Although repetitive behaviors are not part of BDD’s diagnostic criteria, virtually all patients perform such behaviors, usually in an attempt to improve, hide, examine, or be reassured about the perceived flaw.7,9 (See Box 3 for a partial listing.) These behaviors are usually time-consuming, occurring for many hours a day, and, like the preoccupations, are typically difficult to resist or control. With the exception of camouflaging, however, they often do not diminish appearance concerns. In fact, some of them (e.g., mirror checking) may actually increase anxiety about the perceived flaw.
Comorbidity is common in patients seen in clinical settings.2,8 Major depression is the most frequent comorbid disorder, which often appears secondary to BDD.10 Other common comorbidities include substance-use disorders, obsessive-compulsive disorder (OCD), social phobia, and personality disorders (most often, avoidant personality disorder).
Individuals with BDD are distressed over their appearance, many to the point of contemplating, attempting, or completing suicide.4,5 Nearly one quarter of patients seen in a clinical setting have attempted suicide.9 Although some patients appear to function reasonably well, they usually function below their capacity—for example, by avoiding social situations or meetings at work where others will see them. Others are completely incapacitated by their BDD symptoms, unable to work or socialize, and may be housebound for years.2,8,9 In a study that used the SF-36 to measure health-related quality of life, outpatients with BDD scored notably worse in all mental health domains than did the general U.S. population and patients with depression, type II diabetes, or a recent myocardial infarction.2
DIAGNOSING BDD: Questions to ask patients
- Are you worried about your appearance in any way? If yes: What is your concern? OR Are you unhappy with how you look? If yes: What is your concern?
- Does this concern preoccupy you? That is, do you think about it a lot and wish you could worry about it less? OR If you add up all the time you spend each day thinking about your appearance, how much time would you estimate you spend?
- What effect has this preoccupation with your appearance had on your life? Has it:
BDD is diagnosed in patients who 1) are concerned about a minimal or nonexistent appearance flaw, 2) are preoccupied with the “flaw” (e.g., think about it for at least an hour a day), and 3) experience clinically significant distress or impairment in functioning as a result of their concern.
BDD CLUES
- Mirror checking or avoidance, or checking other reflective surfaces, such as windows, car bumpers, or the backs of spoons
- Reassurance seeking, that is, asking other people how they look or insisting that they look bad
- Skin picking, which may be manifested by skin lesions or scarring
- Excessive grooming, for example hair styling, applying makeup, shaving, tweezing hair, or cutting hair or wigs
- Camouflaging with a hat, toupee, makeup, sunglasses, clothes, or body position
- Excessive tanning, to darken “pale” skin
- Ideas or delusions of reference, thinking others take special notice of the “flaw” in a negative way (e.g., mock it or stare at it)
- Treatment-resistant anxiety, especially social anxiety, or depression
- Social avoidance or being housebound
- Unnecessary surgery, dermatologic treatment, or other nonpsychiatric treatment (e.g., electrolysis)
Guidelines for treating BDD
- Establish trust. It is important to convey that you take the patient’s appearance concerns seriously. Many patients with BDD fear being considered silly or vain and do not divulge their symptoms. It is usually best to avoid reassuring patients that they look fine, since they usually do not believe the reassurance and can interpret it as trivializing their concerns.
- Provide psychoeducation. Explain to patients that they have a relatively common and treatable body image disorder. To decrease the patient’s reluctance to accept the diagnosis and treatment, it can be helpful to emphasize the excessive preoccupation, distress, and other problems their symptoms are causing. Discussions about whether the defect is “real” are usually fruitless, unless the patient already has good insight, which is rare. Several educational books and Web sites for patients are available. See Related Resources.
- Target BDD symptoms in treatment. Ignoring BDD symptoms and focusing treatment on other symptoms only may be unsuccessful because effective treatment for BDD differs in some important ways from that of most other psychiatric disorders, such as depression.10 It appears, for example, that non-selective serotonin reuptake inhibitor (SSRI) antidepressants are generally ineffective for BDD, unless used at higher SSRI doses than are often needed for depression. BDD symptoms also do not necessarily improve in concert with symptoms of other disorders, such as depression or OCD.10
- Avoid nonpsychiatric medical treatment. Although no one can predict how an individual patient will respond to nonpsychiatric treatment, (e.g., surgery or dermatologic treatment), explain that as best we know, such treatment usually appears to be ineffective for BDD and even can make the symptoms worse.11