Evidence-Based Reviews

Beyond the mirror: Treating body dysmorphic disorder

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A multimodal approach appears most effective for this distressing disorder of imagined ugliness.


 

References

Identifying which came first—body dysmorphic disorder (BDD) or comorbid anxiety or depressive disorders—can be as complex as treating the disorder’s delusional thinking and high suicide risk. To help you when working alone or with a psychotherapist, we offer strategies we have found useful for:

  • diagnosing BDD
  • educating patients and families about it
  • choosing and dosing medications
  • addressing inaccurate perceptions with targeted cognitive-behavioral therapies.

Though many recommendations are based on published data, we also draw on our clinical experience because research on effective BDD treatments is limited.

Box

What is body dysmorphic disorder?

Body dysmorphic disorder (BDD) is preoccupation with an imagined defect in physical appearance or excessive concern about a slight physical anomaly that causes significant distress or impairs social, occupational, or other functioning.1 BDD patients have obsessive thoughts about their “flaws” and engage in compulsive behaviors and avoidances related to how they perceive their appearance, similar to behavior seen in obsessive-compulsive disorder. BDD causes great distress and disability, often accompanied by depression and suicidality.2

BDD occurs in an estimated 0.7% of the general population3 and in 6 to 14% of persons receiving treatment for anxiety or depressive disorders.4,5 These estimates may be low, however, as persons with BDD often do not seek treatment. Men and women are equally affected.6 Average age of onset is 16, although diagnosis often doesn’t occur for another 10 to 15 years.7

Assessment

BDD causes patients great distress and disability—often accompanied by major depression—but is easy to miss or misdiagnose (Box).1-7 Even when suicidal, BDD patients often do not reveal their symptoms to clinicians,2 probably because of poor insight or shame about their appearance. When a patient describes being unable to stop thinking about specific aspects of his or her appearance, assess further for BDD.

BDD patients’ conviction that their appearance is defective ranges from good insight to mildly overvalued ideation to frankly delusional.8 They often have ideas of reference (such as thinking others may be looking at their “defective” body part) and delusions of reference (such as being convinced others are talking about their “defective” body part). Asking a patient the questions in Table 1 can help establish the diagnosis. BDD also is included in the Structured Clinical Interview for DSM-IV (SCID). Useful assessment tools include:

  • Body Dysmorphic Disorder Questionnaire,9 a 5-minute, patient-rated scale for screening
  • Body Dysmorphic Disorder Examination,10 to diagnose BDD, survey BDD symptoms, and measure severity
  • Yale-Brown Obsessive-Compulsive Scale modified for Body Dysmorphic Disorder (BDD-YBOCS),11 for measuring symptom severity and changes over time.

Comorbidity. Psychiatric comorbidity is common in BDD (Table 2),6,7,12-14 and deciding which disorder to address first can be difficult. If there is acute mania or non-BDD psychosis, we suggest that you stabilize these before treating BDD. Suicidality or severe substance dependence or abuse may result from BDD and therefore needs to be treated in conjunction with BDD.

If comorbid obsessive-compulsive disorder (OCD) or social phobia symptoms are interconnected with the patient’s BDD, treat concurrently; if not, address sequentially, starting with the more-severe symptoms. For example, symptoms that suggest social phobia (such as fear of public speaking) may be related to BDD, and treatment should focus on BDD. A patient with obsessive fears about how “contaminants” will affect her skin’s appearance may need to have the OCD and BDD addressed concurrently.

For other comorbidities, the treatment hierarchy is less clear. Major depression, for example, may be caused by severe BDD and might not improve until BDD improves. Even when a patient has several concurrent Axis I disorders, don’t over-look treating BDD; otherwise, the patient may remain quite impaired.

Assess suicide risk, as ≥ 25% of BDD patients may attempt suicide in their lifetimes.2 Safety measures include frequent monitoring, medication, family involvement, and—if necessary—hospitalization.

Table 1

Patient interview: Questions to help diagnose BDD

Are you concerned about specific parts of your appearance that you believe are ugly or defective?
Do you find it difficult to stop thinking about parts of your appearance?
Do you avoid certain situations, places, or being seen in general because of your appearance?
Do you feel anxious, ashamed, disgusted, or depressed by specific aspects of your appearance?
Are any of your behaviors influenced by your appearance, such as trying to hide parts of your appearance or taking a long time getting ready to leave your residence?
Does your preoccupation cause you a lot of distress, anxiety, disgust, and/or shame?
Is preoccupation with your appearance interfering with your social life, ability to work, job performance, or other important areas of your life?
Do you tend to use mirrors very often or avoid them?
Does what you see in the mirror determine your mood that day?
How important do you think appearance is in life?
Do you use any oral or topical medications for dermatologic reasons or to prevent hair loss?
Have you ever had cosmetic surgery? If so, how satisfied were you with the outcome? Did you have any revisions?

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