Understanding and treating body dysmorphic disorder.

Body dysmorphic disorder (BDD), also known as dysmorphophobia, is a condition that consists of a distressing or impairing preoccupation with imagined or slight defects in appearance, associated repetitive behaviors and where insight regarding the appearance beliefs is often poor. Despite the fact it is relatively common, occurs around the world and can have a significant impact on a sufferer's functioning, levels of distress, and risk of suicide, the diagnosis is often missed. In this review, we outline the clinical features of BDD including as characterized in the newly published World Health Organization's International Classification of Diseases 11, review the prevalence of BDD within different settings, and highlight the reasons why BDD may be underdiagnosed even within psychiatric settings. We additionally review the cultural considerations for BDD and finally discuss the evidence-based treatment approaches for BDD, particularly the use of serotonin reuptake inhibitor medication and cognitive behavioral therapy.

INTRODUCTION

An Italian psychiatrist first wrote about body dysmorphic disorder (BDD) in 1891: “The dysmorphophobic, indeed, is a veritably unhappy individual, who in the midst of his daily affairs, in conversations, while reading, at table, in fact anywhere and at any hour of the day, is suddenly overcome by the fear of some deformity that might have developed in his body without his noticing it. He fears having or developing a compressed, flattened forehead, a ridiculous nose, crooked legs, etc., so that he constantly peers in the mirror, feels his forehead, measures the length of his nose, examines the tiniest defects in his skin, or measures the proportions of his trunk and the straightness of his limps, and only after a certain period of time, having convinced himself that this has not happened, is able to free himself from the state of pain and anguish the attack put in him. But should no mirror be at hand, or should he be prevented from quieting his doubts in some way or other by means of some mechanism or movements of the most outlandish kinds, the attack does not end very quickly, but rather may reach a very painful intensity, even to the point of weeping and desperation.”[1]

Concerns about one's appearance are recognized and accepted in most cultures as an aspect of normal human behavior. However, if these concerns are excessive and are either significantly distressing or having an impact on the individual's quality of life, the person may be suffering from BDD.

Although BDD was first described over 100 years ago by Italian psychiatrist Enrico Morselli who coined the term “dysmorphophobia,” from the Greek “dysmorphia” which refers to ugliness, the evidence suggests it is still underdiagnosed.[2] Failure to recognize BDD can lead to poor physical and psychiatric outcomes for patients[3] and without treatment BDD appears to have a chronic course.[4]

This review will outline the clinical characteristics, prevalence, cultural considerations, and treatment for BDD to further clinician's knowledge of BDD and to improve the identification and initiation of appropriate treatment for BDD.

CLINICAL CHARACTERISTICS OF BODY DYSMORPHIC DISORDER

The fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental disorders-5 characterizes BDD as a preoccupation with a perceived defect or a markedly excessive concern where there is a slight physical anomaly, with associated significant distress and/or functional impairment.[5] The newly published World Health Organization's International Classification of Diseases 11 (ICD-11) states that BDD is characterized by persistent preoccupation with one or more perceived defects or flaws in appearance that are either unnoticeable or only slightly noticeable to others. Individuals experience excessive self-consciousness, often with ideas of reference (i.e., the conviction that people are taking notice, judging, or talking about the perceived defect or flaw).[6] The criteria for BDD also specify that at some point during the course of illness, the individual will have performed repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, and reassurance seeking) or mental acts (e.g., comparing his or her appearance with that of others) in response to their appearance concerns and painful resulting emotions. These repetitive behaviors and mental acts are not pleasurable and are hard to control/resist.[7]

Individuals with BDD obsess over certain aspects of their appearance. Any part of the body may be implicated in BDD; however, the most common is the face/head, particularly the skin, nose, and hair.[8] On average, over their lifetime, persons with BDD are preoccupied with 5–7 different body parts.[9] Concerns may also involve the appearance of the entire body for instance the muscle dysmorphia form of BDD which consists of the belief that one's body is too small and/or insufficiently muscular.[10] On average people suffering from BDD in a psychiatric service will spend 3–8 h preoccupied with their physical appearance, though 25% will spend >8 h a day. The preoccupations are intrusive, unwanted, and associated with distressing emotions such as shame, disgust, anxiety, and sadness.[11]

Insight regarding the appearance beliefs is often poor, i.e., the beliefs can be of a delusional intensity. Studies have found that current delusional beliefs in BDD range from 32% to 38%.[121314] The presence of delusional beliefs is linked to increased severity of BDD symptom[1516] and is not either a primary psychotic illness or a distinct entity separate from BDD without delusional beliefs.[17] The ICD-11 highlights the important variation in insight that is present for people with BDD with two subcategories. There is a subcategory for BDD with fair to good insight “Much of the time, the individual can entertain the possibility that his or her disorder-specific beliefs may not be true and is willing to accept an alternative explanation for his or her experience. At circumscribed times (e.g., when highly anxious), the individual may demonstrate no insight,” and a category for BDD with poor to absent insight, “Most or all of the time, the individual is convinced that the disorder-specific beliefs are true and cannot accept an alternative explanation for their experience. The lack of insight exhibited by the individual does not vary markedly as a function of anxiety level.”[6]

As a consequence of the preoccupation, the associated distress and concerns that others may reject them, there is almost always associated impairment in one or more areas of social, occupational, academic, and role functioning.[18] Patients may avoid intimate relationships, stop attending educational establishments/work, and avoid social activities and may indeed become completely housebound. BDD is also associated with high rates of suicidality. A recent meta-analysis concluded that patients with BDD were four times more likely to experience suicidal ideation and 2.6 times more likely to engage in suicide attempts compared to individuals without BDD.[19]

Many psychiatric illnesses have been reported to cooccur with BDD, the most common being major depressive disorder, social phobia, obsessive-compulsive disorder, and substance misuse disorders.[92021] A patient may be diagnosed with a comorbid disorder; however, the BDD may be missed, meaning patients do not receive the appropriate treatment they need.

PREVALENCE OF BODY DYSMORPHIC DISORDER

A recent systematic review[2] highlighted the prevalence of BDD within different settings. They found the weighted prevalence of BDD in adults in the community was estimated to be 1.9% though this was increased when looking at specific psychiatric settings (adult psychiatric outpatients (5.8%) and adult psychiatric inpatients 7.4%) and even further increased in the context of other nonpsychiatric specialties such as general cosmetic surgery 13.2%; in rhinoplasty surgery 20.1%; in orthognathic surgery 11.2%; in orthodontics/cosmetic dentistry settings 5.2%; in dermatology outpatients 11.3%; and in cosmetic dermatology outpatients 9.2%.

This finding highlights one challenging aspect of diagnosing BDD, i.e., that a large proportion of patients with BDD will present to nonpsychiatric specialties and may not themselves identify that they are suffering from a mental disorder. Indeed, the evidence suggests that BDD is underdiagnosed and that presentation to nonpsychiatric specialties is just one factor. A number of studies have highlighted that even within psychiatric settings, the diagnosis of BDD is suboptimal. Three studies within inpatient units[222324] and two studies set in outpatient psychiatric settings[2526] have highlighted that when patients are systematically screened for the presence of BDD and the diagnosis is made, almost none of the patients had a BDD diagnosis within their medical records. In fact, only in one study was a single patient out of a total of 14 patients diagnosed with BDD by both the researchers and within the clinical records. In the remaining studies, no patients were. A study by Conroy et al.[27] demonstrated that within an inpatient adult psychiatric ward, 16 patients (16%) had a past (5 patients) or current (11 patients) diagnosis of BDD; however, disclosure was low with patients revealing BDD symptoms to a mean of only 15.1% ±33.7% lifetime mental health clinicians and only one patient disclosing to their current inpatient psychiatrist. This was despite one quarter reporting that BDD was a major reason or somewhat of a reason for their current hospitalization. Reasons for not disclosing, including feeling too embarrassed, being afraid of negative judgment, feeling that their clinician would not understand their concerns, not knowing that there is treatment for BDD, not being asked about BDD, feeling that BDD was not a big problem, not wanting to know that their body image concerns were a problem, and thinking that other people did not have this problem.

The lack of spontaneous disclosure highlights the need for psychiatrists to specifically ask about BDD symptoms when assessing patients. Using specific screening instruments may also be helpful, particularly when assessing patients with disorders that can be comorbid with BDD or may mask the true diagnosis of BDD, such as depression, obsessive-compulsive disorder, or an anxiety disorder. Examples of screening tool that could be used include either the BDD Questionnaire which is a four-item measure that has high sensitivity (94%–100%) and specificity (89%–93%) in detecting BDD in a range of settings[2829] or the cosmetic procedures screening for BDD.[30]

BDD usually begins in adolescence though it can be 10 years or more before diagnosis and appropriate treatment.[921] Compared with adults, adolescents who present with BDD have higher lifetime suicide rates and more delusional beliefs.[31] In a weighted prevalence study,[2] the prevalence of BDD was found to be slightly higher among females (2.1%) than males (1.6%). This data suggests that men are affected by BDD though likely not as commonly as women.

CULTURAL CONSIDERATIONS

There is a lack of research comparing the clinical features of BDD between and within countries among different populations and cultures.[32] The majority of research currently derives from North America and Western Europe.

The only cross-cultural study to date of BDD compared nonclinical samples of American (n = 101) and German (n = 133) students, finding similar prevalence rates in the two groups (4.0% of Americans and 5.3% of Germans).[33] There are also a variety of reports on BDD from different parts of the world, including South America, Turkey, Africa, and the Indian subcontinent which suggests that BDD contains similar clinical features.[3435363738]

However, it is likely that manifestations of BDD may be influenced by cultural ideas around beauty. For example, Japanese case reports discuss eyelids as the feature focus, which is a rare physical complaint in the Western culture.[39] Similarly, the muscle dysmorphia variant of BDD appears to be more common in Western societies compared to East Asia.[40]

TREATMENT

The treatment of choice in BDD is cognitive behavioral therapy (CBT) and serotonin reuptake inhibitor (SRI) medication.

SRI medication refers to all of the selective SRI (SSRI) class of antidepressants (fluoxetine, sertraline, paroxetine, citalopram, escitalopram, and fluvoxamine) and one antidepressant from the tricycle class, clomipramine, which is a potent SRI. The evidence for the use of SRI's in BDD is based on three randomized controlled trials. Phillips et al. (2002)[41] found that fluoxetine was significantly more effective than a placebo in improving BDD symptoms (d = 0.70), and Hollander et al.[42] found clomipramine was more efficacious than the non-SRI antidepressant desipramine for BDD symptoms, depressive symptoms, and functional disability. The third randomized controlled trial examined what happened when patients with BDD who had responded to escitalopram were either switched to a placebo or continued on escitalopram for a further 6 months.[43] They found that the time to relapse was longer in those who continued to receive escitalopram and that the rates of relapse were less for those on escitalopram compared to those switched to placebo (18% vs. 40%). This study highlights that escitalopram is an effective treatment for BDD compared to placebo and additionally that there is a risk of relapse when an efficacious SRI medication is stopped. Five open-label trials of fluvoxamine, citalopram, and escitalopram found that these SRI's improved BDD and associated symptoms in 63%–83% of patients.[4344454647]

There is an absence of dose-finding studies of SRI medications in BDD; however, the clinical experts in the field have suggested that higher doses are required as compared to depression and that some patients may need more than the maximum regulated dose.[18]

CBT for BDD aims to help patients build an alternative understanding of their difficulties, reduce self-focused attention, and ruminating and self-defeating coping strategies. Patients are guided through graded exposure or behavioral experiments to test out their fears.[48] As insight regarding the appearance beliefs is often poor and patients may be very ambivalent about psychological treatment, motivational interviewing techniques will often need to be applied at later stages of therapy also.[49]

The National Institute for Health and Clinical Excellence guidelines recommend CBT that is specific for BDD, which follows a protocol over 16–24 sessions.[50] Evidence for CBT is based on four small randomized controlled trials (RCTs) of CBT for adults with BDD that have demonstrated a greater efficacy of CBT compared with a waitlist,[51525354] though of course, they did not involve a comparison treatment to control for attention and nonspecific therapeutic factors. To date, there is only one study that has compared CBT for BDD versus another type of therapy.[55] This study randomly allocated 46 adult patients with BDD to either receive CBT or anxiety management (AM). Fifty-four percentage of participants were classified as having a delusional BDD. At 12 weeks, CBT was found to be significantly superior to AM in reducing symptom severity and on improving the secondary outcome measures such as quality of life and level of insight. This effect was also seen for those individuals with delusional beliefs or depression suggesting that CBT is just as effective as reducing BDD severity in these more impaired groups. Given the challenges that can be faced by patients trying to access CBT for BDD, one RCT randomized 94 adult patients to either a therapist-guided internet-based CBT program (BDD-NET) or online supportive therapy.[56] They found that BDD-NET was superior to supportive therapy and was associated with significant improvements in the severity of BDD symptoms and that at follow-up, 56% of those receiving BDD-NET were classed as responders, compared with 13% receiving supportive therapy. A meta-analyses of the all of the above six RCTs plus an RCT within the adolescent population concluded that CBT compared to waitlist/psychological placebo was an efficacious treatment for BDD symptoms, depression associated with BDD and levels of insight.[57]

There still remain a number of areas within the treatment of BDD which require further investigation. At this time, it is not known whether either medication or CBT is more efficacious for BDD, as no randomized controlled studies have directly compared them. Furthermore, no RCTs have examined whether SSRI can enhance the outcome of CBT for BDD either in the short-term or long-term though clinical experience suggests this is a useful strategy for severe BDD.

CONCLUSIONS

BDD is a relatively common and debilitating mental health condition which is distinct to normative body appearance concerns. An increasing body of work has identified evidence-based treatments which have been shown to improve symptoms for most patients with BDD, namely, the use of SRI medication and CBT. Certainly, BDD remains underdiagnosed due to a variety of factors which means patients are unlikely to receive the treatment they require and continue to suffer.

Further research is needed to help clinicians be better able to identify BDD and treat it within their populations including cross-cultural differences in presentation, further understanding of the factors predicting treatment response and research into more effective and easily accessible treatment options, including the use of technology.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.