Clinical Features and Treatment of Body Dysmorphic Disorder

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.”

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).

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.

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.

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).

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.

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.