose, belly, and teeth. Most of these patients were female, white, single, and have incomplete superior education. All subjects of the sample demonstrate some concern regarding another very specific area of the body, besides depressive symptoms [64].

Early surveys have been investigated SAD in BDD and concluded that these patients can have high scores of SAD, regarding appearance concerns [39, 65]. BDD rates were higher in patients with SAD compared to control population [66]. Patients with BDD had higher scores at Social Phobia Inventory (SPIN), even not having SAD diagnosed as comorbidity. It was also detected that the typical social aversion of the SAD has contributed to the functional impairment of the patients with BDD [39].

Some features in common of both pathologies have been pointed, such as anxiety and denial. One study also compared sociodemographic and clinical aspects of BDD and SAD, observing that SAD is more common in younger people with lower educational level than BDD [18]. In addition, BDD patients seem to be less propensed to marry and presented more often historic of psychiatric internment than patients with SAD [18]. Another assessment claims that individuals diagnosed with BDD are often single, avoid dating, and report high levels of social isolation [67]. With regard to comorbidities, BDD and SAD have different probabilities. Patients with BDD tend more to evolve with eating disorder or OCD, whereas patients with SAD are more likely to develop anxiety disorders [18].

Based on the above, it is important to emphasize that there are ways to distinguish BDD from SAD. One way is to consider that in BDD, there are repetitive behaviors, already mentioned, such as checking and neurotic excoriation. Besides, in BDD, the main concern of the person is focused on his/her physical appearance and his/her imaginary "defects"; whereas in the SAD, the patient is worried about the judgment that the other can do about his/her behavior and about his/her social exposure. Besides, the comorbidities in BDD are much more in number and gravity than in SAD: eating disorders (bulimia, anorexia, and vigorexia), severe depression, self-mutilation, and suicide [18, 62].

Usually, BDD begins in childhood or puberty. It starts always gradually and its development is related with low quality of life; however, there is no evidence of any difference of quality of life or functional loss between patients in which the disorder started early or later in life [68]. Although, depending of the history of life of the individual, the outcome of the disorder can be suicidal or other comorbidity even more severe than BDD [58, 72], the majority of BDD patients have suicidal ideas (80%), and a considerable percentage of them have already presented suicidal attempts (24%) [60, 69]. Among American population, it has been noticed that suicide rates are 45 times larger in BDD patients when related to the rest of the population. It means there is a higher mortality rate in BDD than compared with what is observed in pathologies like "anorexia nervosa," severe depression, and bipolar disorder [29, 70]. Suicidal rates are most frequently observed in patients with dermatological complaints [71].

the body. Women were also more predisposed to behave repetitively (compulsion), using resources like camouflage of the presumed defects and constant image check; they tend more

BDD individuals usually have lower scores of self-evaluation regarding appearance and high levels of dissatisfaction to their own body compared with normal population, in both genders [4, 63]. It means that the disorder directly affects the self-body image of the patients and it is frequently associated with other disorder in which the individuals refer the fear of being negatively evaluated by other people, which is the same as what occur in the social phobia disorder (SAD). In fact, SAD is considered an outstanding feature of BDD [32, 60], even

Some pathologies can be associated to BDD. A research involving BDD population sample found that the majority of the patients (71%) have not shown concerns related to body weight, but they have bigger concerns related to body parts, such as skin, hair, nose, belly, and teeth. Most of these patients were female, white, single, and have incomplete superior education. All subjects of the sample demonstrate some concern regarding another very specific area of

Early surveys have been investigated SAD in BDD and concluded that these patients can have high scores of SAD, regarding appearance concerns [39, 65]. BDD rates were higher in patients with SAD compared to control population [66]. Patients with BDD had higher scores at Social Phobia Inventory (SPIN), even not having SAD diagnosed as comorbidity. It was also detected that the typical social aversion of the SAD has contributed to the functional impair-

Some features in common of both pathologies have been pointed, such as anxiety and denial. One study also compared sociodemographic and clinical aspects of BDD and SAD, observing that SAD is more common in younger people with lower educational level than BDD [18]. In addition, BDD patients seem to be less propensed to marry and presented more often historic of psychiatric internment than patients with SAD [18]. Another assessment claims that individuals diagnosed with BDD are often single, avoid dating, and report high levels of social isolation [67]. With regard to comorbidities, BDD and SAD have different probabilities. Patients with BDD tend more to evolve with eating disorder or OCD, whereas patients with

Based on the above, it is important to emphasize that there are ways to distinguish BDD from SAD. One way is to consider that in BDD, there are repetitive behaviors, already mentioned, such as checking and neurotic excoriation. Besides, in BDD, the main concern of the person is focused on his/her physical appearance and his/her imaginary "defects"; whereas in the SAD, the patient is worried about the judgment that the other can do about his/her behavior and about his/her social exposure. Besides, the comorbidities in BDD are much more in number and gravity than in SAD: eating disorders (bulimia, anorexia, and vigorexia), severe depres-

Usually, BDD begins in childhood or puberty. It starts always gradually and its development is related with low quality of life; however, there is no evidence of any difference of quality

to the neurotic excoriation and to eating disorder, as well [62].

the body, besides depressive symptoms [64].

SAD are more likely to develop anxiety disorders [18].

sion, self-mutilation, and suicide [18, 62].

ment of the patients with BDD [39].

12 Pathophysiology - Altered Physiological States

though there are remarkable differences between this theoretical constructs.

Comparing the existence of comorbidities in BDD with OCD, the rates were 27.5% and 10.4%. Both conditions presented SAD and severe depression (major depression) as the main comorbidities [72]. The association of BDD cases with psychiatric internment is estimated in 14% of the cases, while the suicide attempts are present in 22–27.5% of the cases [14, 70, 73]. Based on these possible comorbidities linked to BDD, there are studies showing that among patients with BDD, 76.4% present mood disorder, 1.8% present psychotic disorder, 70.9% present anxiety disorder, 16.4% present some type of drug abuse or addiction, 10.9% present eating disorders, 3.6% present somatoform disorder, 66.7% present some type of personality disorder, and only 1.5% do not present any kind of comorbidity [60].

Therefore, BDD at most of the time presents an important association with another psychiatric morbidity, and it can evolve to more severe conditions, like anorexia, vigorexia, bulimia, major depression, and a very high risk of suicide, besides leading to a low capability and quality of life [64, 74]. BDD is linked to other psychiatric symptoms: 80% of the cases are connected with depressive symptoms, 12% has SAD, 48.9% are linked with drug abuse, and 32.5% of the patients diagnosed with BDD have eating disorders as well [50].

There are some diseases more acknowledged and shared by media, characterized as eating disorder, but, actually, they are all derived from a primary BDD and ultimately evolve with very own traits which make easier to diagnose and to treat them. Anorexia, bulimia, and vigorexia are examples of such case [75–77]. In anorexia, BDD gets evident regarding body weight, in which case the patient's self-image is distorted and the person imagines herself/himself with lots more weight than actually has. Trying to compensate it, the patient seeks compulsively to lose these "imaginary" extra pounds by refusing to eat, exercising too much, taking pills (laxatives and diuretics), and/or self-inflicted vomiting episodes. In bulimia, BDD shows up just like anorexia, but there are previous episodes of binge eating followed by extreme regret, which leads the patient to the already described compulsive behavior to try to lose weight immediately. In vigorexia, BDD is related to body size and strength. Patient's self-image is small and weak, which makes the person eat and exercise compulsively, trying to get the maximum of possible muscle mass that one can reach, frequently using steroids to get bigger enough. There is a condition called plasticomania too, in which BDD is evident in one or multiple areas of the body, and the patient do not hesitate to undergo several plastic surgeries, trying to solve the frustration [76, 78, 79].

Although several researches have been concluded, BDD is still an underdiagnosed disease. Too many professionals that should be involved in this disorder recognition ignore the condition and its severity. In studies with patients diagnosed with depression, there are elevated rates of BDD, but most of these patients have their BDD not noticed as the primary pathology, which, usually, lead to a failure of treatment [59]. Some patients may resist referral to psychiatrists and psychologists, because they continue to believe that their problems are physical and not psychological. It is often fruitless to try to convince these patients that their beliefs are irrational [8]. Appearance-enhancing treatments should not be implemented, because these may even exacerbate the psychological symptoms [76]. Concluding, the difficulty in recognizing and diagnosing BDD has been appointed as the main factor of morbidity and mortality of this pathology [29].

sickness. At the day before the appointment, he had punched his father's face. It never happened before. The patient was really regretted and scared with his own behavior. His parents were really worried and shocked because, on top of all, he had just given up on Law School and was obsessed by his own image on the mirror, spending 6–9 h a day in gym working out and more than 3 or 4 h in front of the mirror, checking each part of his body. However, he wasn't happy with himself, like in the case of Narcissus myth; he was in real pain, frustrated, and the parents could hear him whispering "I'm weak, I'm thin." No matter how strong his

Body Dysmorphic Disorder: Characteristics, Psychopathology, Clinical Associations, and…

http://dx.doi.org/10.5772/intechopen.76446

15

His mother said she noticed 6 months before that he was becoming a little agitated and hostile. She tried to talk to him. But he was evasive and avoidant, then she looked through his medicines and found out he was taking steroids for muscles and finasteride for hair loss. I asked about his neonatal history; his mother answered she had a little trouble during labor delivery and he was born with a reduced Apgar score, but nothing that compromised his development; he had some episodes of feverish crisis until 5 years old. But lately, in the past 4 or 5 months, he started to have night terror episodes, which he never had before. However, his younger brother used to have it at the age of 3–4 years. In addition to the night terror, he started to have intense migraine episodes during the day, with photophobia and misophonia. The parents said he was "normal" until 6–8 months before; described him as "just a little over concerned about physical shape, but like other youngster." They confirm that he was introvert and shy during his childhood and became a little more confident after 16 years old when he started to work out. He said to me, after getting better with medication, that he used to be

I deduced that this patient had some temporal lobe level of instability which leads him to feel very intense about his emotional pains. The use of steroids and finasteride may have impaired some of his brain functions, reducing his convulsive threshold. The result was more aggressivity, mood swing, and the severe BDD symptoms escalating from an original simple

He mentioned social anxiety since he was a boy. Therefore, he decided to work out to get stronger. At certain point, influenced by a friend, he started to take steroids and finasteride. He started to get better after quitting the hormones and finasteride. The social anxiety and the BDD were controlled after a week taking oxcarbazepine 600 mg/day and citalopram 10 mg/day. After 6 months of treatment, he stopped medication and continued psychotherapy. I have not

In summary, this chapter has addressed the main characteristics and related psychopathology of the body dysmorphic disorder, as well as some clinical associations and influencing factors. Moreover, this chapter has also presented one illustrative case of the diagnosis and treatment

of body dysmorphic disorder symptoms by an experienced clinical psychiatrist.

body was, he could not notice it. He was very concerned about his hair too.

teased at school for being shorter than the other boys.

unhappiness with his body features.

heard from him since 4 years ago.

**7. Conclusions**
