Friday, 12 May 2017

ABC's of the DSM-V: Body Dysmorphic Disorder aka BDD!

One of the most misunderstood disorders of today is body dysmorphic disorder (BDD). With society focusing on self-image and aesthetic so much nowadays and the rising popularity of body positive activism, BDD patients are caught in the crossfire and grossly misunderstood by each party as being too vain or “already perfect”. Several public figures who have the disorder have received horrific backlash by the public due to poor understanding of the disorder – I distinctly remember a few years ago seeing the documentary “Glamour Models, Mum and Me,” following the story of Alicia Douvall who is most famously known for being the woman who’s addicted to plastic surgery, and thinking there was definitely something wrong with this woman psychologically. Strangely enough, her daughter who was around 16 at the time was the complete opposite to her mother – vehemently against plastic surgery; despite her mother’s attempts to get her to go under the knife, incredibly intelligent, sensible – just very, very grown up.

Liz Atkin's photography focuses on her compulsive skin picking. A symptom commonly seen in BDD patients. Credit
I remember the backlash Douvall got – called irresponsible as a person and as a mother, a bad role model, an awful parent etc. These were people who didn’t see it as being anything more than an obsession with vanity – a self-absorbed model who cares about no one but herself – which is nothing more than assumptions and poorly evidenced claims. BDD warps self-image to the point excessive surgeries are the only option. There is nothing rational about it and that should be taken into account when attempting to judge a person on how many plastic surgeries they’ve had.

Alicia Douvall following BDD remission. Credit
Alicia Douvall is, on the contrary, a good mother considering she has been battling with BDD. As a 12 year old she developed anorexia as a result of her father’s cruel words about her intelligence and looks, his strict rules and inability to show anything more than resentment towards his daughter most likely had a significant impact on her self-esteem and the reason for her rebellious streak as a teenager. After being suicidal at one point and constantly being called ugly, she emerged as a model and became a single mother. Considering an unstable sense of self image and poor mental health, she has done an incredible job which is made evident by her daughter, Georgia – watching her in the documentary is amazing! She’s articulate and caring, which some would agree as being a result of having to take care of her mother most of the time (during surgery recoveries) but that does not mean it’s not a result of Douvall’s parenting as well. The two share a genuine bond, which is clearly seen throughout and their love for each other is enviable – their relationship is healthy considering what Georgia has been put through. That is not to say she has been the best mother – the downtime following surgeries would not allow her to take care of her as best as she would probably like to, Georgia lived with her grandmother until the age of 8 – and Alicia being a teen mother probably had a lot to do with it, one could also argue that all these surgeries and exposure to vanity and warped self-image is a bad influence, but clearly Georgia is clever enough to see past that and understand that her mother has a problem – she can’t help it. Alicia also redeemed herself once she got Georgia back full time, she provided and made an effort – and has turned her life around after the birth of her second child Papaya.

Taken from Leigh De Vries' short film about BDD. Credit
The diagnostic criteria for BDD is as follows:

A.      Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others.
B.      At some point during the course of the disorder, the individual has performed repetitive behaviours (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (e.g., comparing his or her appearance with that of others) in response to the appearance concerns.
C.      The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D.      The appearance preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder.

In essence, BDD is a form of OCD. Repetitive behaviours, irrational preoccupation with something (in this case looks), obsessive outlook – it is an image revolving form of OCD, which is made apparent when looking at what causes it. A study comparing BDD and OCD found that 8% of those with BDD have a family member who also has it, and family studies show that 7% of BDD patients have a first-degree relative who has been diagnosed with OCD. This link between the two can give an insight into risk factors of BDD or OCD - having a family member diagnosed with one puts you at higher risk of developing it or the other due to genetics.

Liz Atkin's. Credit
A disturbed dopaminergic system has been observed in BDD patients similar to OCD patients. Particularly in the caudate nucleus – an area that is implicated in “visual beauty” and aesthetics (!!!) – and the putamen which is theorised to be involved in the “hate” circuit which is responsible for feelings of disgust and contempt. These feelings and studies implicating these areas show that the basal ganglia is responsible for the pathophysiology of BDD, and that the disorder is based on extreme emotions – love and hate.
Quick Fact: The basal ganglia is a cluster of neurons responsible for motor control as well as motor learning, higher functions, behaviours and emotions. Learn more about it here!

In regards to neuroanatomy, less than a handful of studies have been conducted so there is very little literature on this, however an fMRI study focusing on facial recognition in BDD patients and control subjects found that those with BDD are a lot more detail orientated when looking at faces. This mechanism of recognising faces is interesting – BDD is a detail orientated disorder, even when the issues aren’t there or very obvious, the littlest things regarding self-image feel extreme, and that detail to attention is apparently projected onto other people when they look at them.
Eye Candy by Khrysta Lloren. Credit
Treatment is predominantly therapy based. BDD patients believe that having cosmetic surgery will relieve their symptoms and think that it is the best type of “treatment” – however this is how it began with Douvall – cosmetic treatments do not improve symptoms and can only get worse if procedures fail or the patient realises how easy it is to “fix” things with surgery. This brings into play the argument about cosmetic procedures and BDD – are cosmetic surgeons responsible for exacerbating symptoms and putting patients at risk for monetary gain? Or are they not in a position to dictate what someone can do with their body? One could argue that if they are to do it then they would be out of business – their entire job is to do cosmetic surgeries, something that is done as a choice for the patient, not out of medical obligation. It’s an ethical gray area; people go under the knife because they are unhappy with their looks, which is no different to what a person diagnosed with BDD wants, but it’s the idea of bodily autonomy that has people concerned – with BDD, the wants of that person is clouded and irrational, and something like a nose job may seem okay for a neurotypical person unhappy with their looks, may be a painful, unnecessary procedure for someone with BDD. Douvall has spoken out about the responsibilities of cosmetic surgeons and been heavily involved in calling for new regulations regarding cosmetic surgery; she’s stated that she wants to ‘slap’ her surgeon who allowed her to go through with the procedures, stating she regrets them and how women who visit cosmetic surgeons are already vulnerable as it is, and the surgeons themselves are just like car salesmen – selling easily to the vulnerable.

Real Monsters by Toby Allen. Credit
The other avenue of treatment is antidepressants - specifically SSRI's. Studies have found patients to respond to medications such as citalopram and fluvoxamine, showing an increase in quality of life and improvement of symptoms. This could help in understanding the underlying psychopharmacology of BDD - prospective future studies can focus on these treatment responses and the underlying neurotransmitter function as it's desperately needed in today's society where warped body image and poor self esteem is a risk for young, impressionable adolescents everywhere. However, treatment can only do so much and the biggest area that needs to be looked at is education. Many physicians are still not well educated on the disorder which leads to frustration and depression, and due to the cosmetic surgery aspect being such an ethical grey area at the moment it needs to looked at to create better guidelines when doing surgery on this vulnerable group.

BDD is not about vanity, it's an an irrational obsession with something that isn't there. It's more than just about "looking good" - it's a problem. A disease that needs to be taken more seriously by surgeons, GP's and mental health professionals.

What do you think? Are surgeons ethically responsible? Or are they not in a position to dictate what someone does to their body? 

Alicia Douvall released a book - "Don't Call Me Ugly" - spilling her heart out about her childhood, motherhood and stardom, all whilst battling body dysmorphic disorder. To get a copy, click here. Buying from my links helps me fund this blog and bring you quality content.

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