A proposal for the inclusion of ‘obesity dysmorphia’ in the Diagnostic and Statistical Manual of Mental Disorders

Obesity is a heterogeneous condition with a complex and incomplete etiology; however, there is growing evidence for considering the salience of obesity for the psychiatric nomenclature. Currently, the Diagnostic and Statistical Manual of Mental Disorders (DSM; American Psychiatric Association, 2013) does not adequately categorize individuals with marked distress in relation to quantifiable aesthetic concerns such as obesity. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) acknowledges that weight is related to several psychiatric conditions, but its authors appear reluctant to be drawn into the debate as to whether obesity is, in its own right, a psychiatric disorder. We agree that there is currently insufficient evidence that would allow for obesity to be included in the DSM, but we would argue that obesity has numerous psychiatric comorbidities, one of which we advocate reflects a similar condition to that of body dysmorphic disorder (BDD). We therefore propose a new term ‘obesity dysmorphia’ (OD), which comprises individuals who are overweight or obese who report disabling dissatisfaction, distress and/or anxiety that is related to specific aspects of their physical appearance. The stimulus for the distorted self-perception would need to be somewhat based on reality (excess weight), but the distortion is in opposition to authentic reality, and external objective observations.

There is an acknowledgment that body dissatisfaction is common among individuals of average weight, the so-called ‘normative discontent’. Body dissatisfaction in an overweight or obese population is currently not widely acknowledged or accepted, due principally to the lack of specific diagnostic criteria. However, the same instruments that measure body dissatisfaction among the ‘normative discontent’ have been shown to find clinically significant body dissatisfaction among the overweight and obese (Sarwer and Polonsky, 2016).

The notion that obesity is intricately linked with poor body image is already an accepted premise (Larkin and Martin, 2016). Dissatisfaction with physical appearance and body image is a common psychological phenomenon in Western society, particularly among the obese. Body image dissatisfaction (BID) is frequently reported in those who have excess weight, having a significant impact on self-esteem and quality of life (Sarwer and Polonsky, 2016). It is often argued that excess weight and BID are the motivational catalyst that drives individuals toward body contouring procedures and bariatric surgery (Larkin and Martin, 2016; Sarwer and Polonsky, 2016). The DSM recognizes BID as a symptom of numerous psychiatric disorders, which include anorexia nervosa, bulimia nervosa and BDD, all of which can contraindicate aesthetic treatments (Sarwer and Polonsky, 2016).

BDD is defined within the DSM as a preoccupation with slight or imagined defects in appearance that may lead to marked distress or social and occupational impairment (American Psychiatric Association, 2013). BDD is thought to affect about 1–2% of the general population, but around 15% of patients seeking aesthetic surgical procedures (Sarwer and Polonsky, 2016). It is estimated that aesthetic surgery (liposuction and abdominoplasty) has increased by 94% from 1997 to 2015 (Sarwer and Polonsky, 2016). Females will often seek surgical procedures to reduce the appearance of thighs and hips, whereas males often request procedures on the abdomen. In total, 15% of patients who present for aesthetic medical treatment have some form of BDD (De Brito et al., 2016; Sarwer, 2016). A total of 90% report no improvement in their BDD, and many report worsening symptoms following aesthetic treatment (Sarwer, 2016). Diagnosing BDD in a medical setting is fraught with difficulties, as many aesthetic surgeons are trained to assess and treat the defects regardless of the degree of emotional distress; the perceived difference in appearance is invariably seen as ‘treatable’ (De Brito et al., 2016; Sarwer, 2016). It could be argued that patients who consider abdominoplasty have more than slight or imagined defects, but the motivations and expectations for treatment, alongside thoughts and behaviors about their appearance, may be suggestive of BDD (Sarwer, 2016). In many of these cases, patients report little or no improvement in psychological functioning following aesthetic procedures. It is therefore imperative that aesthetic surgeons are encouraged to assess the patients’ body image distortions before the onset of treatment and be prepared to refer patients to mental health professionals, where necessary (Sarwer, 2016).

The rationale for the entry of a new category of OD in the DSM would be the same as all other disorders currently described in the DSM, to help select appropriate therapeutic interventions, reduce stigma and facilitate professional care through evidence-based insights. This new category would almost certainly add clarity, and sharpen the focus of research avenues to explore this disorder in much greater detail, and gain appreciation for individuals whose psychological well-being is affected by excess weight.

There is convincing evidence that overweight and obese individuals may experience body dissatisfaction, concurrent with depression, social anxiety and obsessive compulsive disorder (Larkin and Martin, 2016). Co-diagnosis of OD in these circumstances may significantly facilitate the position of their clinical assessment and would also have treatment ramifications.

Emulating the standards used in the DSM, the proposed criteria for OD are based on comprehensive research findings. Specific recommendations are outlined here: The affected individuals would report dissatisfaction, distress and/or anxiety that would be related to some aspect of their physical appearance, which is primarily due to excess weight. There would be a degree of impairment in social relations, social activities or occupational functioning. There would be an affective component, in which the individual has marked distress or anxiety in relation to aspects of their appearance. They would need to show cognitive distortions regarding appearance, which are in opposition to reality, and external objective observations. Individuals would need to show a behavioral avoidance of social situations, in which physical appearance evaluation by others or self may occur (e.g. physical intimacy or shopping for clothes) and avoidance of situations involving self-evaluation such as looking into a mirror or being weighed. Individuals would also need to demonstrate a propensity for perceptual over estimation of body size. Mild symptoms would result in minor impairments in social and cognitive functioning, whereas severe symptoms would show marked interference in social relationships and demonstrate severe cognitive distortions. Treatment pathways would parallel that of BDD.

Conclusion

An understanding of the psychological basis of body image preoccupations and the clinical presentation of OD is important in the selection of appropriate therapeutic interventions to promote research, reduce stigma and facilitate professional care.

Although OD shares several diagnostic features with that of BDD, OD differs fundamentally. For the overweight and obese, BDD is a diagnostic criterion of exclusion, whereas OD is a diagnostic criterion of inclusion, in which it is acknowledged that overweight and obese individuals may have distorted perceptions of body image that is somewhat anchored in reality.

Specific diagnostic tools to assess OD will need to be developed and validated through rigorous empirical trials, which would provide a necessary database to reveal associations between obesity and clinical distortions in body image.

We present evidence, which argues that obesity has many consequences that impinge on a person’s psychological well-being. We additionally argue that one consequence of obesity may manifest as OD. Without the opportunity to receive a psychiatric assessment for OD, many overweight and obese individuals could be left unsupported while in need of psychiatric assistance when, for example, making choices to seek body contouring procedures. The implementation of OD may serve as a framework for potential research, facilitating a better understanding of the impact on body image, and obesity.