© Springer International Publishing Switzerland 2017Katlein França and Mohammad Jafferany (eds.)Stress and Skin Disorders10.1007/978-3-319-46352-0_11
11. The Role of Stress in Body Dysmorphic Disorder
Boston University School of Medicine, Boston Medical Center, 609 Albany St, Boston, MA 02118, USA
Boston University Center for Ethnic Skin, Cosmetic and Laser Medicine, Department of Dermatology, Boston University School of Medicine, Boston Medical Center, 609 Albany St, J602, Boston, MA 02118, USA
KeywordsBody dysmorphic disorderStressQuality of lifeSelf-perception
Body dysmorphic disorder (BDD), originally termed dysmorphophobia by Enrico Morselli in 1981, was derived from the Greek work dysmorphia, meaning ugliness, specifically of the face. While most would admit to having something they do not like about their appearance, those with BDD develop a persistent, intrusive preoccupation with an imagined or slight defect. They are compelled to perform repetitive and compulsive behaviors in response to concerns regarding their appearance. These compulsions can be behavioral, such as excessive mirror checking, or mental acts, such as comparing one’s appearance with that of other people. Many times, they are consumed by these preoccupations and compulsions, to the extent that it interferes with their daily functioning. Ninety-nine percent of subjects with BDD report that their symptoms interfere moderately or severely with social functioning, and 80 % report that they interfere with their occupational or academic functioning . Furthermore, approximately 30 % of patients with this disorder have been reported to be completely housebound for at least a week because of their symptoms [1, 2].
Despite reports of significant impairment in psychosocial functioning, there are a relatively small number of studies examining the impact of BDD on the quality of life. The first study evaluating quality of life in patients with BDD was published in 2000 . In this report, those with BDD were found to have notably poorer mental health-related quality of life when compared to the general population, as well as when compared to those with depression, acute medical conditions (recent myocardial infarction), and chronic medical conditions (type II diabetes mellitus). The outcomes of this study were not explained by concomitant depressive symptoms in those with BDD.
These findings were confirmed in a subsequent, larger sample study, evaluating similar quality of life measures, in addition to psychosocial functioning . Those with BDD had very poor scores across all functioning and mental health domains, including psychological distress, emotional well-being, work, school, role activities, leisure activities, household functioning, all components of social functioning (friends, extended family, parental, family unit, and primary relationship), and life satisfaction. A remarkably high proportion of subjects were unemployed (36 %), and 79 % considered BDD as their most problematic disorder. Likewise, another study demonstrated that those with BDD had lower income, less likelihood of living with a partner, and higher unemployment rate than the general population [5, 6].
On comparison to those with other body-image disorders such as anorexia nervosa (AN) and bulimia nervosa (BN), BDD was still found to have a more negative impact on quality of life, as measured using the body image quality of life inventory [6, 7]. Similarly, an evaluation of admitted adolescent inpatients at a psychiatric hospital demonstrated that one-third had a body image disorder, and these patients had significantly higher levels of depressive and anxiety symptoms compared to adolescents with other psychiatric disorders . Not surprisingly, individuals with BDD have been shown to have high levels of perceived stress, with perceived stress scores 2.3 SD units higher (i.e. worse) than a large national probability sample .
The reported poor quality of life and high perceived stress have translated to devastating statistics. These patients have been found to have high rates of psychiatric hospitalization (48 %), suicidal ideation (45–82 %), and suicide attempts (22–24 %) [1, 10]. Another study also found that those with BDD have higher rates of suicidal ideation and suicide attempts when compared to the general population (31 % vs. 3.5 % and 22 % vs. 2 %, respectively) .
Association Between Early Stress and the Development of BDD
Despite the strong association between BDD and impaired psychosocial functioning, greater perceived stress, and reduced quality of life, a question arises as to whether these individuals also have greater underlying stressors or traumatic experiences that may contribute to the development of BDD.
A semi-structured interview was conducted on 18 patients with BDD and 18 normal controls, between the ages 17 and 49 years . It was found that those with BDD tended to have significantly more spontaneously occurring images that were negative, recurrent, and viewed from the observer perspective than the normal participants. That is, they were more likely to report distressing images related to being bullied or teased because of their appearance. This suggests that negative self-images may have developed early on in these individuals, thereby contributing to the development of BDD symptoms.
Beyond childhood events related specifically to appearance, early traumatic or stressful experiences in general, have been also shown to serve as risk factors in the development of BDD. The majority of those with BDD reported a history of childhood mistreatment (79 %), which included emotional neglect (68 %), emotional abuse (56 %), physical abuse (35 %), physical neglect (33 %), and sexual abuse (28 %) . Further, all patients suggested that their traumatic experience preceded their BDD symptoms.
Another study also showed that on comparison with normal controls, individuals with BDD were more likely to experience traumatic events in childhood or adolescence. They reported significantly more physical and sexual abuse and a trend towards a higher rate of emotional abuse compared to controls . A possible explanation for the association between early-life traumatic experiences and the development of BDD may be extrapolated from the experiences of survivors of sexual abuse. Survivors of sexual abuse have been shown to have a distorted view of their body, especially the body part that they associate with the abuse and often develop general dissatisfaction, shame, and hatred towards that body part [13–15]. As such, it can be hypothesized that early-life traumatic experiences may shape a person’s negative core belief, instilling feelings of inferiority and deficiency, and thereby contributing to a negative perception of their appearance. This may in part explain the high rate of suicide attempts among those with BDD. In addition to the distress of the BDD symptoms themselves, it is recognized that individuals with a traumatic history are also more likely to have attempted suicide .
Among the various environmental influences, the family arguably has the most profound impact on a child’s development. One review specifically examined the family environment in pediatric populations with obsessive-compulsive and related disorders . Disorders considered to be in the obsessive-compulsive spectrum include BDD, trichotillomania (hair pulling disorder), skin picking disorder, and hoarding. A strong relationship was demonstrated between obsessive-compulsive disorders (OCD) and poor parental mental health, with greater symptoms of anxiety, stress, and depression in parents of those with OCD. In addition, parenting styles tended to induce conflicting control beliefs in children (i.e. perceived low levels of control over one’s life coupled with a desire for increased control). Further, there was a correlation between OCD and family dynamics (low family cohesion, family violence, and distress), familial emotional climate (higher levels of parental guilt, worry, and anger), and low levels of parental warmth. Again, these findings suggest that early-life experiences, especially within the family unit, are extremely important in a child’s cognitive and behavioral development. Further, negative or stress-inducing environments seem to increase the likelihood of developing obsessive-compulsive and related disorders.