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FOCUS, VOL. 3, No. 2

CLINICAL SYNTHESIS | April 01, 2005

Clinical Features and Treatment of Body Dysmorphic Disorder

Katharine A. Phillips, M.D.

From Butler Hospital and the Department of Psychiatry and Human Behavior, Brown Medical School, Providence, Rhode Island.

FOCUS 2005;3:179-183.

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AcknowledgmentThis work was supported by grant K24-MH63975 from the National Institute of Mental Health.

CME Disclosure StatementKatharine A. Phillips, M.D., Department of Psychiatry and Human Behavior, Brown Medical School, Providence, Rhode Island. Current and recent research support: Forest Laboratories, UCB Pharma, Eli Lilly, Pfizer.

Disclosure of Unapproved, Off-Label, or Investigational Use of a ProductAPA policy requires disclosure by CME authors of unapproved or investigational use of products discussed in CME programs. Off-label use of medications by individual physicians is permitted and common. Decisions about off-label use can be guided by the scientific literature and clinical experience. This article contains discussion of unlabeled use of a commercial product or investigational use of a product not yet approved for this purpose.

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Abstract

Body dysmorphic disorder (BDD), a distressing or impairing preoccupation with an imagined or slight defect in appearance, is a severe and relatively common disorder that usually goes undiagnosed in clinical practice. Individuals with BDD have a high rate of functional impairment, a markedly poor quality of life, and high rates of suicidal ideation and suicide attempts. A majority receive nonpsychiatric medical (e.g., dermatologic) or surgical treatment, which is usually ineffective. In contrast, serotonin reuptake inhibitors (SRIs) and cognitive behavior therapy seem to be efficacious for a majority of patients. Although data are limited, it appears that higher SRI doses and longer treatment trials than those used for many other psychiatric disorders are often needed to treat BDD effectively. This article provides a clinically focused overview of BDD, including its clinical features, recognition and diagnosis of the disorder, and effective treatment strategies.

Figures in this Article

Body dysmorphic disorder (BDD) is a severe and relatively common disorder that has been described for more than a century (1—3). It is characterized by a distressing or impairing preoccupation with an imagined or slight defect in appearance (Table 1). Patients are typically ashamed of and embarrassed by their symptoms and usually do not reveal them to mental health professionals unless specifically asked about body image concerns. Alternatively, many patients present to dermatologists, surgeons, and other non—mental health professionals, seeking a physical solution to a psychiatric problem. These patients have a markedly poor quality of life and high rates of functional impairment and suicidality (1—3). It is important to screen for BDD to identify patients with the disorder so that appropriate psychiatric treatment can be given.

Clinical context

Abstract | Clinical context | Treatment strategies and evidence | Conclusion | References

A patient with BDD

Ms. A, a 28-year-old single Hispanic teacher, presented with the chief complaint: "I’m obsessed with my appearance, and my plastic surgeon has been trying to get me to see a psychiatrist for four years." Since early adolescence, Ms. A had disliked "everything" about her appearance, including her supposedly "scarred" and "discolored" skin, "flat" hair, "big and bumpy" nose, "receding" chin, "thin" lips, "high" forehead, "flabby" thighs, "fat" stomach, and "stumpy" legs. She thought about these supposed flaws for more than 8 hours a day. Because she believed she looked "hideous and revolting," she did not date and avoided most social situations unless she first became intoxicated with alcohol to diminish her anxiety. Her preoccupation with her appearance and her frequent mirror checking diminished her concentration and productivity at work. She missed work several times a month and was underemployed because she felt too ugly to be seen and too distressed to try a more challenging job. Ms. A had undergone 15 cosmetic surgeries, which had cost nearly $100,000 and drained her family’s finances. These procedures had not alleviated her body image concerns. As she stated, "After each surgery I just started hating something else."

Clinical features of BDD

BDD’s clinical features have been described consistently in a variety of studies and settings (1—8). The disorder occurs in all age groups and most often begins during early adolescence. The reported gender ratio varies but is in the range of 1:1 to 3:2 females to males. BDD’s clinical features appear to be similar in men and women and in different age groups, races, and cultures (2, 3, 7).

Obsessional preoccupation with perceived appearance "defects"

Individuals with BDD are obsessed with the belief that there is something wrong with how they look (1—8). They may describe themselves as looking ugly, unattractive, "not right," deformed, abnormal, hideous, or like a freak or a monster. The preoccupation most often focuses on the face or head, typically the skin (e.g., acne, scarring, and skin color), hair (e.g., thinning), or nose (e.g., size or shape). However, any body area can be the focus of concern. Most patients are preoccupied with numerous body areas, and some dislike virtually every body area. Insight is usually poor or absent; most patients are convinced or fairly certain that they truly look abnormal, and referential thinking is common. On average, the preoccupations with appearance occur for 3 to 8 hours a day, and usually they are difficult to resist or control.

Repetitive and safety behaviors

Nearly all patients with BDD perform repetitive behaviors or behaviors aimed to prevent danger (i.e., safety behaviors) (1—8). The most common behaviors are camouflaging the perceived defects (e.g., with clothing or makeup), comparing with other people, checking mirrors and other reflective surfaces, excessive grooming, touching the body areas, seeking reassurance about the perceived flaws, clothes changing, and skin picking. These behaviors are usually time-consuming and, like the preoccupations, are typically difficult to resist or control.

Functioning, quality of life, and suicidality

Individuals with BDD experience significant distress and impairment in social, occupational, and academic functioning (1—9). Level of functioning varies but is typically poor. A high proportion of patients are not employed or in school because of their symptoms and have been housebound or psychiatrically hospitalized (2, 3, 5, 7—9). They have high lifetime rates of suicidal ideation (78%—81%) and suicide attempts (22%—28%) (5—8, 10). Several studies have found that mental health—related quality of life is poorer for patients with BDD than for those with many other severe psychiatric disorders, including depression and posttraumatic stress disorder (2, 3, 9).

Comorbidity

Comorbidity is common (2—5, 7, 8), with major depression the most common comorbid disorder. Other frequently occurring comorbid disorders are obsessive-compulsive disorder (OCD), social phobia, and substance use disorders. In one study, 68% of individuals with a comorbid substance use disorder reported that BDD contributed to their substance use (11).

Prevalence

Studies of community and nonclinical student samples have reported BDD rates ranging from 0.7% to 13%; studies using more rigorous methodology have consistently found community rates of 0.7% to 1.1% (2, 3, 12, 13). BDD is relatively common in dermatology settings (9%—12%), cosmetic surgery settings (6%—15%), and among patients with psychiatric disorders (2, 3). In a study of 122 psychiatric inpatients, 13% had BDD, a rate higher than for many other disorders; in this study, 81% of patients with BDD said that BDD was their major or biggest problem (14).

Recognizing and diagnosing BDD

BDD usually goes undiagnosed in clinical settings (2, 3, 5, 14). Even though most patients want their care provider to know about their body image concerns, many are too embarrassed and ashamed to spontaneously reveal them (14). Instead, they may reveal only depression, anxiety, or substance use, which may lead to misdiagnosis or diagnosis of comorbid disorders but not BDD.

BDD can be diagnosed with relatively straightforward questions such as those listed in Table 2. Clues to the presence of BDD include the above-noted behaviors, ideas or delusions of reference, depression or anxiety, social avoidance or being housebound, and unnecessary cosmetic surgery, dermatologic treatment, or other nonpsychiatric treatment (e.g., electrolysis).

A diagnostic complexity is that if the patient’s appearance beliefs are nondelusional, the diagnosis is BDD, a somatoform disorder, whereas if the beliefs are delusional, the diagnosis is delusional disorder, somatic type. Delusional disorder may be double-coded with BDD (i.e., delusional patients may receive diagnoses of both BDD and delusional disorder), reflecting the likelihood that BDD’s delusional and nondelusional variants are actually one and the same disorder, characterized by a range of insight (2, 3). Indeed, BDD’s delusional and nondelusional variants appear to have far more similarities than differences and appear to respond to the same treatments.

Treatment strategies and evidence

Abstract | Clinical context | Treatment strategies and evidence | Conclusion | References

Establishing an alliance and providing psychoeducation

It is important to take the patient’s appearance concerns seriously rather than dismissing them by simply reassuring the patient that he or she looks normal. Most patients with BDD do not believe reassurances and may interpret it as trivializing their concerns. At the same time, it is important not to agree with the patient’s view of his or her appearance, as this may be devastating and even trigger suicidal thinking.

It is helpful to provide psychoeducation, telling patients that BDD is a relatively common and treatable body image disorder in which sufferers view their appearance differently than other people do and experience a distressing and impairing preoccupation with the flaws they perceive (2). For patients who resist the diagnosis and treatment and insist that they truly are ugly, it is best to avoid arguments over how they actually look and to focus instead on the potential for psychiatric treatment to diminish their excessive preoccupation, suffering, and impaired functioning.

Surgery and nonpsychiatric medical treatment

Most patients seek and receive nonpsychiatric treatment, most often dermatologic and surgical (5, 6, 8, 15). Available data, while limited, indicate that such treatment is usually ineffective and leaves most patients dissatisfied (6, 15). Some BDD patients do self-surgery (e.g., do a face-lift with a staple gun) (2). Reports of BDD patients being litigious or violent toward surgeons, or committing suicide in a dermatology setting, underscore the importance of providing psychiatric treatment for BDD (2, 3, 16).

Pharmacotherapy

The strategies below are based on evidence from controlled studies, open-label trials, and the author’s clinical experience. More detailed pharmacotherapy reviews and recommendations are available elsewhere (2, 17). No medications currently have approval from the Food and Drug Administration for treatment of BDD.

SRIs are the medication of choice for BDD, including delusional BDD

Controlled studies, open-label studies, and clinical series consistently indicate that serotonin reuptake inhibitors (SRIs) are often efficacious for BDD, improving preoccupations, distress, and insight; BDD behaviors; functioning; and associated symptoms such as depression (2, 3, 17). In a double-blind crossover trial, clomipramine was more efficacious than desipramine for BDD symptoms and functional disability (18). In a placebo-controlled study, fluoxetine was significantly more efficacious than placebo for BDD symptoms and functional disability (19). Four systematic open-label SRI studies have been reported, two with fluvoxamine, one with citalopram, and one with escitalopram. Response rates in these studies ranged from 63% to 83% (17). A substantial proportion of patients who do not respond to a trial with one SRI will respond to a subsequent SRI. Other medications, including other antidepressants (with the possible exception of venlafaxine), appear less effective than SRIs, although data are limited (2, 17).

The BDD symptoms of delusional patients appear as likely as symptoms of nondelusional patients to respond to an SRI (3, 17—19). In contrast, an antipsychotic as monotherapy does not appear to be efficacious for delusional BDD, although data are limited (3, 17).

Relatively high SRI doses are often needed

Although dose-finding studies have not been done, it appears that BDD often requires higher SRI doses than those typically used in the treatment of depression (2, 3, 17). Some patients benefit from doses that exceed the maximum recommended dose (this approach is not advised for clomipramine, however).

The average time to response with SRIs has varied among studies, ranging from 4—5 weeks to 9 weeks (3, 17). However, many patients will not respond until the 10th or 12th week of SRI treatment, even with a fairly rapid dose titration. If response is inadequate after 12—16 weeks of treatment and the highest dose recommended by the manufacturer or tolerated by the patient has been tried for 2—3 weeks, it is recommended that a different medication be tried.

SRI augmentation strategies

In the only reported placebo-controlled SRI augmentation study, pimozide was not more effective than placebo (20). Clinical experience suggests that atypical antipsychotics are more promising as SRI augmenters, especially for anxiety and agitation. Buspirone may be a helpful SRI augmenter for BDD symptoms, and adjunctive benzodiazepines should be considered for very distressed, anxious, or agitated patients (2, 17).

Cognitive behavior therapy

Although research on the use of psychotherapy in the treatment of BDD is limited, data from clinical series and studies using waiting-list control subjects indicate that cognitive behavior therapy (CBT), provided individually or in a group format, is often efficacious for BDD (21—23). There are currently no published data to support the use of other types of psychotherapy for BDD, although studies are needed.

CBT for BDD usually consists of the following core elements (2, 21—23):

Some clinicians use approaches such as mindfulness and mirror retraining in addition to these core elements.

Clinical experience suggests that CBT for BDD must differ in some ways from CBT for "near-neighbor" disorders because of important differences between BDD and these disorders. These differences include the content of the preoccupation (appearance), the presence of compulsive behaviors (unlike social phobia or depression), and the poorer insight, more frequent depression, and greater social avoidance in BDD than in OCD.

The optimal session frequency and treatment duration are unclear. Treatment provided in studies has ranged from eight weekly 2-hour sessions to 12 weeks of daily CBT (60 sessions). Most experts would recommend weekly or more frequent sessions for at least 4 to 5 months, plus regular homework. Maintenance or booster sessions following treatment should be considered for patients with more severe BDD to reduce the risk of relapse.

Conclusion

Abstract | Clinical context | Treatment strategies and evidence | Conclusion | References

It is important to screen for BDD in both psychiatric and medical and surgical settings. Patients with BDD usually will not reveal their concerns about their appearance unless they are specifically asked about them. First-line treatment is an SRI, often at a relatively high dose, and/or CBT that targets BDD symptoms specifically. It is important not to simply attribute BDD symptoms to depression or to focus treatment only on depressive or other comorbid symptoms, as this approach may not successfully treat BDD.

BDD has received much less empirical study than most other serious mental illnesses, and thus research is needed on virtually all aspects of the disorder. Particularly useful would be additional research on treatment—for example, placebo-controlled studies of SRIs and other medications, studies of augmentation of SRIs with pharmacotherapy or CBT, and continuation, maintenance, and relapse prevention studies. CBT for BDD needs to be more fully developed and tested, and studies are needed that compare CBT with an SRI and with combined CBT/SRI treatment. Research is also needed to build on the very limited neuroimaging, genetics, and neuropsychological research that has been done (2) in order to elucidate BDD’s pathoetiology. Such work can be expected to clarify the relationship of BDD to other disorders and may provide fruitful new leads for the treatment and prevention of BDD.

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Table 1. DSM-IV-TR Diagnostic Criteria for Body Dysmorphic Disorder

A.	Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person’s concern is markedly excessive.
B.	The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C.	The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in anorexia nervosa).

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Table 2. Questions to Ask Patients to Diagnose BDD

1.	Are you very worried about your appearance in any way?
	Or: Are you unhappy with how you look?
	If yes: What is your concern?
2.	Does this concern preoccupy you? That is, do you think about it a lot and wish you could worry about it less? If you add up all the time you spend each day thinking about your appearance, how much time would you estimate you spend?
3.	What effect has this preoccupation with your appearance had on your life? Has it: Significantly interfered with your social life, dating/marriage, schoolwork, job, other activities, or other aspects of your life? Caused you a lot of distress? Affected your family or friends?
BDD is diagnosed in patients who are 1) concerned about a minimal or nonexistent appearance flaw, 2) preoccupied with the "flaw" (e.g., they think about it for a total of at least an hour a day), and 3) experience clinically significant distress or impairment in functioning as a result of their concern.
Source: Adapted from Phillips KA: The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder. New York, Oxford University Press, 1996

References

Abstract | Clinical context | Treatment strategies and evidence | Conclusion | References

Phillips KA: Body dysmorphic disorder: the distress of imagined ugliness. Am J Psychiatry 1991; 148:1138—1149 [PubMed]

Phillips KA: The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder. New York: Oxford University Press, 1996 (revised and expanded edition in press)

Phillips KA: Body dysmorphic disorder, in Somatoform and Factitious Disorders. Edited by Phillips KA. Washington, DC, American Psychiatric Publishing, 2001, pp 67—94

Hollander E, Cohen LJ, Simeon D: Body dysmorphic disorder. Psychiatr Ann 1993; 23:359—364

Phillips KA, McElroy SL, Keck PE Jr, Pope HG Jr, Hudson JI: Body dysmorphic disorder: 30 cases of imagined ugliness. Am J Psychiatry 1993; 150:302—308 [PubMed]

Veale D, Boocock A, Gournay K, Dryden W, Shah F, Willson R, Walburn J: Body dysmorphic disorder: a survey of fifty cases. Br J Psychiatry 1996; 169:196—201 [PubMed][CrossRef]

Perugi G, Akiskal HS, Giannotti D, Frare F, Di Vaio S, Cassano GB: Gender-related differences in body dysmorphic disorder (dysmorphophobia). J Nerv Ment Dis 1997; 185:578—582 [PubMed][CrossRef]

Phillips KA, Menard W, Fay C, Weisberg R: Demographic characteristics, phenomenology, comorbidity, and family history in 200 individuals with BDD. Psychosomatics, in press

Phillips KA, Menard W, Fay C, Pagano M: Psychosocial functioning and quality of life in body dysmorphic disorder. Compr Psychiatry, in press

Phillips KA, Coles M, Menard W, Yen S, Fay C, Weisberg RB: Suicidal ideation and suicide attempts in body dysmorphic disorder. J Clin Psychiatry, in press

Grant JE, Menard W, Pagano ME, Fay C, Phillips KA: Substance use disorders in individuals with body dysmorphic disorder. J Clin Psychiatry 2005; 66:309—311 [PubMed][CrossRef]

Otto MW, Wilhelm S, Cohen LS, Harlow BL: Prevalence of body dysmorphic disorder in a community sample of women. Am J Psychiatry 2001; 158:2061—2063 [PubMed][CrossRef]

Bienvenu OJ, Samuels JF, Riddle MA, Hoehn-Saric R, Liang KY, Cullen BA, Grados MA, Nestadt G: The relationship of obsessive-compulsive disorder to possible spectrum disorders: results from a family study. Biol Psychiatry 2000; 48:287—293 [PubMed][CrossRef]

Grant JE, Won Kim S, Crow SJ: Prevalence and clinical features of body dysmorphic disorder in adolescent and adult psychiatric inpatients. J Clin Psychiatry 2001; 62:517—522 [PubMed][CrossRef]

Phillips KA, Grant JD, Siniscalchi J, Albertini RS: Surgical and nonpsychiatric medical treatment of patients with body dysmorphic disorder. Psychosomatics 2001; 42:504—510 [PubMed][CrossRef]

Cotterill JA, Cunliffe WJ: Suicide in dermatological patients. Br J Dermatol 1997; 137:246—250 [PubMed][CrossRef]

Phillips KA: Pharmacologic treatment of body dysmorphic disorder: review of the evidence and a recommended treatment approach. CNS Spectr 2002; 7:453—460 [PubMed]

Hollander E, Allen A, Kwon J, Aronowitz B, Schmeidler J, Wong C, Simeon D: Clomipramine vs desipramine crossover trial in body dysmorphic disorder: selective efficacy of a serotonin reuptake inhibitor in imagined ugliness. Arch Gen Psychiatry 1999; 56:1033—1039 [PubMed][CrossRef]

Phillips KA, Albertini RS, Rasmussen SA: A randomized placebo-controlled trial of fluoxetine in body dysmorphic disorder. Arch Gen Psychiatry 2002; 59:381—388 [PubMed][CrossRef]

Phillips KA: Placebo-controlled study of pimozide augmentation of fluoxetine in body dysmorphic disorder. Am J Psychiatry 2005; 162:377—379 [PubMed][CrossRef]

Neziroglu F, Khemlani-Patel S: A review of cognitive and behavioral treatment for body dysmorphic disorder. CNS Spectr 2002; 7:464—471 [PubMed]

Veale D, Gournay K, Dryden W, Boocock A, Shah F, Willson R, Walburn J: Body dysmorphic disorder: a cognitive behavioural model and pilot randomized controlled trial. Behav Res Ther 1996; 34:717—729 [PubMed][CrossRef]

Rosen JC, Reiter J, Orosan P: Cognitive-behavioral body image therapy for body dysmorphic disorder. J Consult Clin Psychol 1995; 63:263—269 [PubMed][CrossRef]

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Table 1. DSM-IV-TR Diagnostic Criteria for Body Dysmorphic Disorder

A.	Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person’s concern is markedly excessive.
B.	The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C.	The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in anorexia nervosa).

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Table 2. Questions to Ask Patients to Diagnose BDD

1.	Are you very worried about your appearance in any way?
	Or: Are you unhappy with how you look?
	If yes: What is your concern?
2.	Does this concern preoccupy you? That is, do you think about it a lot and wish you could worry about it less? If you add up all the time you spend each day thinking about your appearance, how much time would you estimate you spend?
3.	What effect has this preoccupation with your appearance had on your life? Has it: Significantly interfered with your social life, dating/marriage, schoolwork, job, other activities, or other aspects of your life? Caused you a lot of distress? Affected your family or friends?
BDD is diagnosed in patients who are 1) concerned about a minimal or nonexistent appearance flaw, 2) preoccupied with the "flaw" (e.g., they think about it for a total of at least an hour a day), and 3) experience clinically significant distress or impairment in functioning as a result of their concern.
Source: Adapted from Phillips KA: The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder. New York, Oxford University Press, 1996