**3. Neuroanatomic findings**

**1. Introduction**

4 Pathophysiology - Altered Physiological States

the disorder [7, 8].

In the context of a society where beauty is directly related to success and simultaneously hard to achieve, this is the background for the manifestation of the most of the appearance disorders. Among them, we observe the body dysmorphic disorder (BDD), classified as the most

The body dysmorphic disorder (BDD), previously denominated as dysmorphophobia, consists in a severe psychiatric condition, with high incidence and frequently incapacitating. It is characterized by psychic suffering caused by a possible physical imperfection in appearance, always focused in a specific body part, as a common example, nose, hair, freckles, or breast size. Any part can or body characteristic can be the focus, including the presence of body hair

Although BDD is an unrecognized and often not diagnosed in our society, it causes significant clinical suffering to the patient, social, and professional prejudice and affects others spheres of the individual life. Nowadays, new characteristics have been added to the disorder as repetitive behavior and mental acts related to self-image preoccupation. To acquire a better knowledge and help in BDD diagnosis should be a priority, not only for psychological and psychiatric professionals but also for aesthetical, cosmetic, and physical educators, because these patients may search for the solution with appearanceenhancing treatments, an action that can worsen the psychological symptoms caused by

BDD is defined by a recurring and persistent concern about a specific trait or a group of characteristics, noticed in the self-image. The etiology is associated to a perfectionist pre-morbid personality, teasing in school, or a traumatic event. Recent research suggests that more than three-quarters of individuals with BDD reported a perception of childhood maltreatment [2]. The patient relates that these traits are ugly, unattractive, abnormal, or even crippled. The selfnoticed flaws are not necessarily bad or abnormal to other individuals. These appearence concerns range from seem unattractive or inappropriate, to horrible, repulsive or often described as monstrous. Patients can focus in specific details or several parts. It is very frequent that the skin is the focus of the disorder, for example, acne, scars, wrinkles, pale skin, or body hair, characteristics of hair, hair loss, and unwanted facial hair, nose (size and shape). However, any part can be the focus of this disorder. Some even present concern about the perception of asymmetry of body parts. The perceptions are intrusive, unwanted, and take time (about

The BDD can be classified according to the level of insight. In the good or reasonable insight, the individual can recognize that the beliefs of BDD may not be true. In the case of poor insight, the individual believes that it is most likely true. In the absence of an insight or a

fragilizing and afflictive pathology related to body image [1–3].

excess or the body shape as a whole [4–6].

**2. Definitions and characteristics**

3–8 h a day); it is usually hard to avoid or control [9–11].

In the past, BDD used to be part of somatoform disorder spectrum [16], which now is known as somatic symptoms disorders [9]. This spectrum is featured by the presence of physical symptoms, which suggests a medical general condition underlying the behavior symptoms, because there is no detectable neurobiological imbalance or other psychiatry disorders to justify the symptoms. It is important to emphasize that this classification has changed much and do not include BDD anymore [9].

Nowadays, BDD has been included in the range of obsessive compulsive disorders (OCDs), because the neuroanatomic findings presented new evidences about BDD, pointing biological features to its etiopathogeny. One study detected that orbitofrontal cortex and anterior cingulate cortex volumes of BDD patients were significantly smaller than healthy individuals. It means that their brain has more white substance than the control group. Besides, there is a tendency of an increase of thalamic volume in BDD patients compared with that in the control group [17, 18].

behavior known as repetitive acts. Some studies sustain that 90% of people with BDD engage

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

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

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Among the repetitive acts of compulsive behavior of BDD patients, there are check, camouflage, dressing-up excessively, and self-mutilation. In check behavior, patients spend most of their time checking their own image in front of the mirror; it is known as "mirror checking" or "mirror gazing." Around 80% of people with BDD usually have mirror gaze behavior. There are reports of patients who can spend 11 h per day looking themselves at the mirror [23]. It can be explained as a cycle, and it begins when a person views an external or an internal representation of their appearance. External events include looking at a mirror. Internal events include somatic sensations or intrusive thoughts. Such events activate a distorted mental image or a "felt" impression of the self. People with BDD selectively focus on this image, which leads to a magnification of perceived imperfections. It showed that people with BDD endorse assumptions such as "if my appearance is inadequate, life is not worth living." Negative assumptions result in rumination, decreased mood, and safety behaviors such as mirror gazing, which uphold the distorted mental image, increase doubts, and reinforce the cycle [24]. The mirror checking is perceived as being uncontrollable, addictive, and trapping. On a "bad day," motivations for mirror gazing are punitive and tortuous as patients usually report. Some patients describe what they see in the mirror by comparing themselves

In the camouflage, patients waste too much time trying to hide the defect [3, 25, 26]. It includes the habit of buying compulsively objects like make-up items, scarfs, and so on [19, 27]. In the dressing-up excessively, patients spend most of the day beautifying themselves and trying to look better. They imagine that people are constantly observing and evaluating them; this feel-

The self-mutilation behavior is considered the most severe and harmful of the symptoms. A typical self-mutilation injury is called neurotic excoriations (or pathological skin picking), which is defined for the irresistible impulse of causing or worsening skin damage, by scratching, biting, clawing with nails, fingers, or objects. The self-mutilation can be used to provoke the amputation of the "ugly" part of the body [29, 30]. The lesions are polymorphic. Newer lesions are angulated excoriated crusted erosions, while older lesions have depigmented scarred center and hyperpigmented periphery. Lesion numbers vary from few to hundred and are in all stages of development. Prurigo nodularis is an extreme variant of this entity. Distribution of the lesions reflects their self-inflicted nature with lesions concentrated over the most accessible sites. Neurotic excoriation is differentiated from dermatitis artefacta by its conscious and compulsive nature. However, a patient should be evaluated for all cutaneous

Acne excoriee is a variant of neurotic excoriation where patients have either only facial or predominant facial involvement. Few patients develop lesions after picking acne lesions while majority did not have acne at any time. It is most common in females with an average age of 30 years. Another very common habit is "tricolomania," which is characterized by the act of, recurrently, pulling the own hair or body hair, for pleasure, satisfaction, or tension relief. The most usual areas are scalp, eyelashes, and eyebrow. This behavior pattern is relevant only if it

in compulsive behaviors [10, 22].

to inanimate creatures like monsters [10].

ing creates a great emotional pain and functional impairment [28].

and systemic causes of pruritus before making this diagnosis [31].

Neuroanatomic evidence in the limbic system was also found, more specifically in the amygdalas, between BDD, anxiety, and self-evaluating visual process. Self-image is captured by ventral visual system, which is later interpreted by the brain's amygdalas. That structure is involved in emotional control in a higher level, like companionship, love, affection, mood swings, fear, rage, and hostility. They are involved in some anxiety manifestations too. Interestingly, only the right amygdala volume has shown a significant correlation with BDD symptom severity, which suggests a different lateral involvement of these brain regions [19].

One study conducted by researchers at the University of California, Los Angeles, shows that people with BDD may process visual information differently than people without the disorder. Researchers showed 25 people, half with BDD and half without the disorder, three different images of faces in high, regular, and low resolutions. Magnetic resonance image (MRI) results showed that participants with BDD used the left side of the brain (the analytical side) to process all three images. The other participants used the brains' left hemisphere for only the high-resolution images. This could mean that the minds of people with BDD strive to acutely process visual details, even when there is nothing to process. This might be why they can see flaws in themselves, even when those flaws might not exist [20].

Another biological factor under consideration is that people with BDD seem to have a chemical imbalance of the neurotransmitter serotonin, because they often respond well to the selective serotonin reuptake inhibitor (SSRI) class of antidepressants. While doctors know that the differences in brain and neurotransmitter functions exist, they do not know whether BDD causes the differences or if the differences cause BDD. For this reason, it is so important to know and to analyze the other factors involved in BDD [21].
