Complications
BDD is associated with high rates of suicidality (approximately 80% lifetime suicidal ideation, 24% to 28% lifetime suicide attempts).[95] Suicidality appears to be more common in BDD than in a range of other severe psychiatric disorders, including major depression, bipolar depression, obsessive-compulsive disorder, eating disorders, and post traumatic stress disorder.[59][60] The rate of completed suicide is markedly elevated (although data are very limited).[50]
Regarding suicidality in youth, in an inpatient study adolescents (ages 12-17 years) with BDD had more severe anxiety and depression and significantly higher scores on a standardized measure of suicide risk than adolescents without significant body image concerns.[96] And in two independent twin samples (n=6,027 and n=3,454), BDD was associated with a substantial risk of suicidal ideation and behaviors in late adolescence and early adulthood.[97]
More severe BDD, more severe depression, substance use disorder, and other factors are associated with increased suicidal ideation and/or suicide attempts in BDD.[95] Ongoing monitoring of suicidality is needed. Effective selective serotonin-reuptake inhibitor (SSRI) treatment decreases and protects against suicidal ideation in adults with BDD.[75][76] This has not been studied in children and adolescents with BDD; clinical observations indicate that suicidality in children and adolescents usually decreases with effective SSRI treatment. SSRI manufacturers warn that antidepressants may increase the risk of suicidal thoughts and behavior in children, adolescents, and young adults. Closely monitor all patients started on SSRIs for the emergence of or worsening of suicidal thoughts and behaviors, and advise families and caregivers of the need for close observation.
For high levels of suicidal ideation, the addition of an atypical antipsychotic such as aripiprazole early in the course of an SSRI trial might reduce suicidality (but this has not been studied). Cognitive behavioral therapy focused on suicidality may be helpful.[98] Psychiatric hospitalization may be needed.
Surgeons, dermatologists, obstetricians-gynecologists, and other medical specialists who provide aesthetic treatment should screen for BDD in their patients. When BDD is identified, aesthetic/cosmetic treatment should not be offered, because it is virtually never effective for BDD.[35][36][99] Instead, provide psychoeducation about BDD, and refer the patient to a mental health professional who is knowledgeable about BDD. There is a risk of legal action and violence against providers of cosmetic treatment. In a survey of surgeons who had provided cosmetic surgery for patients with BDD, 40% reported that they had been threatened legally, physically, or both legally and physically by a dissatisfied patient with BDD.[36]
Levels of psychosocial functioning vary in patients with BDD, but virtually all experience at least moderate impairment in functioning due to BDD symptoms. On average, psychosocial functioning and quality of life are poor. Patients typically experience impairment in social, academic, work, or other role functioning. Reasons include time-consuming and distracting appearance preoccupations and repetitive behaviors (rituals), not wanting to be seen by other people, and believing that others take special notice of them in a negative way because of how they look. Patients with BDD may be unable to work, drop out of school, and be housebound because of BDD symptoms. Children and adolescents with more severe BDD may experience delays in psychosocial development, especially if they drop out of school and avoid social interactions. More severe BDD symptoms are associated with poorer psychosocial functioning and quality of life.[32]
About 75% of people with BDD experience past or current major depressive disorder. It is the most common comorbid disorder.[101] It can be difficult to determine the relationship of depressive symptoms to BDD symptoms with certainty. However, many patients state that they are depressed because of their BDD symptoms, which typically cause significant emotional distress, difficulty functioning, and suicidal thinking. In addition, onset of BDD usually precedes onset of major depressive disorder.[101] In a prospective follow-up study, BDD had significant longitudinal associations with major depression – that is, change in the status of BDD and major depression was closely linked in time, with improvement in major depression predicting BDD remission, and, conversely, improvement in BDD predicting depression remission.[102] With effective treatment for BDD (medication or cognitive behavioral therapy), depressive symptoms usually improve or fully remit.[69][79]
Because BDD involves distorted body image, rather than being a problem with actual appearance, most patients with BDD are dissatisfied with the outcome of cosmetic treatment.[100] Following cosmetic treatment, a minority of patients are less preoccupied with the treated body part, but in these cases overall BDD virtually never improves (because, for example, dissatisfaction with other body areas remains or because dissatisfaction with a new body area develops).[35] Some patients are initially satisfied with the outcome of cosmetic treatment but over time become increasingly dissatisfied.[99] In a minority of cases, BDD becomes more severe following cosmetic treatment.[35] This can cause increased suicidality, need for psychiatric hospitalization, or threats against the surgeon, dermatologist, or other cosmetic treatment provider.
Around 30% to 50% of people with BDD have a lifetime substance use disorder.[39][101] Misuse of alcohol and cannabis are most common.[103] The muscle dysmorphia form of BDD has an even higher rate of comorbid substance use disorders (85%); this includes abuse of or dependence on anabolic androgenic steroids, which may have serious adverse psychiatric and physical effects.[42] Substance use disorders in BDD are associated with a higher rate of suicide attempts, and they can interfere with effective BDD treatment.[39] Nearly 70% of individuals with BDD report that their BDD symptoms have contributed to their substance use disorder.[103] About half report that they use alcohol or illicit drugs because their body image concerns are upsetting, to forget about their body image concerns, or to feel more comfortable about their appearance when around other people.[46][104] Compared with community norms, endorsement of drinking to cope with negative affect is more elevated in people with BDD than drinking to enhance positive affect or sociability.[46] For both illicit drug and alcohol use, coping motives are significantly associated with suicide attempts.[46][104]
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