BDD is treatable; even patients with beliefs of delusional severity may respond to proper treatment. Generally, pharmacotherapy alone is more effective than psychotherapy alone, however an intense, multimodal approach is more effective than either alone. Barriers to effective treatment include lack of knowledge about BDD (especially on the part of providers); inaccurate diagnosis; patient embarrassment and shame; trivialization of symptoms by others; and the stigma attached to mental illness and patients' general reluctance to seek psychiatric treatment.
Patients with BDD may respond with anger and denial to a mental health referral. Insisting on a psychiatric referral may result in losing the patient to follow-up. Phrase the need for referral as "routine" to determine "if surgery or another treatment approach is right for you." Referral for vocational rehabilitation may also help.
Corrective surgical procedures rarely ease the patient's symptoms and may exacerbate them. Contraindications to an attempt at surgical correction include the absence of any true physical deformity, generalized dysmorphophobia, pressure from outside sources to have the procedure done, inadequate assessment of the deformity, unrealistic expectations of life change through surgery, previous unsatisfactory cosmetic surgery, coincidence of symptoms with a life crisis, and hostile or threatening behavior on behalf of the patient.
Many believe the diagnosis of BDD contraindicates cosmetic surgery. A possible exception is for the patient with Thersites complex, who may respond positively to surgical correction. Ineffective treatments include electroconvulsive therapy, various diets, uncovering early trauma in psychotherapy, insight-oriented therapy, hypnosis, and simply "trying harder." Reassurance generally helps only briefly, if at all, and may seem patronizing to the patient. Ordering referrals and further testing to reassure or appease the patient may actually promote anxiety and strengthen the patient's distorted somatic beliefs.
The clinician should validate the patient's concern but not directly confront delusional beliefs. Promote social function and avoidance of dysfunctional repetitive behaviors, such as mirror gazing and excessive grooming.
Encourage the patient's significant other to take the disorder seriously, talk openly about BDD, advocate and support psychiatric treatment, avoid blaming himself or herself, and be patient and remain hopeful. Advise the patient's partner to avoid: participating in behavioral rituals, giving reassurance (because seeking reassurance is a ritual behavior), arranging specialty referrals, and trying to talk the patient out of his compulsions. Instead, partners should encourage the patient to keep active and functioning at a higher level and to participate in family events. Caution partners to be vigilant for suicidal ideation; they should encourage psychiatric treatment by emphasizing that it may diminish pain and feeling of lack of control.
Psychotherapy can be a valuable part of any treatment regimen. During a medication discontinuation trial, patients were less likely to relapse following cognitive-behavioral therapy (CBT). CBT is the only approach proven effective for nondelusional patients. Consider CBT before pharmacotherapy if symptoms are mild and comorbidity that otherwise would require pharmacotherapy is absent. Treatment should be intense, with frequent sessions and homework. Components of effective CBT for BDD include psychoeducation, encouragement to gradually abandon ritual behaviors, exposure and response prevention, systematic desensitization to feared situations, and instruction in thought-stopping and relaxation techniques. Patients should also learn to stop camouflaging behaviors and avoiding mirrors. CBT for BDD encourages patients to limit grooming time and keep busy with other activities. Though therapeutic approaches are similar to those of OCD, the symptoms of BDD are more difficult to treat than those of OCD. Make psychotherapy referrals only to those therapists specifically trained in CBT approaches for OCD or BDD.
How Paul Has Progressed
Paul has been taking citalopram 60 mg daily for almost 2 years and has had no difficulty with depressed mood. His anxiety regarding appearance has diminished significantly. He has stopped picking at his skin and has had little difficulty with mirror gazing. He married a neighbor with 3 children a year ago and has been much more socially active, primarily with her family. He induces vomiting only a couple of times a week and has been using alcohol only in moderate amounts socially on weekends. He also occasionally attends social events associated with his wife's employment. He spends his days caring for his wife's children and is considering a part-time day or early evening job outside of the home. BDD is a tragic illness, monopolizing the patient's life and interfering with the attainment of academic, occupational, and social goals. The secrecy and shame associated with BDD prevent early diagnosis. An astute clinician should entertain the possibility of BDD when a patient's level of functioning appears more impaired than expected given other medical problems, individual talents, and environment. Fortunately, BDD usually responds well to treatment, allowing the patient to resume a healthy, fulfilling life.
Table 1: DSM Criteria For Body Dysmorphic Disorder
A. Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person's concern is markedly excessive.
B. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. The preoccupation is not better accounted for by another mental disorder (eg, dissatisfaction with body shape and size in anorexia nervosa).
Table 2: Questions Helpful In The Diagnosis Of BDD
1. Do you worry about the appearance of your face or body? If so, what is your concern? How bad do you think your face or body part appears?
How much time do you spend worrying about the appearance of your face or body part?
Have you done anything to hide the problem or rid yourself of the problem?
Does this concern with your appearance affect any aspect of your life (eg, school, job, social life)?
What effect has this preoccupation with your appearance had on your life (social, school, job, or other)?
Has it affected your family or friends?
2. Do you often check your appearance in mirrors or other reflecting surfaces such as windows? Or, do you frequently check your appearance without using a mirror, by looking directly at the disliked body part?
3. Do you frequently compare yourself to others and often think that you look worse than they do?
4. Do you spend a lot of time grooming — for example, combing or arranging your hair, tweezing or cutting your hair, applying makeup, or shaving?
Do you spend too much time getting ready in the morning, or do you groom yourself frequently during the day?
Do others complain that you spend too much time in the bathroom?
Do you try to cover or hide parts of your body with a hat, clothing, makeup, sunglasses, your hair, your hand, or other things? Is it hard to be around other people when you haven't done these things?
5. Do you think that other people take special notice of you because of how you look?
6. Is it hard for you to leave your house because of how you look?
7. Have you wanted to get cosmetic surgery, dermatologic treatment, or other medical treatment to fix your appearance when other people (for example, friends or doctors) have told you such treatment isn't necessary?
Have surgeons been reluctant to do cosmetic surgery, saying the defect is too minor or they're afraid you won't be pleased with the results?
8. Have you had cosmetic surgery and been disappointed with the results? Or have you had multiple surgeries, hoping that with the next procedure your appearance problems will finally be fixed?
9. Are you late for things because you worry you don't look OK or because you're trying to fix an appearance problem?
10. Have you felt that life wasn't worth living because of your appearance?
11. Do you feel more comfortable going out at night, or sitting in a dark part of a room, because your defects will be less visible?
12. Why are you seeking help now?
13. How might things be better if this problem were corrected?
Table 3: Clues To The Presence Of Body Dysmorphic Disorder
Patient presents with minor or nonexistent cosmetic abnormality
Excessive avoidance of social situations
Poor social support system
Poor occupational or academic involvement
Attempts to camouflage defect
Excessive grooming behaviors
Evidence of skin-picking
Excessively seeking reassurance from practitioner and others Extreme dissatisfaction with prior treatments
Multiple consultations with dermatologists, plastic surgeons, or otolaryngologists
History of multiple surgical procedures for correction of a defect in appearance
Unrealistic treatment expectations
Patient presents photographs, diagrams, or proposed corrective procedure
- John, Don St.; Imagined Ugliness: Body Dysmorphic Disorder; Physician Assistant, 87507544, Jul2003, Vol. 27, Issue 7
Nonpsychiatric Medical Treatment of Body Dysmorphic Disorder
- Crerand, C. E., Phillips, K. A., Mendard, W., and Fay, C. (2005). Nonpsychiatric Medical Treatment of Body Dysmorphic Disorder. Psychosomatics, 46(6). p. 549-555.
Reflection Exercise #10
The preceding section contained information
about evaluating treatment options for BDD. Write three
case study examples regarding how you might use the content of this section in
What is the most effective form of psychotherapy for most BDD clients? To select and enter your answer go to Test.