Evidence-Based Reviews

Beyond the mirror: Treating body dysmorphic disorder

Current Psychiatry. 2005 October;4(10):69-82

References

1. Diagnostic and statistical manual of mental disorders (4th ed. text rev.). Washington, DC: American Psychiatric Association; 2000.

2. Phillips KA, Coles ME, Menard W, et al. Suicidal ideation and suicide attempts in body dysmorphic disorder. J Clin Psychiatry 2005;66(6):717-25.

3. Otto MW, Wilhelm S, Cohen LS, Harlow BL. Prevalence of body dysmorphic disorder in a community sample of women. Am J Psychiatry 2001;158(12):2061-3.

4. Wilhelm S, Otto MW, Zucker BG, Pollack MH. Prevalence of body dysmorphic disorder in patients with anxiety disorders. J Anxiety Disord 1997;11(5):499-502.

5. Phillips KA, Nierenberg AA, Brendel G, Fava M. Prevalence and clinical features of body dysmorphic disorder in atypical major depression. J Nerv Ment Dis 1996;184(2):125-9.

6. Hollander E, Cohen L, Simeon D. Body dysmorphic disorder. Psychiatr Ann 1993;23:359-64.

7. Veale D, Boocock A, Gournay K, et al. Body dysmorphic disorder. survey of fifty cases. Br J Psychiatry 1996;169(2):196-201.

8. Phillips KA. Psychosis in body dysmorphic disorder. J Psychiatr Res 2004;38(1):63-72.

9. Dufresne RG, Phillips KA, Vittorio CC, Wilkel CS. A screening questionnaire for body dysmorphic disorder in a cosmetic dermatologic surgery practice. Dermatol Surg 2001;27(5):457-62.

10. Rosen JC, Reiter J. Development of the body dysmorphic disorder examination. Behav Res Ther 1996;34(9):755-66.

11. Phillips KA, Hollander E, Rasmussen SA, et al. A severity rating scale for body dysmorphic disorder: development, reliability, and validity of a modified version of the Yale-Brown Obsessive Compulsive Scale. Psychopharmacol Bull 1997;33(1):17-22.

12. Gunstad J, Phillips KA. Axis I comorbidity in body dysmorphic disorder. Compr Psychiatry 2003;44(4):270-6.

13. Perugi G, Akiskal HS, Giannotti D, et al. Gender-related differences in body dysmorphic disorder (dysmorphophobia). J Nerv Ment Dis 1997;185(9):578-82.

14. Zimmerman M, Mattia JI. Body dysmorphic disorder in psychiatric outpatients: recognition, prevalence, comorbidity, demographic, and clinical correlates. Compr Psychiatry 1998;39(5):265-70.

15. Phillips KA. The broken mirror. New York: Oxford University Press; 2005.

16. Rauch SL, Phillips KA, Segal E, et al. A preliminary morphometric magnetic resonance imaging study of regional brain volumes in body dysmorphic disorder. Psychiatry Res 2003;122(1):13-19.

17. Veale D. Body dysmorphic disorder. Postgrad Med J 2004;80(940):67-71.

18. Saxena S, Winograd A, Dunkin JJ, et al. A retrospective review of clinical characteristics and treatment response in body dysmorphic disorder versus obsessive-compulsive disorder. J Clin Psychiatry 2001;62:67-72.

19. Phillips KA, Najjar F. An open-label study of citalopram in body dysmorphic disorder. J Clin Psychiatry 2003;64(6):715-20.

20. Phillips KA, Dwight MM, McElroy SL. Efficacy and safety of fluvoxamine in body dysmorphic disorder. J Clin Psychiatry 1998;59(4):165-71.

21. Phillips KA, Albertini RS, Rasmussen SA. A randomized placebo-controlled trial of fluoxetine in body dysmorphic disorder. Arch Gen Psychiatry 2002;59(4):381-8.

22. Hollander E, Allen A, Kwon J, et al. Clomipramine vs desipramine crossover trial in body dysmorphic disorder: Selective efficacy of a serotonin reuptake inhibitor in imagined ugliness. Arch Gen Psychiatry 1999;56(11):1033-9.

23. Phillips KA, McElroy SL, Dwight MM, et al. Delusionality and response to open-label fluvoxamine in body dysmorphic disorder. J Clin Psychiatry 2001;62(2):87-91.

24. Phillips KA, Albertini RS, Siniscalchi JM, et al. Effectiveness of pharmacotherapy for body dysmorphic disorder: a chart-review study. J Clin Psychiatry 2001;62(9):721-7.

25. Phillips KA. An open study of buspirone augmentation of serotonin-reuptake inhibitors in body dysmorphic disorder. Psychopharmacol Bull 1996;32(1):175-80.

26. Phillips KA, McElroy SL, Keck PE, Jr, et al. A comparison of delusional and nondelusional body dysmorphic disorder in 100 cases. Psychopharmacol Bull 1994;30(2):179-86.

27. Phillips KA. Placebo-controlled study of pimozide augmentation of fluoxetine in body dysmorphic disorder. Am J Psychiatry 2005;162(2):377-9.

28. Phillips KA. Olanzapine augmentation of fluoxetine in body dysmorphic disorder. Am J Psychiatry 2005;162(5):1022-3.

29. Grant JE, Menard W, Pagano ME, et al. Substance use disorders in individuals with body dysmorphic disorder. J Clin Psychiatry 2005;66(3):309-16.

30. Foa EB. Failures in treating obsessive-compulsives. Behav Res Ther 1979;17:169-76.

31. Phillips KA, McElroy SL, Keck PE, Jr, et al. Body dysmorphic disorder: 30 cases of imagined ugliness. Am J Psychiatry 1993;150(2):302-8.

Table 2

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

Study	N	Major depression	Social phobia	OCD	Substance use disorders
Gunstad and Phillips (2003)*¹²	175	75	37	30	30
Zimmerman and Mattia (1998)¹⁴	16	69	69	38	6
Perugi et al (1997)¹³	58	41	12	41	†
Veale et al (1996)⁷	50	8	16	6	2
Hollander et al (1993)⁶	50	68	12	78	22
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.

Pharmacotherapy

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-label^19,20 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*^†

Drug	Dosage range (mg/d)
Citalopram	40 to 100
Clomipramine	150 to 250
Escitalopram	20 to 50
Fluoxetine	40 to 100
Fluvoxamine	200 to 400
Paroxetine	40 to 100
Sertraline	150 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?”