Body Dysmorphic Disorder Criteria May Expand

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SAN FRANCISCO -- Three criteria for diagnosing body dysmorphic disorder could increase to four under a proposal aimed at requiring that the patient demonstrate repetitive behaviors or mental acts in response to appearance concerns at some point during the course of the disorder.

Acts such as mirror checking, excessive grooming, skin picking, or reassurance seeking would be considered repetitive behaviors. "Mental acts" could include comparing one's appearance with that of others, Dr. Katharine A. Phillips said at the meeting.

The proposed change for the fifth Diagnostic and Statistical Manual of Mental Disorders (DSM-5) would retain the three existing criteria for body dysmorphic disorder. The first criterion is a preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person's concern is markedly excessive. Second, the person's preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Third, the preoccupation is not better accounted for by another mental disorder (such as anorexia nervosa, which involves dissatisfaction with body shape and size), said Dr. Phillips, director of the Body Dysmorphic Disorder Program at Rhode Island Hospital, Providence.

The diagnosis matters because the disorder is common and very distressing, markedly impairing a person's functioning and quality of life, said Dr. Phillips, also professor of psychiatry and human behavior at Brown University, Providence.

The prevalence of body dysmorphic disorder has been reported as about 2% in nationwide epidemiologic studies, 2%-13% in nonclinical student samples, and 13%-16% in psychiatric inpatients. Suicide attempts occur in 24%-28% of people with body dysmorphic disorder. Preliminary, unpublished data from Dr. Phillips and her associates suggest that the annual rate of completed suicides is 22-36 times higher among people with this disorder compared with the general population, she said.

The disorder most commonly first appears at 13 years of age. "Impulsivity and distress can quickly lead to a suicide attempt," she said. It might be equally common among males and females, or somewhat more common in females.

The obsessional, distressing preoccupation with appearance can focus on any body area but most often involves the skin, hair, and nose. Patients find it difficult to resist or control the preoccupation with appearance, which consumes 3-8 hours of their attention each day, on average. They spend much of this time in ritualistic behaviors such as checking mirrors, excessive grooming, camouflaging their alleged defect, skin picking, comparing themselves to others, and seeking reassurance about their appearance.

Accounts of body dysmorphic disorder have surfaced from around the world for more than a century, but there is little research to guide management, Dr. …