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Body Dysmorphic Disorder

Abstract and Keywords

Body dysmorphic disorder (BDD) is characterized by a preoccupation with an imagined defect in one's appearance. Alternatively, there may be a minor physical abnormality, but the concern is regarded as grossly excessive. It must also cause significant distress or handicap. This chapter reviews comorbidity, demographics, risk factors, and the role of cosmetic procedures in BDD. A cognitive behavioral model is described and the therapy outlined. The chapter also describes the use of pharmacotherapy and treatment guidelines.

Keywords: body dysmorphic disorder, BDD, cognitive behavioral therapy, cosmetic surgery, pharmacotherapy

Body dysmorphic disorder (BDD) is classified as a somatoform disorder in DSM–IV–TR (American Psychiatric Association [APA], 2000). However, at the core of BDD is an anxiety disorder characterized by a preoccupation with an imagined defect in one's appearance. Alternatively there may be a minor physical abnormality, but the concern is regarded as grossly excessive. To receive the diagnosis, the person must also either be significantly distressed or handicapped such as in his or her ability to work or to interact socially. Lastly it may not be better accounted for by another mental disorder such as anorexia nervosa (APA, 2000).

History

Body dysmorphic disorder was previously known as dysmorphophobia. An Italian psychiatrist, Morselli, first coined the term in 1886, but it is used less often nowadays probably because ICD-10 (World Health Organization, 1992) has subsumed dysmorphophobia under hypochondriacal disorder.

One of Freud's patients (Freud, 1959) who was subsequently analyzed by Brunswick 1971 was known as the “Wolf Man” and was preoccupied with imagined defects on his nose. Brunswick wrote: “He neglected his daily life and work because he was engrossed, to the exclusion of all else, with the state of his nose. On the street he looked at himself in every shop window; he carried a pocket mirror, which he took out at every few minutes. First he would powder his nose; a moment later he would inspect it and remove the powder. He would then examine the pores, to see if they were enlarging, to catch the hole, as it were in its moment of growth and development. Then he would again powder his nose, put away the mirror, and a moment later begin the process anew.”

Psychopathology

There is frequent comorbidity in BDD, especially for depression, social phobia, and obsessive-compulsive disorder (OCD) (Neziroglu et al., 1996; (p. 542) Phillips & Diaz, 1997; Veale et al., 1996). There is also heterogeneity in the presentation of BDD, from individuals with borderline personality disorder and self-harming behaviors to those with muscle dysmorphia (Pope et al., 1997) who are less handicapped. Individuals with BDD are preoccupied with the notion that one or more features of their appearance is unattractive, ugly, or deformed. Any part of the body may be involved, though the preoccupation most commonly centers on skin, hair, or facial features—eyes, eyelids, nose, lips or mouth, jaw, or chin. The preoccupation is often focused on several parts of the body simultaneously (Phillips et al., 1993). The typical complaint involves flaws on the face (whether perceived or actual), asymmetry, body features felt to be out of proportion, incipient baldness, acne, wrinkles, vascular markings, scars, or extremes of complexion, ruddiness, or pallor. While some complaints are specific in the extreme, others are vague or amount to no more than a general perception of ugliness. The nature of the preoccupation may change over time, and this may explain why, after cosmetic surgery, the patient's focus may shift to another area of the body. Beliefs about defects in appearance usually carry strong personal meanings. A belief that his nose was too big caused one patient to feel that he would end up alone and unloved and that he might look like a crook. Another, preoccupied with flaws in her skin, found them disgusting and thought of her skin as “dirty.” Patients such as these tend to have little if any insight (Phillips, 2004; Phillips et al., 1994). On the contrary, they are likely to display delusions of reference, believing that the people around them notice their “defect” and evaluate them negatively or humiliate them as a consequence of their ugliness. A further aspect of BDD is the time-consuming behaviors adopted to examine the “defect” repeatedly or to disguise or improve it. Examples include gazing into the mirror to compare particular features with those of others, excessive grooming, which can be quite deleterious especially where the skin is concerned, camouflaging the “defect” with clothes or make-up, skin picking, reassurance seeking, dieting, and pursuing dermatological treatment or cosmetic surgery.

Cosmetic Procedures in BDD

There are two retrospective surveys that have reported the outcome of cosmetic surgery in BDD patients seen in a psychiatric clinic. Phillips et al. 2001 reported the outcomes of 58 BDD patients seeking cosmetic surgery. A large majority (82.6%) reported that symptoms of BDD were the same or worse after cosmetic surgery. Veale 2000 reported on 25 BDD patients in a psychiatric clinic in the United Kingdom who had had a total of 46 procedures. Repeated surgery tended to lead to increasing dissatisfaction. Some operations, such as rhinoplasty, appear to be associated with higher degrees of dissatisfaction. Mammaplasty and pinnaplasty tended to have relatively higher satisfaction ratings. These operations tend to be unambiguous in that patients can usually describe the problem that concerns them and their desired outcome, and the cosmetic surgeon can understand their expectations. Most of the patients in the study had multiple concerns about their appearance and, after 50% of the procedures, reported that the preoccupation and other symptoms of BDD transferred to another area of the body. When patients were dissatisfied with their operation, they often felt guilty or angry with themselves or the surgeon at having made their appearance worse, thus further fuelling their depression at a failure to achieve their ideal. This in turn tended to increase mirror gazing and a craving for more surgery. The main weakness of studies in psychiatric clinics is that the data are retrospective, and there is a selection bias of patients in favor of treatment failures. Mental health practitioners are unlikely to be consulted if patients are satisfied with their cosmetic surgery and their symptoms of BDD improve.

Body dysmorphic disorder is not uncommon in cosmetic surgery clinics. Studies have found that between 5% and 15% of patients in cosmetic surgery clinics have BDD (Ishigooka et al., 1998; Sarwer et al., 1998) and an incidence of 12% has been reported from a dermatology clinic in the United States (Phillips et al., 2000). Only one study has followed up on patients with a diagnosis of BDD preoperatively (Tignol et al., 2007) evaluated the effect of cosmetic surgery in 30 patients with a minimal defect in appearance (of whom 12 had BDD and 18 non-BDD) 5 years after their request for cosmetic surgery. Of the 30, it was possible to re-evaluate 24 (80%) by telephone interview (10 with BDD and 14 non-BDD). Seven participants with BDD had undergone cosmetic surgery versus 8 non-BDD. Patient satisfaction with the surgery was high in both groups. Nevertheless, at follow-up, 6 of the 7 operated BDD patients still had a diagnosis of BDD and exhibited higher levels of handicap and psychiatric comorbidity compared to people without BDD. Moreover, 3 non-BDD patients had developed BDD after surgery. Patient satisfaction with surgery may contribute to explaining why some plastic surgeons continue to operate.

(p. 543) The major questions are what predicts satisfaction with cosmetic surgery and can some patients with BDD be satisfied with the procedure (but continue to be preoccupied and distressed)? A recent study examined the differences between 23 individuals without BDD in a cosmetic surgery clinic who were satisfied with their rhinoplasties and 16 patients in a psychiatric clinic diagnosed with BDD (Veale et al., 2003). The BDD patients were selected because they craved rhinoplasty but for various reasons had not obtained it; for example, they could not afford it or had a fear of the operation failing. The BDD patients were significantly younger than the rhinoplasty patients, but there was no significant difference in sex. As expected, the BDD patients had greater psychological morbidity than the rhinoplasty patients. The BDD patients had higher scores on the Yale-Brown Obsessive Compulsive Scale modified for BDD (Phillips et al., 1997) and for anxiety and depression on the Hospital Anxiety and Depression Scale (Zigmond & Snaith, 1983). The mean scores of the BDD patients were all in the clinical range, while those of the rhinoplasty patients were not. Individuals with BDD were more distressed and reported much greater interference in their social and occupational functioning and in intimate relationships because of their nose. They were more socially anxious and more likely to avoid situations because of their nose. They were more likely to check their nose in mirrors or to feel it with their fingers. These patients were more likely to believe that cosmetic surgery would significantly change their life (e.g., help them to obtain a new partner or job) and were significantly more likely to be dissatisfied with other areas of their body. They were likely to have attempted do-it-yourself (DIY) surgery in the past. (Examples of DIY surgery included using a pair of pliers in an attempt to make the nose thinner, using sticky tape to flatten the nose, and placing tissue up one side of the nose to try to make it look more curved.)

In summary, BDD patients who desire cosmetic rhinoplasty are quite a different population from those patients who obtain routine cosmetic rhinoplasty. A number of clues from this study could be used in the development of a short screening questionnaire or structured interview to help cosmetic surgeons to identify individuals with BDD who are unsuitable for cosmetic surgery. We do not yet know whether the diagnosis of BDD by itself is a contraindication to surgery. Additional factors such as an unrealistic psychosocial outcome may be more important. However good the interview, patients may be economical with the truth, and, even when a surgeon identifies possible symptoms of BDD, the patient may not agree to a referral to a mental health practitioner and may merely go to another surgeon. Prospective outcome studies are required to identify BDD patients and when, if ever, a cosmetic procedure is indicated in BDD.

Comorbidity and Handicap

Body dysmorphic disorder is associated with a high rate of depression and suicide and with DIY cosmetic surgery (Veale, 2000), and in comparison with all other body image disorders, these patients are the most distressed and handicapped by their condition. Phillips et al. 2000 used a quality of life measure and found a degree of distress worse than that of depression, diabetes, or bipolar disorder. Almost all patients with BDD suffer social handicap, avoiding social situations where they may feel self-conscious or that may lead to dating or intimacy. Strategies for enduring such situations include the use of alcohol, illegal substances, or safety behaviors similar to those seen in social phobia. Body dysmorphic disorder can disrupt study and employment. Patients may become effectively housebound. All these factors can and frequently do lead to discord within the family if other members cannot empathize with the sufferer's situation.

Demographics

The prevalence of BDD in the community has been reported as 0.7% in two studies (Faravelli et al., 1997; Otto et al., 2001) with a higher prevalence of milder cases in adolescents and young adults (Bohne et al., 2002). Most surveys of BDD patients attending a psychiatric clinic tend to show an equal sex incidence. They are usually single or separated and unemployed (Neziroglu & Yaryura-Tobias, 1993; Phillips & Diaz, 1997; Phillips et al., 1993; Veale et al., 1996). It is possible that, in the community, more women are affected overall, with a greater proportion experiencing milder symptoms. No cross-cultural studies in BDD have been done except for a small survey of German and American students (Bohne et al., 2002). However, case studies suggest that the clinical presentation of BDD is similar across all cultures. Some cultures may, however, place more emphasis on the importance of appearance, resulting in higher rates of BDD and cosmetic surgery.

(p. 544) Presentation

Although the age of onset of BDD is during adolescence, patients are most likely to present to cosmetic surgeons, dermatologists, ear, nose, and throat surgeons. They are usually not formally diagnosed by mental health professionals until 10–15 years after the onset (Phillips, 1991; Veale et al., 1996). Body dysmorphic disorder may also present in children with symptoms of refusing to attend school and planning suicide (Albertini & Phillips, 1999). Body dysmorphic disorder patients generally feel misunderstood and are secretive about their symptoms because they think they will be viewed as vain or narcissistic. They may indeed be stigmatized by health professionals who view only true disfigurement as worthy of their attention or who confuse BDD with body dissatisfaction (Carter, 2001). Therefore, when they do present to health professionals, patients are more likely to complain of depression or social anxiety unless they are specifically questioned about symptoms of BDD.

Even when BDD is finally diagnosed, patients are often treated inappropriately with antipsychotic medication (Phillips, 1998) or by a therapist who has little experience in treating BDD patients or lacks an effective treatment model. There is, therefore, an unmet need for the diagnosis and effective treatment of BDD. However, promising results have been obtained by cognitive behavioral therapy and the use of serotonin reuptake inhibitors, which are discussed at the end of this chapter.

Risk Factors

As yet, only limited data are available on risk factors for the development of BDD. The research agenda is to distinguish between risk factors that are specific to BDD and those that predispose to other disorders. Various risk factors are hypothesised for the development of BDD (Veale, 2004). These include a genetic predisposition, shyness, perfectionism, an anxious temperament, childhood adversity such as teasing or bullying (about either appearance or competence), poor peer relationships, social isolation or lack of support in the family, sexual abuse, a history of dermatological or other physical stigmata (e.g., acne) as an adolescent (since resolved), and being more aesthetically sensitive than average. Aesthetic sensitivity can be defined as an awareness and appreciation of beauty and harmony. This results in a greater emotional response to more attractive individuals and placing a greater value on the importance of appearance in their identity. This would manifest in an increased likelihood of seeking education or The onset of BDD is in adolescence, and therefore, particular attention will need to be given to identifying risk factors preceding the onset. For example, teasing about appearance is commonplace among children, yet comparatively few go on to develop BDD. One aim of future research is to determine which factors (or combination of factors) predict future persistence of extreme self-consciousness so that interventions may be devised for those at risk. Compared with other body image disorders, such as eating disorders or anxiety disorders, BDD is greatly underresearched and is only now beginning to attract interest. Many of the suggested risk factors remain speculative. training in art and design (Veale et al., 1996; Veale & Lambrou, 2002; Veale et al., 2002). Aesthetic sensitivity may have three components: (1) perceptual (the ability to differentiate variations in aesthetic proportions); (2) emotional (the degree of emotion experienced when presented with beauty or ugliness); and (3) evaluative (aesthetic values, standards, and identity). Lambrou 2006 found that individuals with BDD have problems in the emotional and evaluative processing when viewing their self-image, rather than in their perceptual processing. Using a comparative group design, 50 BDD individuals were compared with two nonclinical control groups; 50 art and design controls and 50 nonart controls. A digital facial photograph of each participant was manipulated using computer graphic techniques to create a symmetry continuum consisting of 9 images (1 real image and 8 manipulated images). Presented with the symmetry continuum on a computer, participants were required to select and rate facial images representing actual self, ideal self, idea of perfect, most physically attractive, most pleasure, and most disgust. Applying the same methodology, symmetry continua were created for two control conditions, a standardized other face and a building, to illustrate the hypothesised emotional/evaluative disturbance in BDD individuals would be specific to their own face. The difference in BDD individuals was in their emotional and evaluative processing when viewing their own self-image, rather than in their perceptual processing. The art and design group had similar perceptual skills to the BDD group, which were more accurate than the controls.

Cognitive Behavioral Model of BDD

A cognitive behavioral model has been described that emphasizes the maintenance of symptoms (Veale, 2004; Veale et al., 1996). It is proposed that the cycle begins when an external representation of (p. 545) the person's appearance (e.g., looking in a mirror) activates a mental image. The process of selective attention increases awareness of the image and of specific features within the image. The image is used to construct how the person looks in the mirror and provides information about how he or she appears to others from an observer perspective and is fused with reality.

The evidence for imagery in BDD so far comes from a descriptive study that compared 18 BDD patients with 18 healthy controls using a semistructured interview and questionnaires (Osman et al., 2004). The BDD patients and controls were equally likely to experience spontaneous images of their appearance. However, BDD patients were likely to rate the images as significantly more negative, recurrent, and vivid than normal controls. Images in BDD patients were more distorted, and the “defective” features took up a greater proportion of the whole image. They typically reported visual images, which were sometimes associated with other sensations (e.g., organic sensations of hunger or fatigue). Of particular significance is that the images were more likely to be viewed from an observer perspective than from a field perspective, similar to a finding in social phobia (Hackmann et al., 1998). An observer perspective consists of the individual looking at himself or herself from another person's perspective. A field perspective consists of an individual looking out from his or her own body. It is proposed that activation of imagery is associated with an increased self-focused attention directed toward specific features of an image, leading to a heightened awareness and a relative magnification of certain aspects, which contributes to the development of a distorted body image. Furthermore, any image becomes “fused” with reality, as in the concept of thought-action fusion (Rachman, 1993) or cognitive fusion (Hayes et al., 1999).

The next step in the model is the negative appraisal and aesthetic judgment of the image, by the activation of assumptions and values about the importance of appearance. In BDD, appearance has become overidentified with the self and at the center of a “personal domain” (Veale, 2002). Typical assumptions include: “If I am unattractive, then life is not worth living,” “If I am defective, then I will be alone all my life,” or “I can only do something when I feel comfortable about my appearance” (Veale et al., 1996). Individuals value the importance of appearance in defining their self or identity, although this may have occurred as a consequence of feeling ugly (and would not be present if they did not have a preoccupation with their features). Individuals with BDD may also lack a self-serving bias that occurs in normal individuals as has been found in eating disorders (Jansen et al., 2006). This has been described as losing the rose-tinted glasses that normally occurs in individuals without a body image disorder.

The preoccupation is maintained by various safety seeking or “submissive” behaviors, such as mirror checking or camouflaging to reduce scrutiny by others or to enhance appearance. However, these tend to increase the doubts and reinforce the behavior in a further vicious circle. The preoccupation is further reinforced by ruminations (e.g., “Why am I so ugly?”; “If only I was born with a different nose”), which leads to a further deterioration in mood and further questions that cannot be answered. Alternatively individuals are trying to solve a nonexistent problem or hypothetical catastrophes (“What if someone humiliates me?”), which lead to further questions, similar to a process of worry.

Cognitive Behavioral Therapy (CBT)

The efficacy of CBT for BDD has recently been reviewed (Williams et al., 2006) and CBT is included in the clinical guidelines on treating OCD and BDD from the National Institute of Clinical Excellence (NICE) in the UK (National Collaborating Centre for Mental Health, 2006). There are only two randomized controlled studies, both of which used a waitlist comparison group (Rosen et al., 1995; Veale et al., 1996). One of the criticisms of the study by Rosen et al. 1995 is that their patients were not representative as the sample contained only women, several of whom who had disordered eating and they were less handicapped than those seen in other centers. Both studies did not conduct a long-term follow-up and neither study measured delusionality. There are also case-control studies (Geremia & Neziroglu, 2001) and several case series (e.g., Wilhelm, Otto, Lohr, & Deckersbach, 1999). A randomized controlled trial is now required that compares later versions of CBT against an attentional control treatment with equal credibility and a selective serotonin reuptake inhibitor (SSRI). Randomized controlled trials (RCTs) are also required for the use of CBT in adolescents. Key components of CBT include engagement and helping patients to develop a good psychological understanding of the factors that maintain BDD.

Engagement in CBT is helped by the credibility of a clinician who has treated other patients (p. 546) and can talk about the disorder knowledgeably. It is important to validate the patient's beliefs and not discount or trivialize them (Linehan, 1993) (e.g., “What you feel about your appearance is very understandable given that you were bullied as a child”).The clinician should search for and reflect upon the evidence collected by patients for their beliefs (rather than seek evidence against the belief they are defective) and the factors that have contributed to the development of those beliefs. The aim is then to normalize their experience and help them to understand what the problem is. Therapists should avoid repeatedly reassuring patients that they look “all right” as it does not fit with their experience and they have heard it many times. They may be recommended a psychoeducational book about BDD that is written for sufferers (Phillip, 1996; Wilhelm, 2006; Veale, Willson, & Clarke, 2008) or to meet other patients in a support group or national charity.

Patients assume a model of “What you see is what you get” in front of a mirror. An alternative model of “What you see is what you feel” is presented because of selective attention to the “picture in their mind” and the emotional component of body image. Body image will depend more upon their mood, early memories, the meaning that they attach to their appearance and the expectations that they bring to a mirror. This leads to a description of a cognitive behavioral model for BDD and how a person with BDD becomes excessively aware of his or her appearance and to giving examples of selective attention in everyday life. It is important not to refer to a “distorted” body image as there is emerging evidence that BDD sufferers may be more accurate in their aesthetic sensitivity (Lambrou, 2006). Instead they may lack the self-serving bias that occurs in healthy individuals, similar to a process in patients with eating disorders (Jansen et al., 2006). The therapist might ask the patient to suspend judgment about his or her appearance and to test out the alternative cognitive behavioral model for the period of therapy. This might lead to a discussion of the prejudice model of information processing and how this may affect their judgment (Padesky, 1993).

Another method of engagement in CBT is similar to that described for hypochondriasis (Clark et al., 1998). A patient is presented with two alternative theories to test out in therapy. The first theory (that the patient has been following) is that he is defective and ugly and he has tried very hard to camouflage or change his appearance. The alternative theory to be tested during therapy is that the problem is being excessively self-focused on a picture in his mind and making his appearance the most important aspect of his identity. Patients are asked to suspend judgment for the duration of therapy in order to test out whether their experience in various behavioral experiments best fits with that of Theory A or Theory B. An idiosyncratic version of the model is drawn that identifies the various factors that increase an individual's preoccupation and distress with his or her appearance (Veale, 2004). Some patients are impossible to engage in either CBT or pharmacotherapy and have to go through a long career of unnecessary surgery, beauty therapies, dermatological treatment, or suicide attempts before seeking help for their BDD from a mental health professional. Patients will, however, often discount the experience of other BDD patients and the results of studies on cosmetic surgery as they see themselves as ugly and not suffering from BDD.

Once a patient is engaged in therapy and willing to test out alternatives, the therapist can chose from a variety of strategies depending on the formulation and presenting problems. These include (1) behavioral experiments to test out the effect of increasing or decreasing self-focused attention or other safety behaviors, (2) self-monitoring and response prevention for behaviors such as mirror gazing, (3) self-monitoring with a tally counter and habit reversal for behaviors such as skin-picking, (4) task concentration training to help refocus attention away from the self and an observer perspective, and (5) functional analysis on the effect of comparing or ruminating.

An early goal is to improve function with behavioral activation to overcome social withdrawal as depressed mood and isolation reinforces rumination (Martell, et al., 2001). A functional analysis may be conducted on the effect of rumination and whether it increases preoccupation and distress and further avoidance of one's valued directions in life. Problems of being critical and attacking self and shame may be assisted by a “two-chair technique” and compassionate mind training (Gilbert, 2005). Beliefs about being ugly or defective (e.g., “My nose is too crooked”) are not directly challenged. However, the meaning of being defective and the importance of appearance to the person's identity may be tackled. Values are best challenged by questioning the functional costs and by reducing the importance of the value to the self in small degrees on a continuum similar to motivational interviewing of anorexia nervosa (Treasure & Ward, 1997). A fundamental thinking error is (p. 547) personalization, in which a patient identifies his or her “self” through his or her appearance and all the other values and selves are diminished. In this regard, a patient may be helped by the concept of “Big I” and “little I,” whereby the self or “Big I” is defined by thousands of “little i's” in the form of beliefs, values, likes and dislikes, and characteristics since birth (Dryden, 1998; Lazarus, 1977). Patients are therefore encouraged to focus on all the other characteristics of the self to develop a more functional view and to pursue their valued directions in life despite their preoccupation and distress. Reverse role-play can also be used to strengthen an alternative belief in which patients can practice arguing the case for their alternative belief while the therapist argues the case for the old beliefs or values. Newel & Shrubb (1994) have described this in BDD but have focused on patients' beliefs about their “defect.” If I use reverse role-play then it is more likely to be on (1) the meaning or assumptions about being defective or ugly, and (2) the values (e.g., about the importance of appearance and identification with self).

Social Anxiety

The cognitive model of social phobia (Clark & Wells, 1995) can be adapted to BDD to derive an idiosyncratic version of patients' experience in a recent social situation. Patients will need to expose themselves to social situations but with experiments in shifting attentional focus away from the self and the dropping of safety behaviors. Attentional shifting to external cues (whether in social situations or not) may be helped by Task Concentration Training (Bogels, Mulkens, & De Jong, 1997).

Mirror Gazing

Mirror gazing is an early target for intervention as it feeds the selective attention on appearance. Some patients try to cover up or take down mirrors (or a previous therapist may have encouraged this). However, in our experience, this can lead to a different set of problems of mirror avoidance. In this scenario, a patient is likely to maintain his or her distorted body image and symptoms of BDD. Furthermore, he or she will be overwhelmed by a reflection that he or she accidentally catches when he or she passes a mirror. It may be better that patients learn to use mirrors in a healthy way with time limits depending on the activity (e.g., using a limited amount of make-up). Patients (whether they are gazing or avoiding) may need some guidance on their use of mirrors (for examples, see Table 1). In general, patients are encouraged to be aware of their appearance in the external reflection of a mirror but to suspend judgment (similar to “mindfulness”) (Linehan, 1993). Some patients benefit from video feedback if it is possible to test out specific hypotheses by making various predictions (e.g., that their face is a particular shade of red) before the feedback.

Table 1. Goals for Mirror Use

1.

To use mirrors at a slight distance that are large enough to show most of my body.

2.

To focus attention on my reflection in the mirror rather than an internal impression of how I feel.

3.

To use a mirror only for an agreed function (e.g., shaving, putting on make-up) and for a limited period.

4.

To suspend judgment and rating of my appearance in the mirror.

5.

Not to use mirrors that magnify my reflection.

6.

To use a variety of different mirrors and lights rather than sticking to one that I ‘trust.’

7.

To focus attention on the whole of my face rather than selected areas.

8.

Not to use ambiguous reflections (e.g., windows, the backs of CDs, or cutlery).

9.

Not to use a mirror whenever I feel I have to know what I look like, but to try to delay the response and do other activities until the urge has diminished.

Pharmacotherapy

The neurobiology of BDD is speculative. For example, there are case reports of the worsening of BDD with serotonin antagonists. Others have found impaired executive functioning, which implies frontostriatal dysfunction and an excessive input of anxiety. Body dysmorphic disorder is conceptualised as being on the spectrum of OCD, which may preferentially respond to a potent or selective serotonergic reuptake inhibitor (SSRI) rather than a noradrenergic reuptake inhibitor (for which there is equal efficacy in the treatment of depression). There is evidence for the modest benefit of SSRI antidepressants in two randomized controlled trials and several case series. Phillips et al. 2002 conducted an RCT of the SSRI fluoxetine, which demonstrated fluoxetine was more effective than a placebo. Of note is that patients with and without a delusional disorder did equally well with fluoxetine. In a second study, Hollander et al. (1999) conducted a crossover RCT of clomipramine versus desipramine. It demonstrated greater effectiveness for clomipramine (a potent serotonergic reuptake (p. 548) inhibitor) than desipramine (a potent noradrenergic inhibitor). Expert opinion is that before concluding that an SSRI is ineffective, the maximum tolerated dose must be taken for at least 12–16 weeks (similar to OCD).

There is no evidence for the benefit of antipsychotic medication alone in BDD or as an augmentation agent. Phillips et al. 2005 has demonstrated that adding an antipsychotic, pimozide, to an SSRI was no more effective than adding a placebo to patients who had not responded to an SSRI alone. Lastly Phillips 2005 reported on adding olanzapine to fluoxetine in six patients with BDD. Symptoms were only minimally improved in two patients and unchanged in four. There are no published RCTs on an SSRI in children and adolescents with BDD.

The Future

There is an unmet need for the early detection, diagnosis, and effective treatment of BDD. The gaps in our knowledge are recognized in the National Institute of Health and Clinical Excellence (NICE) guidelines on OCD and BDD, which identified as a research priority the assessment of “the acute and long-term efficacy, acceptability and the cost effectiveness of CBT and SSRIs, alone and in combination, compared with each other and with appropriate control treatments for both the psychological and pharmacological conditions. The trials should be powered to examine the effect of treatment for combined versus single-strand treatments and involve a follow-up of 1, 2 and 5 years” (National Collaborating Centre for Mental Health, 2006, p. 245). It further recommends “appropriately designed studies should be conducted to compare validated screening instruments for the detection of OCD and BDD. For BDD, specific populations would include young people or adults who consult in dermatology or plastic surgery and those with other psychiatric disorders” (p. 246). Much research is therefore required before BDD can catch up on other anxiety disorders, but results of existing studies are promising.

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