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Aetiology of body dysmorphic disorder

Socio-cultural factors

There has been little systematic research into the social and cultural factors associated with the development of body dysmorphic disorder. However, given the importance placed on physical appearance in society, it is not unreasonable to suspect that societal beliefs and attitudes have a role to play. There is certainly evidence that the media can infl uence our perceptions of what is healthy and attractive: attitudes that may differ across cultures. An example of this can be found in an increasing desire for muscularity among European and American males rarely reported by men from Far Eastern countries. Yang et al. (2005) speculated that these differences may arise because European and American magazines frequently portray undressed and muscular men. In Far Eastern countries, this occurs much less frequently. Despite these societal infl uences, most people do not become as obsessed or concerned about their appearance as people with body dysmorphic disorder. Other factors may give rise to a specifi c vulnerability to such infl uences, although what contributes to this vulnerability is largely speculative at present.

Psychoanalytic models

A psychoanalytic view suggests that body dysmorphic disorder arises from an individual’s unconscious displacement of sexual or emotional confl ict or feelings of guilt and poor self-image to specifi c parts of the body (Sobanski and Schmidt 2000). The displacement is thought to occur because the underlying problem is so threatening to the ego that it is unconsciously displaced into the more psychologically manageable issue of appearance. The body part of concern, such as the nose, may represent another, more emotionally threatening, body part, such as the penis (Phillips1996a).

A psychological model

Rosen (1996) suggested a key factor in the development of body dysmorphic disorder involves critical events or traumatic incidents that involve an individual’s appearance. The most common example is being teased about weight or size (Buhlmann et al. 2007), with many people with body dysmorphic disorder reporting repeated criticism about their appearance from members of their own family. More general vulnerability factors may involve being neglected as a child, leading to feelings of being unloved, insecure and rejected (Phillips 1991). Other trauma, such as sexual abuse or assault, may also be involved. Many people with body dysmorphic disorder also report having experienced a physical injury or illness. According to Rosen, these critical events activate dysfunctional assumptions about the normality of physical appearance and the implications of appearance for self-worth and acceptance. In one exploration of this phenomenon, Osman et al. (2004) conducted a semi-structured interview with people with body dysmorphic disorder and ‘normal’ controls.

During the interview, the people with body dysmorphic disorder evidenced more spontaneously occurring negative appearance-related images than did control participants. These images were linked to early stressful memories. Once established, the disorder may be maintained by selective attention to perceived physical problems or information that supports this belief. In addition, Rosen suggested that rehearsal of negative and distorted self-statements about physical appearance results in them becoming automatic and believable. Finally, the positive emotional responses associated with avoidance, checking and reassurance-seeking behaviours reinforce and maintain the condition. Buhlmann et al. (2006) provided experimental evidence of some of the cognitive distortions held by many people with body dysmorphic disorder. In their study, people with body dysmorphic disorder and a ‘normal’ control group completed two questionnaires accompanying facial photographs of people in various everyday situations. One questionnaire included self-referent scenarios (‘Imagine that the bank teller is looking at you. What is his facial expression like?’); the other included other-referent scenarios (‘Imagine that the bank teller is looking at a friend of yours  .  .  .’). They were asked to identify the emotion evident in each face. Overall, people with body dysmorphic disorder had more diffi culty identifying emotional expressions in selfreferent scenarios than did the comparison group. They also misinterpreted more expressions as contemptuous and angry in self-referent scenarios than did controls.

Biological explanations

There have been relatively few studies of the biological underpinning of body dysmorphic disorder. The role of serotonin has been implicated in its aetiology as a result of its similarities with obsessive-compulsive disorder and its successful treatment with SSRIs. Data from two case reports also provide some relevant evidence. Barr et al. (1992) noted a dramatic increase in symptoms after a woman was placed on a diet low in tryptophan (a serotonin precursor). Similarly, Craven and Rodin (1987) reported a signifi cant worsening of symptoms following the chronic abuse of a drug known as cyproheptadine, which reduces the uptake of serotonin at the postsynaptic receptors and can be used to treat serotonin toxicity.

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