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is unlikely to have body dysmorphic disorder. Etiology Neurobiological, psychological, and sociocultural factors are thought to play a role in the development of body dysmorphic disorder.51 Neurobiological Factors Although research is limited, there is some evidence to suggest that body dysmorphic disorder has a genetic underpinning. Phillips et al.52 reported that 20 percent of participants (n 200) in their naturalistic study of body dysmorphic disorder had at least one first-degree family member with the disorder. Other studies suggest that body dysmorphic disorder is more common in families of persons diagnosed with obsessive-compulsive disorder, suggesting that there may be a common genetic link between the disorders.53 Abnormal serotonin and dopamine function are thought to play a role in the development of body dysmorphic disorder, as evidenced by the fact that patients seem to respond preferentially to medications that alter levels of these neurotransmitters.54 Case reports suggest that body dysmorphic disorder may be triggered by medical illnesses involving inflammatory processes that can interfere with serotonin synthesis.55 Another case study reported that neural injury to the frontotemporal region of the brain resulted in the onset of body dysmorphic disorder symptoms.56 A study of single-photon emission computed tomographic brain scans conducted on six patients with body dysmorphic disorder revealed deficits in the parietal region of the brain, an area thought to be related to disturbed body perception.57 Neuropsychological testing of patients with body dysmorphic disorder suggests deficits in verbal and nonverbal memory skills, and with organizational encoding abilities.58 Such impairments may be indicative of abnormalities in the frontostriatal and dopaminergic systems.54 A magnetic resonance imaging study of eight women with body dysmorphic disorder revealed abnormal asymmetry of the cauVolume 118, Number 7 • Body Dysmorphic Disorder 169e date nucleus and increased white matter volume as compared with normal controls.59 Similar findings have been found among individuals with obsessive-compulsive spectrum disorders. This study provides further evidence that body dysmorphic disorder may be best classified as an obsessive-compulsive spectrum disorder rather than as a somatoform disorder. Psychologic Factors The cause of body dysmorphic disorder has been explained by at least two psychological theories. Psychoanalytic explanations suggest that body dysmorphic disorder arises from an unconscious displacement of sexual or emotional conflict or feelings of inferiority, guilt, or poor selfimage onto a body part.60 There is, however, no empirical evidence to support this theory. Explanations from a cognitive-behavioral perspective suggest that the disorder arises from an interaction of cognitive, emotional, and behavioral factors.61– 63 Cognitive factors that appear to be instrumental in the development and maintenance of body dysmorphic disorder include unrealistic attitudes about body image related to perfection and symmetry, selective attention to the perceived defect, increased self-monitoring for the presence of appearance flaws, and misinterpretation of the facial expressions of others as being angry or critical.62– 64 Persons with body dysmorphic disorder tend to perceive their actual appearance as being far less attractive than their ideal.65 They also may be more sensitive to aesthetics compared with others. Two studies have found associations between employment or education in the arts and body dysmorphic disorder.66,67 From a behavioral perspective, body dysmorphic disorder is thought to arise from positive or intermittent reinforcement of appearance characteristics and social learning (e.g., observing the importance of appearance from the media or peers).68 Cognitive factors (e.g., negative thoughts about appearance) give rise to anxiety or other negative emotions. Maladaptive behaviors (e.g., excessive mirror checking) then may develop and persist as a means of reducing distress.62,68,69 Sociocultural Factors Sociocultural theories derive explanations for the cause of body dysmorphic disorder from the social histories of patients. For example, being raised in a family that is rejecting, neglectful, and critical, particularly as related to issues of physical appearance, may be associated with the development of body dysmorphic disorder.60,70 The developmental period of adolescence (the typical age of onset for this disorder) and its accompanying physical and psychological changes may also play a role in the onset of body dysmorphic disorder, particularly if a person is teased about his or her appearance. For example, teasing could cause an individual to question the normality of his or her appearance, even if it is not flawed. The increased emphasis on physical perfection in the media is yet another potential factor in the cause of both general body image dissatisfaction and the appearance preoccupations among persons with body dysmorphic disorder.6,70,71 DEMOGRAPHIC AND CLINICAL CHARACTERISTICS Demographic Features Age of Onset Although most persons with body dysmorphic disorder do not seek treatment until their early thirties, the mean age of onset of body dysmorphic disorder, as noted above, is late adolescence.72,73 In one

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