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Date posted: February 1, 2012

A behavioral problem of modern word needing consideration
D .Anoop Kumar Srivastav

“Mirror, mirror on the wall, who is the fairest of all”?
“Am I dark”? “Is my nose crooked”? “Do my legs look short”?

Some of us do question ourselves, though occasionally about our body image. “30-40% of the population has some kind of dissatisfaction with their bodies” says Carol Watkins, M.D. of the Northern County Psychiatric Association in Baltimore, Maryland. But some of them get really preoccupied that there is something wrong with a particular part of the body. This 1-2% of individual suffers from Body dysmorphic disorder or BDD.

Body dysmorphic disorder (BDD) is defined by the DSM-IV-TR as, “a condition marked by excessive preoccupation with an imaginary or minor defect in a facial feature or localized part of the body.” The diagnostic criteria specify that the condition must be sufficiently severe to cause a decline in the patient’s social, occupational, or educational functioning.

Body dysmorphic disorder (BDD) is a type of somatoform disorder characterized by an excessive preoccupation with a real or imagined defect in one’s own physical appearance. People with BDD have a distorted or exaggerated view of how they look and are obsessed with actual physical characteristics or perceived flaws, such as a certain facial feature or imperfections of the skin. They often think of themselves as ugly or disfigured. People with BDD have difficulty in controlling negative thoughts about their appearance, in spite of being assured that they look fine or that their flaws are not noticeable.

Most people at some time wish to change or improve some aspect of their physical appearance, but, people suffering from BDD get so much obsessed with the idea, that they are unable to interact with others or for fear of ridicule and humiliation.

BDD combines obsessive and compulsive aspects, which has linked it to the OCD spectrum disorders among psychologists. People with BDD may engage in compulsive mirror checking or in some cases mirror avoidance, they may spent hours planning about camouflaging the ‘problem’ feature. In severe cases, they think themselves to be unspeakably hideous and so shun all social contacts to become home bound. The disorder is linked to an unusually high suicidal rate among all mental disorders.

History of BDD
BDD was first documented in 1886 by the researcher Morselli, the condition being known as “Dysmorphophobia”. The word dysmorphic comes from two Greek words, dys that means ‘bad’, or ‘ugly’, and morphos that means ‘shape’ or ‘form’.

In his practice Freud eventually had a patient Sergei Pankejeff’, nicknamed ‘the Wolf Man’ who was constantly preoccupied with his nose, hindering his routine life. This disorder has been referred to as “imagined ugliness” (Barlow-2006).

The disorder was first defined as a formal diagnostic category by the DSM-III-RIN 1987.

Incidence
It is estimated that BDD affects 1-2% of the population. The usual age of onset of BDD is late childhood or early adolescence, average age of patients diagnosed with the disorder is 17 years. Most research and treatment studies to date have been done on adults aged 35 and older. It has been diagnosed in 1.9% of non-clinical patients and 12% of psychiatric out patients. The DSM-IV-TR gives a range of 5-40% of patients in clinical mental health settings diagnosed with anxiety or depressive disorders to be diagnosed with BDD. The prevalence of BDD is equal in men and women, and causes chronic social anxiety for those suffering from the disorder.

Causes
The cause of BDD is unclear. However, researchers believe that a number of factors may be involved, and they fall into two major categories. This are-
1. Neurobiological causes
2. Psychosocial causes

Neurobiological causes:
Research indicates that the patients diagnosed with BDD have level of Serotonin (a neurotransmitter) lower than normal. Low serotonin levels are associated with depression and other mood disorder.

Psychosocial causes: Another important factor in the development of BDD is the influence of the mass media in developed and developing countries, particularly the role of advertisements in glorifying “perfect” men and women image. Impressionable teenagers and adolescents absorb the message that anything short of physical perfection is unacceptable. They may then develop distorted perceptions of their own faces and bodies.

Children whose parents are themselve obsessed with appearance, dieting, or bodybuilding; or who are highly critical of their children’s looks, are at greater risk of developing BDD.

In some cases a history of childhood trauma or abuse may emerge in form of obsession about a part of the face or body. For example, an adolescent who suffered in childhood by physically abusive parents may develop an obsession for the need of muscular power in his later life.

Signs and symptoms:
The signs and symptoms of body dysmorphic disorder include:

  • Frequently comparing the flaw in appearance with that of others,
  • Repeatedly checking the appearance of the specific body part in mirrors or other reflective surfaces,
  • Refusing to have pictures taken,
  • Wearing excessive clothing, makeup and hats to camouflage the perceived flaw,
  • Using hands or posture to hide the imagined defect,
  • Frequently touching the perceived flaw,
  • Picking at one’s skin,
  • Frequently measuring the imagined or exaggerated defect,
  • Elaborate grooming rituals,
  • Excessively researching about the perceived defective body part,
  • Seeking surgery or other medical treatment despite personal opinions of others and recommendations of doctors that the flaw is minimal or doesn’t exist or that treatment is unnecessary,
  • Seeking reassurance about the perceived defect or trying to convince others that it’s abnormal or excessive,
  • Avoiding social situations in which the perceived flaw might be noticed ,
  • Feeling anxious and self-conscious around others (social phobia) because of the imagined defect ,
  • People with severe BDD may drop out of school, quit their jobs or avoid leaving their homes. In the most severe cases, people with BDD may consider or attempt suicide.
  • Certain physical obsessions are common in a person with BDD. These include:
  • Overall size, shape or symmetry of a certain facial feature, such as size or shape of nose,
  • Moles or freckles perceived as too large or noticeable,
  • Acne and blemishes,
  • Minor scars or skin abrasions,
  • Too much facial or body hair ,
  • Baldness,
  • Breast size,
  • Muscles perceived as too small,
  • Size or shape of genitalia ,

Common locations of imagined defects
• hair
• nose
• skin
• teeth
• genitalia
• eyes
• head/face
• overall body build
• legs/knees • cheeks
• arms/wrists
• lips
• chin
• stomach/waist
• breasts/pectoral
• buttocks
• eyebrows

Diagnosis of BDD
Researchers prefer a semi structured interview called the BDD Data form to collect information about the disorder from patients. The BDD Data form includes demographic information, information about body areas of concern and the history and course of the illness, and the patient’s history of hospitalization or suicidal attempts, if any. The diagnostic questionnaire most frequently used to identify BDD patients is the structured clinical interview for DSM-III-R disorders or SCID- II.

According to the American Psychiatric Association, a questionnaire called the Body Dysmorphic Disorder Questionnaire (BDDQ) is used by psychiatrists or psychologists to diagnose cases with BDD. The questionnaire is conducted during an official visit with the patient and as part of an interview focusing his concerns about his physical appearance. Another tool used to help diagnose BDD, the Body Dysmorphic Disorder Examination (BDDE), consists of a series of questions to evaluate these key tendencies of the disorder:

  • Preoccupation with and evaluation of appearance.
  • Degree of self-consciousness and feelings of discomfort in public.
  • Tendency to overvalue appearance in determining overall self-worth.
  • Avoidance of social situations and physical contact with others.
  • Excessive altering of one’s appearance through grooming, cosmetics or dress.
  • Tendency to frequently check one’s appearance, perform repetitive grooming and seek reassurance from others.

To diagnose the disorder, the physician asks questions about obsessions, compulsions and disappointments regarding appearance, and about emotional well-being of the patient. He should even talk to the friends and relatives of the patient about his behavior.

Complications

  • Body dysmorphic disorder tends to be chronic and can bring about other health problems and complications in individual life:
  • Depression. Chronic BDD leads to depression affecting moods, feelings, behavior and physical health of individual.
  • Social isolation. BDD is commonly associated with social isolation, social phobia and other negative impacts, such as dropping out of school, quitting a job or becoming completely homebound.
  • Unnecessary medical procedures. Some patients in an attempt to rectify or improve their assumed defect seek excessive medical procedures such as cosmetic surgery eventually covering the flaw.
  • Suicidal attempts. BDD patients have high risk of self destructive behavior, including performing surgery on themselves at home (liposuction followed by skin stapling, sawing down teeth) and often attempted suicide to get rid of their condition.

Management:
Medications-
Treatment with SSRIs- Low levels or insufficient use of serotonin has been implicated with the disorder and so selective serotonin reuptake inhibitors (SSRIs) are found to give high rate of positive responses. Some of the commonly used drugs include Fluoxetine, Fluvoxamine, Paroxetine, Citalopram, Celexa, Clomipramine, Anafranil.

Psychotherapy-
CBT (Cognitive Behavioral Therapy) coupled with exposure therapy has been shown to be effective in the treatment of BDD. This includes education about BDD and its specific treatments to deal with faulty thoughts, assumptions (Cognition’s) and problematic behaviors.

The cognitive aspects involve discovering, challenging and changing the underlying negative thoughts and beliefs the sufferer keeps thinking.

Alternative treatments- Although no alternative or complementary form of treatment has been recommended specifically for BDD,

  • Herbal remedies for depressed feelings, such as St. John’s wort, have been reported to help some BDD patients.
  • Aromatherapy appears to be a useful aid to relaxation techniques as well as a pleasurable physical experience for BDD patients.
  • Yoga has helped some persons with BDD acquire more realistic perceptions of their bodies and to replace obsessions about external appearance with new respect for the inner structure and functioning of their bodies.

Prognosis
Researchers do not know enough about the lifetime course of body dysmorphic disorder to offer a detailed prognosis. The DSM-IV-TR notes that the disorder “has a fairly continuous course, with few symptom-free intervals, although the intensity of symptoms may wax and wane over time.”

Management with homoeopathy-
Homoeopathy is a method of curing the sufferings of a person by the administration of drugs which have been experimentally proved to possess power of producing similar sufferings in a healthy human being.

Homoeopathy, the holistic healing, heals the sick and not the sickness. The homoeopathic approach treats the patient as a whole. According to it, a person is sick and not his body parts. A diseased or sick individual is one whose condition is deviated from the normal. Homoeopathy preaches the prescribing of medicine to the person which brings him back to his normal healthy state.
So homoeopathy treats people with BDD, not the BDD.

The pros of homoeopathic treatment-

  • Treat the whole person irrespective of his disease.
  • Considered safe, without the side effects of Serotonin and other medication.
  • Uses natural non-toxic medicines.
  • Heals physical as well as emotional symptoms.
  • Beneficial effects last for months or year rather than hours.
  • Inexpensive and cost-effective.
  • Unique treatment for unique individuals.
  • Treating people, not diagnoses.

Homoeopathic view on BDD
Body dysmorphic disorder is a somatoform disorder where the symptoms are psychological, without any structural anomaly or pathological background.
The patient is preoccupied with some fictious or unnoticed anomaly in his body. This means that the defect is excessive concern of the mind and its abnormal beliefs.

As usually done, Homoeopathy does not separate the mind and the body; it advocates that body and mind are dynamically interconnected and that both directly influence each other. Virtually every homoeopathic prescription is based on the physical and psychological symptoms of the sick person. Psychological symptoms often play a major role in the selection of the correct medicine.

Our master Samuel Hahnemann has written about the importance of the psychological symptoms in his Organon of Medicine as-

“This holds true to such an extent, that the state of disposition often chiefly determines the choice of homoeopathic remedy.” …….sec. 211.

“There is no powerful medicinal substance in the world which does not very notably alter the state of the disposition and mind in the healthy individual who tests it, and every medicine dose so in a different manner.” …….sec. 212.

In Homoeopathic Materia Medica the mental symptoms of the various remedies have been beautifully brought out, which makes the choice easy. The state of the patient has to be compared with the mental and general state of the various remedies in the materia medica in order to choose one which is exactly suitable.

The core symptoms of BDD i.e. both obsession and the compulsion come from false perception i.e. Delusion. With the help of psychotherapy, the patient is made aware of the reality. The homoeopathic medicine also helps in this context and moreover it helps the patient to cope up with the reality. In this way the patient slowly and gradually but permanently reverts back to the normal healthy self. Thus the cases with BDD can be cured with the homoeopathic treatment.

Understanding of Miasm in BDD
The miasmatic view of BDD can be understood in three ways
1. According to predisposing factors.
2. According to pathology.
3. According to symptomatology.

According to predisposing factors – AGE- The incidence of BDD is more in teenagers and adults showing sycotic nature of disease.

According to pathology- Research indicates that low level of serotonin plays important role in BDD. This indicates psoric background of the disease.

According to symptomatology – As we know the progression of the disease and the progression of the miasm are always interlinked, so for better understanding of the development of miasm in BDD we should understand the onset and development of the symptoms presented in diseased state.

(A) The disease starts with excessive concern with a specific facial feature or body part creating

  • Constant checking reflection in mirrors, reflection doors and glasses and any other reflective materials.
  • Compulsive skin touching, especially to feel or measure the perceived defect.
  • Obsessive viewing of certain favorite celebrities, models, he or she wants to resemble.
  • Excessive grooming behaviors, combing hairs, plucking eyebrows, shaving etc.

These behaviors show the suspicious nature of the patient. The person is suspicious about her own body, to her surroundings etc. she even dare not trust herself so she keeps looking in mirror again and again or compulsive skin touching, especially to feel or measure the perceived defect.

At This level of suspiciousness and obsessive compulsions the disease is purely sycotic.

(B) This suspiciousness when turned upon others, leads to the worst form of Jealousy and person becomes jealous of her relatives, friends etc. This jealous nature is also sycotic.

(C) In the next run the patient develops a habit of excessive grooming, makeup in order to camouflage his perceived flaw. He may even run abut for unnecessary medical procedures. This hiding tendency again depicts a sycotic nature.

(D) In next stage severe anxiety about body is developed and this will be manifested by outward expressions. Due to dissatisfaction there is lack of concentration on certain things, which may lead to mental restlessness and lack of confidence.
Restlessness, dissatisfaction and loss of confidence are all sycotic feature.

(E) In the next course of disease fixed ideas and manias are developed, various abnormal sensations
e.g. Thinks poor he is; thinks body is made-up of wood, he is ugly etc. This develops an  inferiority feeling; lack of honest thinking and lastly repenting over past events which may lead  to suicidal impulse.
Fixed ideas and manias, inferiority feeling with suicidal impulse is also a sycotic feature.

(E) In the last stage, patient falls in to depression and long continued depressive phases may in some  cases lead to commit suicide. At this stage the miasm changes itself in the more destructive form and becomes syphilitic.

In conclusion one can say that BDD is disease with predominately sycotic manifestation with psora in the background, but in the last stage it may turn to degenerative phase and becomes syphilitic.

Rubrics to be found helpful in cases of BDD are-
From Synthetic Repertory:
1. Delusions, imaginations, hallucinations, illusions; appreciated she is not.
2. Delusions, imaginations, hallucinations, illusions; blind he is.
3. Delusions, imaginations, hallucinations, illusions; body black it is.
4. Delusions, imaginations, hallucinations, illusions; body brittle, is.
5. Delusions, imaginations, hallucinations, illusions; body deformed, some part is.
6. Delusions, imaginations, hallucinations, illusions; body heavy and thick, has become.
7. Delusions, imaginations, hallucinations, illusions; body spotted brown, is
8. Delusions, imaginations, hallucinations, illusions; body thick, is.
9. Delusions, imaginations, hallucinations, illusions; body thin, is.
10. Delusions, imaginations, hallucinations, illusions; chin is too long.
11. Delusions, imaginations, hallucinations, illusions; left side of body is smaller.
12. Delusions, imaginations, hallucinations, illusions; short he is.
13. Delusions, imaginations, hallucinations, illusions; shrunken, parts are.
14. Delusions, imaginations, hallucinations, illusions; small, he is.
15. Delusions, imaginations, hallucinations, illusions; thin, he is too.
16. Delusions, imaginations, hallucinations, illusions; diminished, whole body is.
17. Delusions, imaginations, hallucinations, illusions; dirty, he is.
18. Delusions, imaginations, hallucinations, illusions; double nose is.
19. Delusions, imaginations, hallucinations, illusions; emaciation, of
20. Delusions, imaginations, hallucinations, illusions; enlarged body is.
21. Delusions, imaginations, hallucinations, illusions; enlarged body, parts of.
22. Delusions, imaginations, hallucinations, illusions; enlarged neck.
23. Delusions, imaginations, hallucinations, illusions; enlarged chin is.
24. Delusions, imaginations, hallucinations, illusions; enlarged eyes are.
25. Delusions, imaginations, hallucinations, illusions; eyelashes are.
26. Delusions, imaginations, hallucinations, illusions; enlarged forearm is.
27. Delusions, imaginations, hallucinations, illusions; enlarged head is.
28. Delusions, imaginations, hallucinations, illusions; scrotum is swollen.
29. Delusions, imaginations, hallucinations, illusions; eyelashes prolonged.
30. Delusions, imaginations, hallucinations, illusions; eyes of big.
31. Delusions, imaginations, hallucinations, illusions; face distorted.
32. Delusions, imaginations, hallucinations, illusions; face elongated.
33. Delusions, imaginations, hallucinations, illusions; finger-nails seem as large as plates.
34. Delusions, imaginations, hallucinations, illusions; goiter, he has a.
35. Delusions, imaginations, hallucinations, illusions; head large, seems too.
36. Delusions, imaginations, hallucinations, illusions; large, parts of body seem too.
37. Delusions, imaginations, hallucinations, illusions; legs conversing, are.
38. Delusions, imaginations, hallucinations, illusions; toe is conversing with thumb.
39. Delusions, imaginations, hallucinations, illusions; legs four, has.
40. Delusions, imaginations, hallucinations, illusions; legs long, too.
41. Delusions, imaginations, hallucinations, illusions; legs three, has.
42. Delusions, imaginations, hallucinations, illusions; limbs are crooked.
43. Delusions, imaginations, hallucinations, illusions; lip is swollen, lower.
44. Delusions, imaginations, hallucinations, illusions; long, chin seems too
45. Delusions, imaginations, hallucinations, illusions; long leg is too, one
46. Delusions, imaginations, hallucinations, illusions; neck is too large.
47. Delusions, imaginations, hallucinations, illusions; nose, has a transparent.
48. Delusions, imaginations, hallucinations, illusions; nose, longer, seems
49. Delusions, imaginations, hallucinations, illusions; two noses, has.
50. Delusions, imaginations, hallucinations, illusions; poor, he is.
51. Delusions, imaginations, hallucinations, illusions; scrotum is swollen, is.
52. Delusions, imaginations, hallucinations, illusions; swollen, he is.
53. Delusions, imaginations, hallucinations, illusions; tall, he is.
54. Delusions, imaginations, hallucinations, illusions; she is very.
55. Delusions, imaginations, hallucinations, illusions; thin, is getting.
56. Delusions, imaginations, hallucinations, illusions; thin body is.
57. Delusions, imaginations, hallucinations, illusions; transparent, he is.
58. Delusions, imaginations, hallucinations, illusions; transparent, head and nose are.
59. Delusions, imaginations, hallucinations, illusions; warts, he has.
60. Delusions, imaginations, hallucinations, illusions; withering, body is.

Medicines to be considered-
Medicines are prescribed according to the symptoms presented, constitution and temperament of the patient and on the basis of the miasmatic background. Some drugs indicated in cases of BDD are :
Aconite; Aethusa; Ambra; Arg-nit; Ars; Aur; Bapt; Bell; Calc; Camph; Cann-I; Cann-s; Cocc; Coff; Crot-c; Cupr; Glon; Hell; Hep; Hyos; Ign; Kali-br; Lach; Lyco; Lyss; Mag-p; Merc; Nit-ac; Oena; Opium; Petro; Ph-ac; Phos; Plat; Psor; Puls; Rhus-t; Sabad; Sec; Sil; Staph; Stram; Sulph; Vler; Verat; Zinc.

Dr.Anoop Kumar Srivastav
Railway Colony, Jaipur (Raj.)
Email-: dr_anoup@rediffmail.com

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