Clinical Features and Treatment of Body Dysmorphic Disorder

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

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

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

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.