Clinical features

Individuals with BDD are preoccupied with a perceived or minor defect in one or more aspects of their appearance. The most common preoccupations concern the hair, nose and skin (e.g., balding, misshapen nose, acne, or skin tone), but any body part can be the focus of concern. Whilst BDD appears to affect women and men roughly equally, women with the condition are particularly likely to be concerned about weight, hips, breasts and excessive body hair (Phillips, Menard, et al., 2006). Some concerns are specific, while others are vague or amount to no more than a general perception of ugliness. The mean number of reported appearance concerns can range from five to seven (Phillips, Menard, et al., 2005). However, this average may be an underestimate, as most patients are too embarrassed or reluctant to disclose specific appearance concerns. The nature of preoccupations can fluctuate over time, either with the addition of defects or substitution of defects (Fontenelle et al., 2006). The preoccupations are typically difficult to resist or control and, on average, consume 3 to 8 hours daily.

Almost all people with BDD perform compulsive behaviors that serve to examine, improve or hide their perceived defect. Checking the defect in mirrors and other reflective surfaces occurs in almost all patients with BDD, while the remainder will periodically avoid mirrors to try to prevent the distress of seeing their own reflection and the time consumed when using them (Veale & Riley, 2001). Other common behaviors are comparing one’s appearance with that of others, touching the body area of concern, excessive grooming, seeking reassurance about the perceived flaw or trying to convince others of its unattractiveness and camouflaging the perceived defect with makeup or clothing (Grant et al., 2006). These behaviors typically occur for several hours a day and are difficult to resist or control. Skin picking can also occur in BDD, notably in women, and usually with a desire to achieve “perfect flat skin.” However, these behaviors can lead to skin lesions and infections that are truly unsightly (Castle et al., 2004; Phillips, 2004).

Epidemiology

Because of the lack of large‐scale epidemiological studies, exact prevalence rates for BDD remain unclear. Rief and colleagues (2006) administered a self-report diagnostic measure to a large, representative sample of the German population (N = 2,552) and reported a prevalence rate of 1.7%. In a large United States (US) nationwide prevalence study (N = 2,513), Koran et al. (2008) reported a BDD prevalence rate of 2.4%. In other large community samples, reported rates of BDD were 0.7% (Italy; Faravelli et al., 1997), 1.1% (US; Bienvenu et al., 2000), 0.7% in women aged 36 to 44 (US; Otto et al., 2001) and 2.3% in adolescents (US; Mayville et al., 1999).

In psychiatric settings, reported rates of BDD range from 3.2% to 16.0% (Conroy et al., 2008; Grant et al., 2001; Zimmerman & Mattia, 1998). In these settings, however, BDD is often underdiagnosed or underrepresented because individuals are secretive about their symptoms because of embarrassment or shame (Phillips, 1998). Zimmerman and Mattia (1998), for example, noted that clinicians failed to recognize the 16 (3.2%) of 500 consecutive psychiatric outpatients who fulfilled diagnostic criteria for BDD, despite 11 of them indicating that their BDD symptoms were one of the reasons they were seeking treatment. Comparable results were reported by Grant et al. (2001), who found that although 13.1% of one sample of psychiatric inpatients (N = 122) fulfilled criteria for BDD, these patients reportedly did not disclose their BDD symptoms to the clinician unless specifically asked.

Another factor contributing to underdiagnosis of the disorder is that individuals with BDD tend to consult dermatologists, cosmetic surgeons or dentists, rather than seeking psychiatric assistance (Crerand et al., 2006; Sarwer et al., 1998). This trend is highlighted in reported prevalence rates of BDD ranging from 3.2% to 16.6% in cosmetic surgery settings (Altamura et al., 2001; Aouizerate et al., 2003; Bellino et al., 2006; Crerand et al., 2004; Sarwer et al., 1998; Vulink et al., 2006) and from 8.5% to 15% in dermatologic settings (Bowe et al., 2007; Dufresne et al., 2001; Phillips et al., 2000; Uzun et al., 2003; Vulink et al., 2006).

Dermatological, cosmetic and other nonpsychiatric procedures, however, do not appear to improve BDD symptoms. Crerand et al. (2005) found that non-psychiatric treatment was sought by 71% and received by 64% of 200 patients with BDD. However, 91% of individuals receiving such treatments did not experience any improvement in their overall symptoms of BDD. Phillips et al. (2001) similarly reported that although non-psychiatric treatment was sought by 76.4% and received by 66.0% of 289 patients with BDD, these treatments rarely improved BDD symptoms. Indeed, most patients with BDD who do undergo cosmetic procedures are unhappy with the outcome, often returning for repeat procedures and/or suing, threatening or even murdering the cosmetic surgeon (Sarwer & Crerand, 2008)!

Course of the illness

For both women and men, the age of onset of BDD is typically late adolescence at 16 to 18 years of age (Phillips, Grant, et al., 2005), but subclinical BDD (i.e., dislike of one’s appearance) can begin at 12 to 14 years of age (Phillips, Menard, et al., 2005) or even earlier. BDD tends to follow a chronic and deteriorating course. Phillips and Diaz (1997), for example, asked 188 patients with BDD to describe retrospectively the course of their BDD symptoms. The mean duration of BDD was 15.7 years (SD = 11.9). In most patients (82%), BDD was found to have a chronic course, with less than 1 month of remission since the onset of the disorder, and almost half of all patients experiencing a deteriorating course of the disorder (49.5%).

In another retrospective study, Phillips et al. (2005) assessed the status of 95 outpatients with BDD by chart review at 6-month intervals over 4 years. At the 6‐month and/or 12‐month assessments, 24.7% of patients had achieved full remission and 57.8% attained partial of full remission. Over the full 4 years, 58.2% of patients reported full remission and 83.8% had experienced partial or full remission at one or more 6‐month assessment points. However, 28.6% of those patients who attained partial or full remission at one or more assessment points had relapsed. At the conclusion of the study, 16.7% of patients were in full remission, 37.8% were in partial remission and 45.6% still met full criteria for BDD. However, the limitations of this study are that retrospective chart review methods were used and that patients received treatment in a BDD specialty program, potentially limiting the ability to generalize these findings to other treatment settings.

Recognizing this limitation, Phillips et al. (2006) prospectively investigated the course of symptoms for 183 patients with BDD over 12 months. Over two-thirds of the sample were women. Over this timeframe, 9% of patients experienced full remission (i.e., minimal or no BDD symptoms) and 21% experienced partial remission (i.e., meeting less than full diagnostic criteria for at least 8 consecutive weeks). The mean proportion of time that the patients met full BDD criteria during the 12‐month period was 80%, despite most patients receiving mental health treatment during the follow‐up period.

Comparable results were reported by Phillips et al. (2005) in their prospective study of the course of symptoms for 161 patients with BDD over 12 months. Patients with BDD who received psychiatric treatment did not have a greater likelihood of remitting from BDD than those who did not. However, greater BDD severity at intake, longer BDD duration and the presence of a comorbid personality disorder predicted a lower likelihood of remission.

In sum, BDD tends to onset in childhood or adolescence, has a mean duration of about 16 years and remission rates of the disorder are low. The remission rates may not differ between those patients receiving psychiatric treatment for their BDD symptoms and those who are not. However, these rates may be influenced by the severity of and duration of BDD symptoms, and comorbidity with a personality disorder.

BDD in women

Although there are similar BDD prevalence rates for women and men in adult clinical samples, several gender differences in BDD phenomenology have been reported. Phillips and Diaz (1997) examined gender differences in 93 female and 95 male patients with BDD. Men were more likely than women to be concerned with thinning or balding, their genitals and their body build (e.g., muscularity), while women were more likely to be preoccupied with their weight, hips and excessive body hair. Women are also more likely to pick their skin and use cosmetics on their hands for camouflage, whereas men were more likely to use a hat for camouflaging their hair concerns.

Comparable results were reported by Phillips et al. (2006) in their investigation of gender differences in 137 female and 63 male patients with BDD. Women were more likely to have a younger age of subclinical BDD onset than men. Males were more likely to be concerned with their genitals, body build and thinning or balding hair. Females were more likely to be preoccupied with their skin, stomach, weight, breasts, buttocks, thighs, legs, hips, toes and excessive body hair. Women were also more likely to check mirrors excessively, change their clothes often and pick their skin, whereas men were more likely to lift weights excessively.

In sum, women with BDD tend to have an earlier age of subclinical BDD onset and to be preoccupied with their skin, stomach, weight, breasts, buttocks, thighs, legs, hips, toes and excessive body hair. They are also likely to engage in mirror checking, clothes changing and skin picking; and to use cosmetics to camouflage their perceived appearance flaws.

Clinical features

According to DSM-5, AN is characterized by three criteria: restriction of energy intake relative to requirements, leading to significantly low body weight; the experience of intense fear of weight gain or persistent behavior that interferes with weight gain; and a disturbance in the experience of one’s body weight or shape, or a persistent lack of recognition of the seriousness of the current low weight (American Psychiatric Association, 2013). Two subtypes of AN are delineated, namely a restricting type (AN-R) and a binge-eating purging (AN-BP) type (American Psychiatric Association, 2013). AN-R is distinguished by weight loss accomplished through dieting, fasting and/or excessive exercise, and not through regular engagement in purging (American Psychiatric Association, 2013). In contrast, AN-BP is characterized by regular binging and/or purging aiming to achieve and retain low body weight. The method of purging can take the form of self-induced vomiting, or the misuse of laxatives, diuretics or enemas (American Psychiatric Association, 2013). Though AN can be categorized into these two subtypes, the distinction is not always clear and individuals with AN often alternate between the two over the course of the illness (Eddy et al., 2008a). Individuals with AN are also likely to transition to or from BN, usually within the first 5 years of the illness (Tozzi et al., 2005).

Epidemiology

In 2011, an annual survey carried out by Mission Australia (2011), the National Survey of Young Australians, collected information from close to 46,000 young people aged 11–24 years. The results from the survey indicated that body image concerns were one of the top three issues of personal concern for young people, with 33.1% of respondents expressing the concern, an increase of 7.6% over the previous 3 years. Though body image concerns appear to be on the increase, the incidence of AN does not appear necessarily to be following this trend (Fombonne, 1995; Pawluck & Gorey, 1998). Various studies have reported an increase in the incidence of AN in recent times (Eagles et al., 1995; Hoek, 2006; Hoek & Van Hoeken, 2003; Lucas et al., 1991), particularly for those aged in their 20s and 30s (Pawluck & Gorey, 1998), though the authors do not discount other plausible explanations such as increasing awareness of the condition and improved case detection. However, a comprehensive review of the literature conducted by Hoek & Van Hoeken (2003) reported the incidence of AN increased over the past century until the 1970s, but has since remained relatively stable. Incidence and prevalence rates can also be difficult to estimate due to the nature of the condition as AN is often associated with a high level of denial about the illness and individuals with the condition often do not seek medical attention independently (Strober, 2004; Vandereycken, 2006). Furthermore, incidence rates based on admissions into mental health care or general hospitals may not truly reflect the incidence of AN in the community (Hoek & Van Hoeken, 2003).

The 12-month prevalence of AN is 0.4% among females and approximately one-tenth of that among males (American Psychiatric Association, 2013). The crude mortality rate of individuals admitted into university hospitals with AN is around 5% per decade and is most commonly due to medical complications associated with the physical consequences of the condition or from suicide (American Psychiatric Association, 2013). This is among the highest mortality rate of any psychiatric disorder (Harris & Barraclough, 1998; Sullivan, 1995). The prevalence of AN appears to be much greater in individuals with an upper or upper-middle social status (Crisp et al., 1976; McClelland & Crisp, 2001), and in industrialized societies where there is an abundance of food and where a slim physique is promoted as an attractive physical trait (Keel & Klump, 2003; Miller & Pumariega, 2001). Although AN may be more prevalent in Western cultures, the condition is not only seen in societies promoting a thin ideal, having been described in countries such as Kenya and Iran (Buhrich, 1981; Lee, 1991; Njenga & Kangethe, 2004; Nobakht & Dezhkam, 2000).

Course of the illness

Though the onset of the AN can occur at any age, the typical age of onset is in mid to late adolescence, and rarely occurs in individuals over 40 years (American Psychiatric Association, 2013; Lucas et al., 1991). Within the first few years of onset, many individuals alternate between the AN-R and AN-BP subtypes, with many shifting to the diagnosis of BN (Eddy et al., 2008a; Eddy et al., 2002; Tozzi et al., 2005). There is great variability in the course and outcome of AN, with some individuals making a full recovery after a single episode, others fluctuating between weight gain and relapse, others who experience the illness chronically over many years, yet others who die from the physical consequences of the illness or suicide (Norring & Sohlberg, 1993; Steinhausen, 2002; Strober et al., 1997). Additionally, AN is associated with exceptionally high relapse rates (Eckert et al., 1995; Löwe et al., 2001; Norring & Sohlberg, 1993; Strober et al., 1997; Zipfel et al., 2000). A major contributing factor for the high rates of morbidity and mortality experienced by individuals with this condition is that the cause or causes of the illness are not clear, and although treatment modalities such as cognitive behavior therapy and family therapy have emerging evidence for efficacy, many patients remain under- or unresponsive.

Clinical features

BN is characterized by the experience of recurrent episodes of binge eating and recurrent inappropriate compensatory behavior to prevent weight gain, both of which occur on average at least once a week for 3 months; self-evaluation influenced unduly by body shape and weight; and the disturbance does not occur during an episode of AN (American Psychiatric Association, 2013). Unlike AN, individuals with BN are not typically underweight and usually fall within the normal weight or overweight body ranges (American Psychiatric Association, 2013).

Epidemiology

Like AN, the incidence and prevalence of BN can be difficult to estimate because of the concealing nature of the condition and their avoidance in seeking treatment. Whether rates of BN have been on the rise in the last several years is also difficult to establish, in part as a result of its late inclusion as a diagnostic category in 1980. However, the incidence of BN had been found to be decreasing between 1980s and 1990s to approximately 6.6 per 100,000 from incidence rates as high as 13.5 per 100,000 (Currin et al., 2005; Hoek et al., 1995; Soundy et al., 1995). Yet, the incidence of BN may actually be higher than reported in epidemiological studies as a large majority of individuals with the condition may never seek treatment (Hudson et al., 2007).

The 12-month prevalence of BN is 1–1.5% among young women, and like AN, the prevalence among men is approximately one-tenth of that among women (American Psychiatric Association, 2013). The crude mortality rate of BN is somewhat lower than in AN at approximately 2% per decade (American Psychiatric Association, 2013). The incidence of BN is higher in industrialized areas (Hoek et al., 1995), typically affecting more individuals from Western cultures (Makino et al., 2004), particularly Caucasian people (Striegel-Moore et al., 2003).

Course of the illness

BN is similar to AN with the onset typically during adolescence or young adulthood and rarely before puberty. Increasingly, women are presenting in later adulthood after the age of 40 (American Psychiatric Association, 2013). The binge-eating behaviors often begin during or following an episode of dieting (American Psychiatric Association, 2013). The course of the illness may be chronic or intermittent with many patients alternating between remission and recurrences of illness symptoms. Relapse rates as high as 43% have been reported and rates as high as 67% have been reported for individuals who continue to meet diagnostic criteria for BN at long-term follow-up (Keel & Mitchell, 1997). Furthermore, a small percentage will transition into AN, though this crossover occurs much less frequently than the transition from AN to BN (Eddy et al., 2008b; Tozzi et al., 2005).

Clinical features

BED is characterised by recurrent episodes of binge eating, where an “episode” is described as eating an amount of food within a discrete period of time (usually less than 2 hours) that would be considered considerably larger than what most people would eat in a similar period of time and in similar circumstances; importantly, this behavior is associated with a sense of lack of control over eating during the episode. Episodes are also associated with three or more of the following features: eating much more rapidly than normal; eating until feeling uncomfortably full; eating large amounts of food when not feeling hungry; eating alone because of embarrassment about how much one is eating; feeling depressed and very guilty or disgusted with oneself following the binge. The individual experiences marked distress from the binge eating and the binge eating occurs at least once a week for 3 months. The binge eating is also not associated with inappropriate compensatory behavior as in BN, and does not exclusively occur during a course of BN or AN (American Psychiatric Association, 2013). BED typically occurs in healthy-weight, overweight and obese individuals, but is distinct from obesity per se as most obese individuals do not partake in recurrent episodes of binge eating (American Psychiatric Association, 2013).

Epidemiology

The 12-month prevalence of BED among US adults is 0.8% among men, half the rate of that among women at 1.6% (American Psychiatric Association, 2013). Unlike AN and BN, BED does not appear to have a higher prevalence among Caucasian women from Western cultures, but may occur equally among diverse racial and ethnic groups (Striegel-Moore & Franko, 2003; Grucza et al., 2007).

Course of the illness

As BED has only recently received official recognition in the DSM-5, it is the most understudied of the eating disorders and relatively little is known about the course of the illness. However, like the other eating disorders, BED typically begins in adolescence or young adulthood (Mitchell & Mussell, 1995; Spurrell et al., 1997). It is a relatively persistent condition, with an illness course, severity and duration similar to that of BN, though remission rates are considerably higher than BN or AN, with a greater tendency to be episodic in nature (Fairburn et al., 2000). Unlike the crossover often reported between AN and BN, the crossover from BED to the other eating disorders in uncommon (American Psychiatric Association, 2013).