Debilitating Body Image Disorder Often Begins In Teens; Likely To Be Missed

March 24, 1999

PROVIDENCE, R.I. -- Teen-agers' concerns with their appearance should not be dismissed lightly. The image obsession known as body dysmorphic disorder (BDD) typically begins in young people and left untreated may lead to impairment in functioning and even to suicide attempts, according to a new study by Brown University researchers, the largest study ever conducted on this age group.

In an analysis of 33 children and adolescents diagnosed with BDD (a preoccupation with nonexistent or slight defects in appearance), 94 percent reported impairment in social functioning; 39 percent had been hospitalized; and 21 percent had attempted suicide.

A specific class of antidepressants - serotonin reuptake inhibitors - proved effective in reducing the BDD symptoms for 53 percent of the participants who took them, said study authors Ralph S. Albertini, M.D., and Katharine A. Phillips, M.D., in the April Journal of the American Academy of Child & Adolescent Psychiatry.

The study consisted of 30 females and three males, aged 6 to 17. It is estimated that BDD begins before age 18 in 70 percent of cases, most commonly at age 13. The subjects had been referred for evaluation and treatment to a BDD clinical and research program at Butler Hospital in Providence, R.I., by community therapists, parents or by themselves.

Sixty-one percent of bodily preoccupations focused on the skin; 55 percent on hair; 48 percent on weight; 39 percent on the face; 30 percent on teeth; 27 percent each on legs and nose. All body parts of concern to the subjects appeared to the interviewers to be normal or to have only minimal anomalies.

Most participants spent more than three hours a day thinking about their perceived defects; some said it was all they thought about. Many avoided making friends and dating. Eighty-five percent reported the disorder interfered with academic performance, with those at the extreme end - 18 percent - having dropped out of school. One middle school student had missed more than 100 days of the previous school year because of BDD.

All subjects had associated compulsive behaviors - most often camouflaging the perceived defect with clothes, makeup, or a hat or repeatedly checking mirrors and other reflective surfaces. One patient asked, "Mom, do you think the gap between my front teeth has gotten any wider?" up to 30 times a day.

About half of 19 subjects treated with serotonin reuptake inhibitors experienced a decrease in preoccupation, distress and compulsive behavior and reported improved functioning, researchers found. Subjects responded to the antidepressants after four to 16 weeks of treatment. Many were able to resume normal activities with peers and improve school attendance. Other psychiatric treatments, undertaken by 55 percent of the participants, were generally ineffective, and 36 percent of subjects who received surgical treatment for their perceived flaws had no improvement in symptoms.

Diagnosis of BDD in young people often requires inquiries about specific BDD symptoms because young people are often too embarrassed to divulge them, say the researchers. For example, it may be worthwhile for parents and medical personnel to ask "Is there some aspect of your appearance that you're really unhappy about?" Concerns about appearance are not sufficient for diagnosis unless they cause significant distress or impairment in functioning. "The problem is that adolescence is when this usually begins and it's not being picked up... people see it and trivialize it," said Phillips. "This is not just a phase."

Larger studies on children and adolescents with BDD, including treatment studies with control groups, now need to be done, say researchers. Studies that use a community sample would likely have a more balanced sex ratio than this study. The imbalance likely occurred because patients were recruited from a psychiatric population.

The study was supported by an unrestricted grant from Solvay Pharmaceuticals. Albertini, clinical assistant professor of psychiatry, and Phillips, associate professor of psychiatry, have faculty appointments in the Brown University School of Medicine.
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Brown University

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