Evidence-Based Reviews

Beyond the mirror: Treating body dysmorphic disorder

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Table 2

Lifetime prevalence (%) of comorbid Axis I disorders in BDD

StudyNMajor depressionSocial phobiaOCDSubstance use disorders
Gunstad and Phillips (2003)*1217575373030
Zimmerman and Mattia (1998)14166969386
Perugi et al (1997)1358411241
Veale et al (1996)75081662
Hollander et al (1993)65068127822
N: number of study subjects
OCD: obsessive-compulsive disorder
* Phenomenology group
† not reported
Source: Adapted and reprinted with permission from reference 12.

Patient education

Improving insight. Educate patients that BDD is a brain disorder that creates faulty, inaccurate thoughts and perceptions about appearance. Many patients initially resist a BDD diagnosis; delusional thinking and poor insight lead them to assume the “flaw” they see is an accurate perception. They may need to hear about other persons with similar concerns to realize that a psychiatric disorder is causing their distress.

Other helpful resources for improving insight include:

  • group therapy
  • The Broken Mirror, by Katharine A. Phillips, MD,15 which contains case examples to which BDD sufferers may relate
  • Websites and online forums (see Related resources).

Explaining BDD. Discuss possible causes of BDD, giving patients alternate explanations for the physical defects they perceive. Contributing factors may include:

  • neurobiological abnormalities and genetic factors16
  • a history since childhood of shyness, perfectionism, or anxious temperament
  • being teased, abused, or in poor family and peer relationships.17

Emphasize that multiple, different, converging factors cause BDD for each individual.

The obsessive-compulsive cycle. Explain that thoughts create distressing emotions, and that persons with BDD try to relieve or prevent these emotions by performing compulsive behaviors. Compulsions then strengthen the association between intrusive thoughts about appearance “defects” and negative feelings about appearance.

Review a list of common compulsions (Table 3) with BDD patients, as many have engaged in these behaviors for years without realizing they are compulsions.

Table 3

Common BDD compulsions and avoidances

Excessive grooming
Excessive checking or avoidance of mirrors and other reflective surfaces
Asking for reassurance about appearance
“Camouflaging” (hiding or covering up) supposed defects
Scrutinizing the appearance of other people and comparing to oneself
Avoiding social interactions
Avoidance of certain lighting conditions
Skin-picking to “fix” perceived flaws
Having repeated cosmetic or dermatological procedures, such as dermabrasion, cosmetic surgery, etc.


BDD is a severe and complex disorder that often requires multimodal treatment using cognitive-behavioral therapy (CBT) and medication (algorithm).18 In our experience, most BDD patients need medication for the disorder and for common comorbidities. We recommend starting medications before or when beginning CBT for patients with moderate to severe BDD (BDD YBOCs ≥ 20).

Serotonin reuptake inhibitors (SRIs) have reduced BDD symptoms in open-label19,20 and controlled trials.21,22 As first-line treatments, SRIs decrease distress, compulsions, and frequency and intensity of obsessions about perceived defects; they also can improve insight.21-24 SRIs appear equally effective for delusional and nondelusional patients;21,23 whether CBT is similarly effective is unclear.

Relatively high dosages are usually necessary, according to published flexible-dosing trials in BDD,19-23 a retrospective chart review24 and our experience. Try dosages similar to those used for OCD (Table 4) as tolerated, and monitor for side effects. Twelve to 16 weeks of treatment are often needed for a full therapeutic effect.20-21

Augmentation. Consider adding another agent if a full SRI trial achieves partial symptom relief. One open-label trial of 13 BDD patients found that 6 (46%) improved when buspirone (mean dosage 48.3 mg/d) was added to SRI therapy.25 In a chart review, Phillips et al24 reported variable response rates of BDD patients treated with augmentation trials of clomipramine (4/9), buspirone (12/36), lithium (1/5), methylphenidate (1/6), and antipsychotics (2/13).

Very few studies have examined antipsychotic use in BDD. Placebo-controlled data are available only for pimozide.27 Conventional antipsychotics are unlikely to be effective, either as monotherapy26 or augmentation.27 As for the atypicals, olanzapine augmentation showed little to no efficacy in one small trial, although the average dosage used was low (4.6 mg/d).28 In our experience, atypicals—such as aripiprazole, 5 to 30 mg/d; quetiapine 100 to 300 mg/d; olanzapine, 7.5 to 15 mg/d; or risperidone, 1 to 3 mg/d—can improve BDD core symptoms and improve insight.

Benzodiazepines can be useful for acute anxiety or agitation. Carefully monitor benzodiazepine use, however, as substance abuse is relatively common in BDD patients.29

Table 4

Recommended SRI dosages for treating BDD*

DrugDosage range (mg/d)
Citalopram40 to 100
Clomipramine150 to 250
Escitalopram20 to 50
Fluoxetine40 to 100
Fluvoxamine200 to 400
Paroxetine40 to 100
Sertraline150 to 400
* Off-label use.
† May exceed FDA-recommended maximum dosages.

Specialized cbt techniques

Cognitive restructuring. Trying to convince BDD patients there is nothing wrong with their appearance will not be successful. Instead, we use cognitive restructuring to challenge the rationality of their thoughts and beliefs and to find alternate, more rational ones:

Therapist: “I know I cannot convince you that your (body area) is not defective, but can you give me evidence of how this ‘defect’ has affected your life?”


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