Deborah Brauser

July 01, 2014

LONDON — Specific factors may predict increased risk for the development of "penile dysmorphic disorder" (PDD), new research suggests. PDD is a form of body dysmorphic disorder (BDD) in which men are so preoccupied with the appearance and/or size of their penis that it leads to shame or other problems in their daily lives.

A cohort study of 90 men showed that those with PDD had experienced significantly more teasing about their genitalia and more emotional and physical abuse compared with the participants who had small penis anxiety (SPA) or those who had no penile concerns at all.

The men with PDD also had smaller flaccid penile length than the other 2 subgroups, but there was no significant difference in erect length between the PDD and SPA groups.

"Our main interest is in people with BDD, and we wanted to look at men [with BDD] with a preoccupation with the size of their penis," lead author David Veale, MD, FRCPsych, consultant psychiatrist at the Institute of Psychiatry at King's College London and at the South London and Maudsley NHS Foundation Trust, told Medscape Medical News.

"It's a very underresearched area. And we found a whole list of risk factors, such as things that led to poor attachment, like emotional and physical neglect," added Dr. Veale.

The investigators note that although their findings could be important in understanding the development of BDD in general, such as regarding being teased about specific features, further research is needed to develop interventions specifically for PDD or SPA in men — especially because "there are no effective solutions to increase penile size."

Dr. David Veale

The results were presented here at the International Congress of the Royal College of Psychiatrists (RCPsych) 2014.

Dearth of Research

The researchers write that men with PDD commonly search online for solutions or enhancers to help them deal with their anxiety, or they visit urologists.

"Little is known about the psychosocial risk factors in the development of PDD and whether this is different for men who are worried about their size...but do not meet criteria for PDD," they write. "Risk factors...may be similar to those in BDD in general or there may be specific risk factors for a preoccupation with genital size."

For this study, 26 men with PDD who fulfilled criteria for BDD were enrolled, as were 31 men with SPA and 33 men with no penile concerns (healthy control group). Although the men in the SPA group did not fulfill BDD diagnostic criteria, they reported being dissatisfied and worried about penis size.

Measurements used included the Childhood Trauma Questionnaire, Perception of Appearance and Competency Related Teasing Scale, body mass index (BMI), and penis length and girth.

In addition, all participants were asked about past medical conditions or surgeries and any past experiences of genitalia teasing. The Cosmetic Procedure Screening Questionnaire was used as a BDD screening measure.

Results showed that the group with PDD had significantly higher frequency of past emotional abuse than the other 2 groups (P < .001 for both), as shown on Childhood Trauma Questionnaire scores, as well as more physical abuse (P < .05 for both), physical neglect (P < .01 for both), and emotional neglect (P < .05 compared with the SPA group, P < .01 compared with the healthy control group).

Scores on the Perception of Teasing Scale showed that the PDD group also had significantly more appearance teasing than the other groups (P < .001 against both), more competency teasing (P < .01 against both), and more perceived distress (P < .01 compared with the SPA group, P < .001 compared with the healthy control group).

They also had significantly smaller flaccid penile length than the SPA group (P < .05) and the healthy control group (P < .001) and smaller flaccid girth (P < .05 against both groups).

Although erect length was also significantly smaller for the men with PDD than for the men in the other groups, erect length to the pubic bone was only significantly different between the PDD and the healthy control groups (P < .05). There were no between-group differences in erect girth.

Significant PDD Predictors

Finally, when examining specific predictors of group, significant differences were found between the PDD and SPA groups for perceived appearance-related teasing (odds ratio [OR], 0.76; 95% confidence interval [CI], .60 - .95; P < .01) and for BMI (OR, 0.73; 95% CI, .54 - 1.0; P < .05); and between the PDD and control group for specific genitalia teasing (OR, 35.65; 95% CI, 4.02 - 316.41; P < .01) and BMI (OR, 0.70; 95% CI, .49 - .97; P < .05).

Specific genitalia teasing was also a significant predictor between the SPA and healthy control groups (OR, 0.74; 95% CI, .02 - .37; P < .01).

No significant differences were found between any of the groups for past medical or surgical treatment of the genitalia or past experiences of sexual abuse.

"Men with PDD appear to have some specific vulnerability in comparison to others who are anxious about their penile size," the investigators write.

"These are things that men don't tend to seek help for but instead look for solutions on the Internet, things like potions and extenders and other rubbish," added Dr. Veale.

Overall, he said that poor attachment as a child, general teasing, and specific teasing about penis size can combine to make "a perfect storm" of risk factors for PDD.

"It's important for clinicians to ask leading questions because these are sensitive subjects. Often, these patients will present in urology and sexual medicines, and physicians in these areas need to be aware of these problems," he said.

However, "there's really been nothing published on how to treat these individuals, especially for psychiatrists and psychologists."

"Confusing Term"

Katharine Phillips, MD, director of the BDD Program at Rhode Island Hospital in Providence and professor of psychiatry and human behavior at the Warren Alpert Medical School of Brown University, told Medscape Medical News that PDD is a confusing term.

Dr. Katharine Phillips

"There is no disorder called penile dysmorphic disorder," she said, adding that it is not currently included in the Diagnostic and Statistical Manual of Mental Disorders (DSM) or in the International Classification of Diseases (ICD).

"It would be better to say something like, 'BDD with concerns about the appearance of the penis.' BDD can focus on any body area; the penis is just one of many," said Dr. Phillips, who was not involved with this research.

In addition, she noted that the poster did not thoroughly explain the criteria for PDD or SPA or explain how the participants were initially selected.

Overall, Dr. Phillips said that "it is difficult to draw any conclusions about the study, even though it is interesting."

The study authors and Dr. Phillips have reported no relevant financial relationships.

International Congress of the Royal College of Psychiatrists (RCPsych) 2014. Poster 20. Presented June 24, 2014.

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