**4. Behavior and personality of the BDD patient**

Currently, there are many studies comparing BDD patients' behavior with personality. These are very important clinical evidences of the disorder. As said before, BDD patients usually have perfectionist personality, as a natural trait or a pathological feature; between them, it is possible to observe a very large range of anankastic (obsessive) behaviors, according to each affected individual. Nevertheless, when the BDD is already detected, the patient is very often anguished, afflicted, and tormented; they have social, emotional, and labor impairment. They have maladapted thoughts about their appearance: "if I'm not good looking, I can't be happy." That kind of thought leads to negative self-evaluation, which provokes specific behavior known as repetitive acts. Some studies sustain that 90% of people with BDD engage in compulsive behaviors [10, 22].

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

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

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

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

Currently, there are many studies comparing BDD patients' behavior with personality. These are very important clinical evidences of the disorder. As said before, BDD patients usually have perfectionist personality, as a natural trait or a pathological feature; between them, it is possible to observe a very large range of anankastic (obsessive) behaviors, according to each affected individual. Nevertheless, when the BDD is already detected, the patient is very often anguished, afflicted, and tormented; they have social, emotional, and labor impairment. They have maladapted thoughts about their appearance: "if I'm not good looking, I can't be happy." That kind of thought leads to negative self-evaluation, which provokes specific

can see flaws in themselves, even when those flaws might not exist [20].

know and to analyze the other factors involved in BDD [21].

**4. Behavior and personality of the BDD patient**

group [17, 18].

6 Pathophysiology - Altered Physiological States

regions [19].

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 to inanimate creatures like monsters [10].

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

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

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

An antisocial personality can also be attributed to BDD. Clinical observations suggest that both BDD and social anxiety disorder (SAD) are characterized by a fear of negative evaluation in social situations, as well as avoidance of social interactions, although in BDD, social fear and avoidance are largely related to the perceived bodily "defects." Individuals with BDD also have a tendency to misinterpret neutral interpersonal cues as more negative and threatening when compared to healthy controls. Moreover, the high SAD comorbid rates in BDD

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

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

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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

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 surgi-

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].

(37–40%) suggest that BDD and SAD may be related disorders [38, 39].

**with other disorders**

cal results [51].

24.9% in patients of multiple nationalities [3].

**5. Prevalence, comorbidities, influencing factors, and association** 

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 quality of life of these individuals [27].

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 personality disorders [36].

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 time thinking about the way they look [37].

An antisocial personality can also be attributed to BDD. Clinical observations suggest that both BDD and social anxiety disorder (SAD) are characterized by a fear of negative evaluation in social situations, as well as avoidance of social interactions, although in BDD, social fear and avoidance are largely related to the perceived bodily "defects." Individuals with BDD also have a tendency to misinterpret neutral interpersonal cues as more negative and threatening when compared to healthy controls. Moreover, the high SAD comorbid rates in BDD (37–40%) suggest that BDD and SAD may be related disorders [38, 39].
