SAN FRANCISCO – Three criteria for diagnosing body dysmorphic disorder could increase to four under a proposal aimed at requiring that the patient demonstrate repetitive behaviors or mental acts in response to appearance concerns at some point during the course of the disorder.

Acts like mirror checking, excessive grooming, skin picking, or reassurance seeking would be considered repetitive behaviors. "Mental acts" could include comparing one's appearance with that of others, Dr. Katharine A. Phillips said at the annual meeting of the American College of Psychiatrists.

The proposed change for the fifth Diagnostic and Statistical Manual of Mental Disorders (DSM-5) would retain the three existing criteria for body dysmorphic disorder. The first criterion is a preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person's concern is markedly excessive.

Second, the person's preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Third, the preoccupation is not better accounted for by another mental disorder (such as anorexia nervosa, which involves dissatisfaction with body shape and size), said Dr. Phillips, director of the Body Dysmorphic Disorder Program at Rhode Island Hospital, Providence.

Making the diagnosis matters, because the disorder is common and very distressing, markedly impairing a person's functioning and quality of life, said Dr. Phillips, also professor of psychiatry and human behavior at Brown University, Providence.

The prevalence of body dysmorphic disorder has been reported as approximately 2% in nationwide epidemiologic studies, 2%-13% in nonclinical student samples, and 13%-16% in psychiatric inpatients. Suicide attempts are common, in 24%-28% of people with body dysmorphic disorder. Preliminary, unpublished data from Dr. Phillips and her associates suggest that the annual rate of completed suicides is 22-36 times higher among people with body dysmorphic disorder, compared with the general population, she said.

Body dysmorphic disorder most commonly first appears at 13 years of age. "Impulsivity and distress can quickly lead to a suicide attempt," she said. It might be equally common among males and females, or somewhat more common in females.

The obsessional, distressing preoccupation with appearance can focus on any body area but most often involves the skin, hair, and nose. Patients find it difficult to resist or control the preoccupation with appearance, which consumes 3-8 hours of their attention each day, on average. They spend much of this time in ritualistic behaviors such as checking mirrors, excessive grooming, camouflaging their alleged defect, skin picking, comparing themselves to others, and seeking reassurance about their appearance.

Accounts of body dysmorphic disorder have surfaced from around the world for more than a century, but there is little research to guide management, Dr. Phillips said. Recommended therapy starts with selective serotonin reuptake inhibitors and/or cognitive-behavioral therapy (CBT) tailored specifically to body dysmorphic disorder.

Cosmetic treatment is not recommended, whether it's dermatologic, surgical, dental, or another form. Two-thirds of people with body dysmorphic disorder already will have tried cosmetic treatment before seeing a psychiatrist, and the cosmetic treatment seems to be ineffective in 92%, some data suggest.

Two controlled studies and four open-label trials report that SSRIs are effective in 53%-77% of patients with body dysmorphic disorder (including those with delusions), though relatively high doses often are needed in at least a 12-week trial of SSRI therapy.

The recommendation for tailored CBT as a first-line treatment is backed only by data from case series and three "not well-controlled" studies that used people on waiting lists for treatment, she said. Both cognitive and behavioral elements of CBT are recommended.

Dr. Phillips highly recommended that anyone doing CBT with patients who have body dysmorphic disorder read the book "Cognitive Therapy for Suicidal Patients: Scientific and Clinical Applications" (Washington: American Psychological Association, 2008).

If first-line therapy fails, the best treatment strategies are unknown. "This is very underresearched," she said.

Monotherapy with either venlafaxine or levetiracetam seemed helpful in 17 open-label trials of each.

SSRI augmentation could be considered. Small case series suggest that buspirone might be an effective augmentation agent at average doses of 50-60 mg/day, she said. Minimal data on antipsychotics to augment SSRI therapy mostly suggest that antipsychotics are not helpful, though some clinical experience hints at a possible role for atypicals.

Other augmenting agents that have shown some promise in limited reports include clomipramine, venlafaxine, lithium, and levetiracetam. Stimulants also have had positive results.

Dr. Phillips said she has received donated medications for studies from Forest Laboratories. She also reported receiving royalties from three publishers: The Free Press, Guilford Press, and Oxford University Press.

Body Dysmorphic Disorder Criteria May Expand in DSM-5