Treating body dysmorphic disorder with medication: evidence, misconceptions, and a suggested approach

Body dysmorphic disorder (BDD) is a relatively common and often disabling disorder with high morbidity and mortality. Both psychotropic medication and cognitive behavioral therapy (CBT) are considered first-line treatments for BDD, and medication treatment is often essential for more severely ill and suicidal patients. In this practical overview of the pharmacotherapy of BDD, we briefly describe BDD's clinical features, associated morbidity, and how to recognize and diagnose BDD. We describe the importance of forming a therapeutic alliance with the patient, the need for psychoeducation, and other essential groundwork for successful treatment of BDD. We review available pharmacotherapy research, with a focus on serotonin-reuptake inhibitors (SSRIs, or SRIs), which are currently considered the medication of choice for BDD. Many patients have substantial improvement in core BDD symptoms, psychosocial functioning, quality of life, suicidality, and other aspects of BDD when treated with appropriate pharmacotherapy that targets BDD symptoms. We also discuss practical issues such as dosing, length of treatment, and potential side effects associated with the use of SRIs. In addition, we discuss pharmacotherapy approaches that can be tried if SRI treatment alone is not adequately helpful. Finally, some misconceptions about pharmacotherapy, gaps in knowledge about BDD's treatment, and the need for additional research are discussed.     

The relationship of body dysmorphic disorder and eating disorders to obsessive-compulsive disorder

Body dysmorphic disorder (BDD) and eating disorders are body image disorders that have long been hypothesized to be related to obsessive-compulsive disorder (OCD). Available data suggest that BDD and eating disorders are often comorbid with OCD. Data from a variety of domains suggest that both BDD and eating disorders have many similarities with OCD and seem related to OCD. However, these disorders also differ from OCD in some ways. Additional research is needed on the relationship of BDD and eating disorders to OCD, including studies that directly compare them to OCD in a variety of domains, including phenomenology, family history, neurobiology, and etiology.     

Social anxiety in body dysmorphic disorder

Although clinical impressions suggest that patients with body dysmorphic disorder (BDD) experience distress in social situations, social anxiety in BDD has received little investigation. This study examined social anxiety in 81 patients with BDD and change in social anxiety with pharmacotherapy. Subjects completed the Social Avoidance and Distress Scale (SADS) and were assessed with measures of BDD symptomatology. Participants in a placebo-controlled fluoxetine trial completed measures at baseline and endpoint. The mean SADS score was 1.3 SD units higher than nonclinical sample means but consistent with other clinical sample means. Social anxiety was significantly correlated with BDD severity. Greater depressive symptoms as well as comorbid avoidant personality disorder, but not comorbid social phobia, were also associated with higher SADS scores. Social anxiety did not improve more with fluoxetine than placebo, yet it improved significantly more in fluoxetine responders than in nonresponders. Understanding social anxiety in BDD has implications for reducing rates of misdiagnosis and treatment dropout.     

Self-esteem in body dysmorphic disorder

Although studies indicate that poor body image is associated with poor self-esteem, few investigations have examined self-esteem in a clinical sample of individuals with body dysmorphic disorder (BDD). The present study examined self-esteem in 93 BDD patients and change in self-esteem with pharmacotherapy. Subjects completed the Rosenberg Self-Esteem Scale (RSES) and were assessed with other measures. Participants in a placebo-controlled fluoxetine trial completed measures at baseline and endpoint. The mean RSES score was approximately 1.5 SD units lower than means reported for nonclinical samples. Although poorer self-esteem was associated with more severe BDD and depression, as well as greater delusionality, the relationship between self-esteem and BDD severity was largely mediated by depressive symptoms. Self-esteem did not improve significantly more with fluoxetine than placebo, although it improved significantly more in fluoxetine responders than in nonresponders. It is unclear whether poor self-esteem predisposes to BDD and/or is a consequence of the disorder.     

Cognitive-Behavioral Therapy for Adolescent Body Dysmorphic Disorder

The onset of appearance-related concerns associated with body dysmorphic disorder (BDD) typically occurs in adolescence, and these concerns are often severe enough to interfere with normal development and psychosocial functioning. Cognitive behavioral therapy (CBT) is an effective treatment for adults with BDD. However, no treatment studies focusing on adolescents with BDD have been conducted. The need for an effective treatment in this population led to the development of a brief CBT protocol with family involvement. The treatment focuses on enhancing an adolescent's quality of life through the reduction of maladaptive thoughts and behaviors, and incorporates skills training and parent training. Similar treatment packages have already been shown to be efficacious for children and adolescents with similar disorders, such as obsessive-compulsive disorder and social phobia. The following case illustrates the application of this brief CBT protocol for BDD in an adolescent, and highlights clinical considerations needed when adapting CBT for a pediatric population. Treatment was associated with clinically significant improvement in symptoms of BDD, self-esteem, depression, and quality of life. This report extends extant literature by suggesting that CBT may be a helpful treatment for adolescents with BDD.     

Body image in patients with body dysmorphic disorder: Evaluations of and investment in appearance,health/illness,and fitness

Body image is an important aspect of body dysmorphic disorder (BDD) which has received little investigation. Ninety-two BDD participants who participated in one of three BDD pharmacotherapy studies completed the Multidimensional Body-Self Relations Questionnaire, which assesses attitudinal body image, specifically evaluations of and investment in appearance, health/illness, and physical fitness. Scores were compared to population norms. Compared to norms, BDD participants were significantly less satisfied with their appearance. Less satisfaction was associated with more severe BDD and greater delusionality. Men with BDD were significantly more invested in their appearance compared to male population norms. Compared to population norms, males and females with BDD felt less physically healthy and females were less invested in a healthy lifestyle. However, compared with population females, females with BDD were less alert to being ill. These findings suggest that patients with BDD differ from population norms in a number of important aspects of body image.     

Case Conceptualization and Treatment of Comorbid Body Dysmorphic Disorder and Bulimia Nervosa

Body dysmorphic disorder (BDD) and eating disorders often co-occur and share some clinical features. In addition, the co-occurrence of BDD and an eating disorder may be associated with greater impairment in functioning. Furthermore, clinical impressions suggest that this comorbidity may be more treatment resistant than either disorder alone. The current article discusses the treatment of a 48-year-old female diagnosed with BDD and comorbid bulimia. We attempted to address these co-occurring disorders in a strategic, formulation-based manner using a variety of cognitive-behavioral strategies such as cognitive restructuring, rational disputation, exposure with response prevention, and mirror retraining. Despite the complexity of this case, results suggest that comorbid BDD and bulimia nervosa can be effectively managed with cognitive behavioral therapy.     

Severity of interpersonal problems in individuals with body dysmorphic disorder

Body dysmorphic disorder (BDD) is a relatively common and often severe disorder. Although individuals with BDD have markedly poor psychosocial functioning, the nature of interpersonal problems has been only minimally investigated. This study examined the severity, domains, and correlates of interpersonal problems in 51 individuals with BDD using the Inventory of Interpersonal Problems-64 (IIP-64) and other reliable and valid measures. Compared to norms for a U.S. community sample, individuals with DSM-IV BDD reported greater severity of interpersonal problems across most IIP-64 domains. BDD subjects' scores were most elevated on the Socially Inhibited and Nonassertive subscales. More severe BDD symptoms were significantly correlated with higher scores on the Socially Inhibited, Nonassertive, and Vindictive/Self-Centered subscales and with IIP-64 total score. In a logistic regression analysis, BDD severity and a personality disorder were independently associated with severity of interpersonal problems. These findings suggest that individuals with BDD have significant problems with interpersonal relationships, particularly in the areas of social inhibition and nonassertiveness.     

Cognitive-Behavioral Therapy for Adolescent Body Dysmorphic Disorder: A Pilot Study

Body dysmorphic disorder (BDD) is a relatively common and severe disorder that typically onsets in adolescence, but often goes unrecognized. Despite BDD’s severity and early onset, treatment outcome research on adolescent BDD is scarce. Cognitive-behavioral therapy is the gold-standard psychosocial treatment for BDD in adults and has shown promise in adolescents. The current study examined the development and testing of a new CBT for adolescents with BDD. We tested feasibility, acceptability, and treatment outcome in a sample of 13 adolescents (mean age 15.23 years, range: 13–17) with primary BDD. Treatment was delivered in 12–22 weekly individual sessions. Standardized clinician ratings and self-report measures were used to assess BDD and related symptoms pre- and posttreatment and at 3- and 6-months follow-up. At posttreatment, BDD and related symptoms (e.g., insight, mood) were significantly improved. Scores on the Yale–Brown Obsessive Compulsive Scale for BDD indicated a 50% (intent-to-treat) and 68% (completer) improvement in BDD symptoms. Seventy-five percent of adolescents who started treatment and 100% of completers were considered treatment responders. Treatment gains were maintained at follow-up. High patient satisfaction ratings and patient feedback indicated that treatment was acceptable. This represents the largest study of a psychosocial treatment for adolescent BDD.     

Emotion recognition in body dysmorphic disorder: Application of the Reading the Mind in the Eyes Task

Body dysmorphic disorder (BDD) is characterized by perceived appearance-related defects, often tied to aspects of the face or head (e.g., acne). Deficits in decoding emotional expressions have been examined in several psychological disorders including BDD. Previous research indicates that BDD is associated with impaired facial emotion recognition, particularly in situations that involve the BDD sufferer him/herself. The purpose of this study was to further evaluate the ability to read other people's emotions among 31 individuals with BDD, and 31 mentally healthy controls. We applied the Reading the Mind in the Eyes task, in which participants are presented with a series of pairs of eyes, one at a time, and are asked to identify the emotion that describes the stimulus best. The groups did not differ with respect to decoding other people's emotions by looking into their eyes. Findings are discussed in light of previous research examining emotion recognition in BDD.     

体像障碍的认知机制及治疗

体像障碍是一种对想象的或轻微外表缺陷的先占观念, 这种先占观念给个体带来极大的痛苦。其负性的自我认知框架, 影响个体对信息的选择、组织及评估。因此结合心理实验范式和神经生理综合分析体像障碍的认知过程, 对深化体像障碍认知机制和优化其认知行为治疗具有重要意义。     

Perceived teasing experiences in body dysmorphic disorder

Individuals with body dysmorphic disorder (BDD) are excessively concerned about imagined or slight defects in their appearance (e.g., asymmetrical facial features). Cognitive-behavioral models of BDD propose that several factors, including dysfunctional appearance-related beliefs and life experiences, such as teasing, contribute to the avoidance behaviors or rituals (e.g., mirror checking, grooming) characteristic of BDD. Previous research has demonstrated an association between perceived teasing and body dissatisfaction. In the current study, we examined whether individuals with BDD (n = 16) report to have been teased more often than do mentally healthy controls (n = 17). The group comprising individuals with BDD reported more appearance- and competency-related teasing than did control participants. This study provides preliminary evidence for the association between perceived teasing and BDD.     

A Multimethod Analysis of Incompleteness and Visual “Not Just Right” Experiences in Body Dysmorphic Disorder

Individuals with body dysmorphic disorder (BDD) often report engaging in repetitive behaviors aimed at reducing feelings of imperfection anchored to their appearance. “Not just right” experiences (NJREs) and incompleteness (INC) are constructs related to perfectionism that have traditionally been studied in obsessive-compulsive disorder, though recent research has also linked these phenomena to BDD. We sought to replicate and extend this research via two studies. Study 1 examined BDD symptoms, INC, as well as harm avoidance (HA) in an unselected sample (N = 179); moderate associations were observed between symptoms and both INC and HA. Participants also completed a novel visual NJRE task in which they were shown appearance-related and non-appearance-related images meant to evoke an NJRE response (i.e., discomfort and urge to “fix” stimuli). BDD symptoms predicted reactivity to appearance-related NJRE stimuli above negative affect. Study 2 compared INC, HA, and task reactivity in a BDD sample (N = 50) to nonpsychiatric controls (N = 44). The BDD group evidenced greater INC, HA, and reactivity to both appearance and nonappearance NJRE stimuli, relative to controls; however, group differences did not remain after controlling for age and negative affect. These studies broadly corroborate previous research highlighting NJREs and INC as potential vulnerability factors relevant to BDD, though these phenomena may not be specific to BDD symptoms.     

Reality monitoring in patients with body dysmorphic disorder

Patients with body dysmorphic disorder (BDD) typically have very poor insight into their disorder. Their conviction in their ugliness is often of delusional intensity. Reality monitoring is the ability to distinguish in memory between things that one has imagined and things that one has perceived. Deficits in reality monitoring have been associated with the development of other delusional beliefs. Therefore, in the present study we investigated whether individuals with BDD (n = 20) demonstrate impairments in reality monitoring relative to individuals with obsessive-compulsive disorder (OCD; n = 20) and healthy controls (n = 20). This hypothesized impairment might predispose people with BDD to confuse memories of how they imagine themselves to appear (i.e., ugly) with memories of how they actually appear (i.e., normal). All participants completed a memory task assessing reality-monitoring ability for verbal stimuli. The BDD patients did not exhibit a reality-monitoring deficit despite elevated levels of focal delusionality. The results suggest that impairments in reality monitoring do not contribute to the development or maintenance of appearance-related beliefs in BDD.     

Predictors of Response to Cognitive-Behavioral Therapy for Body Dysmorphic Disorder

Body dysmorphic disorder (BDD) is a common and distressing or impairing preoccupation with a perceived defect in physical appearance. Individuals with BDD engage in time-consuming rituals to check, hide, or “fix” their appearance or alleviate distress. BDD is associated with substantial psychosocial impairment and high rates of depression, hospitalization, and suicidality. Cognitive-behavioral therapy (CBT) is the treatment of choice for BDD, but not everyone benefits. We examined predictors of CBT-related improvement, an important topic that has received very limited investigation. Treatment was delivered in weekly individual sessions over 18–22 weeks. Results indicated that greater motivation/readiness to change (University of Rhode Island Change Assessment Questionnaire), greater treatment expectancy (Treatment Credibility/Expectancy Questionnaire), and better baseline BDD-related insight (Brown Assessment of Beliefs Scale) significantly predicted better CBT response at posttreatment. Baseline BDD symptom severity and depression did not predict outcome, suggesting that even patients with more severe BDD and depressive symptoms can benefit from CBT for BDD. Efforts should be aimed at enhancing readiness to change and confidence in the treatment at treatment onset as well as addressing the poor insight that often characterizes BDD.     

The pathophysiology of body dysmorphic disorder

Body dysmorphic disorder (BDD) is an often severe and disabling condition, affecting up to 2% of the population. Despite its prevalence and clinical significance, very little is known about the pathophysiology of BDD. However, clues to its possible neurobiological substrates and abnormalities in information processing are starting to emerge. This article reviews findings from genetic, brain lesion, neuroimaging, neuropsychological, and psychopharmacological studies that have allowed us to develop a tentative model of the functional neuroanatomy of BDD. There is likely a complex interplay of dysfunctions in several brain networks underlying the pathophysiology of BDD. A combination of dysfunctions in frontal-subcortical circuits, temporal, parietal, and limbic structures, and possibly involving hemispheric imbalances in information processing, may produce both the characteristic symptoms and neurocognitive deficits seen in BDD. An improved understanding of the pathophysiology of BDD will be crucial to guide the development of better treatments.     

Clinical considerations for the treatment of body dysmorphic disorder with cognitive-behavioral therapy

Although cognitive behavior therapy has been found to be very effective in the treatment of body dysmorphic disorder (BDD), there still remain a number of challenges that clinicians face in the treatment of individuals with BDD. In this article, we discuss issues related to comorbid depression, suicidality, substance use disorders, personality disorders as well as the role of early life experiences, delusional intensity of beliefs, and motivation to change. The aim of this review is to provide a treatment aid to clinicians by offering specific recommendations for improved care based on the available literature as well as our clinical experience.     

Discrimination of facial appearance stimuli in body dysmorphic disorder

Cognitive-behavioral models of body dysmorphic disorder (BDD) propose that information-processing biases--in particular, selective attention to a defect in one's appearance as well as improved aesthetical perception--might contribute to the development or maintenance of the disorder. In the present study, the authors tested the hypothesis that patients with BDD discriminate facial appearance stimuli more accurately than controls. Sixty female patients from a dermatological clinic participated in the study: 21 patients with BDD, 19 patients with disfiguring dermatological conditions, and 20 patients with nondisfiguring dermatological disorders. Participants rated dissimilarities between pictures of neutral faces that had been manipulated with regard to aesthetic characteristics. Manipulation ratings of participants with BDD were significantly more accurate than those of both control groups. Implications of these results for cognitive theories of BDD are discussed.