BDD presents as a preoccupation with an imagined defect in appearance; or if a slight anomaly is present, the individual's concern is excessive (American Psychiatric Association, 1994). BDD is also referred to as dysmorphophobia and 'dermatological non-disease' (Cotterill, 1981) in the dermatological literature. In one study 8.8% of patients with mild acne had BDD (Uzun et al., 2003). The complaints in BDD commonly involve imagined or slight flaws of the face or head such as thinning hair, acne, wrinkles, scars, vascular markings, paleness or redness of the complexion, swelling, facial disproportion or asymmetry, or excessive facial hair. The most common areas of concern involve the skin and hair. Some associated features of BDD include repetitive behaviours such as excessive grooming behaviour. This may manifest as excessive hair combing, hair removal, hair picking or picking of the skin, or ritualised make-up application. The main purpose of the repetitive behaviour is to improve or hide the perceived defect in the appearance. Many individuals may camouflage their perceived defect or deformity with make-up or clothing or hair. Most individuals with BDD experience marked distress over their supposed deformity and feelings of self-consciousness over their 'defect', which often leads to vocational and social impairment. In some instances BDD can be life threatening as patients may resort to extreme behaviours to deal with a perceived defect in their appearance, for example they may use razor blades or knives to remove these 'defects'. In some patients the preoccupation with a minimal or imagined 'defect' in appearance can reach delusional proportions.
Patients with eating disorders such as anorexia nervosa and bulimia nervosa often present with excessive concerns about their cutaneous body image in addition to concerns about their weight and shape (Gupta & Gupta, 2001a). The eating disorders can be associated with a wide range of dermatological (Gupta et al., 1987; Gupta & Gupta, 2000) complications related to starvation, bingeing and purging, abuse of laxatives and other related symptoms (American Psychiatric Association, 1994). Acne has a peak incidence during mid-adolescence, a life stage that is associated with a high incidence of eating disorders. In some vulnerable adolescents even mild acne may exacerbate or precipitate an eating disorder such as bulimia nervosa (Gupta et al., 1987; Gupta & Gupta, 2000). The endocrine changes associated with binge eating may cause a flare-up of acne (Gupta et al., 1992), which is frequently observed in patients with eating disorders (Gupta & Gupta, 2000). In these patients the disfigurement caused by the self-excoriation of acne lesions can serve as a 'protective device' or excuse for avoiding some of the social and vocational tasks of adolescence and young adulthood (Cotterill, 1981). Patients with acne excoriee des jeunes filles present with psychological dynamics that are very similar to the dynamics encountered in eating disorders such as difficulties in coping with the developmental tasks of young adulthood. The body image pathologies in conjunction with immature coping mechanisms often result in relatively intractable symptoms in the patients who use their skin lesions as a 'protective device' and a coping mechanism.
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