Empirically Defining Treatment Response and Remission in Body Dysmorphic Disorder Using a Short Self-Report Instrument

Determining response or remission status in body dysmorphic disorder (BDD) usually requires a lengthy interview with a trained clinician. This study sought to establish empirically derived cutoffs to define treatment response and remission in BDD using a brief self-report instrument, the Appearance Anxiety Inventory (AAI). Results from three clinical trials of BDD were pooled to create a sample of 123 individuals who had received cognitive-behavioral therapy for BDD, delivered via the Internet. The AAI was compared to gold-standard criteria for response and remission in BDD, based on the clinician-administered Yale–Brown Obsessive Compulsive Scale, modified for BDD (BDD-YBOCS), and evaluated using signal detection analysis. The results showed that a ≥ 40% reduction on the AAI best corresponded to treatment response, with a sensitivity of 0.71 and a specificity of 0.84. A score ≤ 13 at posttreatment was the optimal cutoff in determining full or partial remission from BDD, with a sensitivity of 0.75 and a specificity of 0.88. These findings provide benchmarks for using the AAI in BDD treatment evaluation when resource-intensive measures administered by clinicians are not feasible.     

Advances in a cognitive behavioural model of body dysmorphic disorder

Body dysmorphic disorder (BDD) is the most distressing and handicapping of all the body image disorders. A cognitive behavioural model of BDD is discussed which incorporates evidence from recent studies and advances in the author’s 1996 conceptual model. The model aims to understand the maintenance of symptoms in BDD, to assist in the process of engagement of therapy and to guide the strategies to use. At the core of BDD is an excessive self-focussed attention on a distorted body image, the negative appraisal of such images leading to rumination, changes in mood and the use of safety behaviours. Evidence for possible risk factors in the development of BDD is also discussed.     

Mirror gazing in body dysmorphic disorder and healthy controls: effects of duration of gazing

Cognitive-behavioural models of body dysmorphic disorder (BDD) suggest that mirrors can act as a trigger for individuals with BDD, resulting in a specific mode of cognitive processing, characterised by an increase in self-focussed attention and associated distress. The aim of the current study was to investigate these factors experimentally by exposing participants with BDD (n = 25) and without BDD (n = 25) to a mirror in a controlled setting. An additional aim was to ascertain the role of duration of mirror gazing in the maintenance of distress and self-consciousness by manipulating the length of gazing (short check vs. long gazing). Findings demonstrated that contrary to what was predicted, not only participants with BDD, but also those without BDD experienced an increase in distress and self-focused attention upon exposure to the mirror. In addition, people without BDD, unlike those with BDD, experienced more distress when looking in the mirror for a long period of time as opposed to a short period of time. This lends some support to the idea that, for people with BDD, gazing in a mirror, regardless of duration, might act as an immediate trigger for an abnormal mode of processing and associated distress, and that this association has developed from past excessive mirror gazing. Further theoretical implications of these findings, as well as subsidiary research questions relating to additional cognitive factors are discussed.     

Experiential avoidance in body dysmorphic disorder

Experiential avoidance (i.e., the attempt to avoid certain internal experiences including bodily sensations, thoughts, emotions, memories, and urges) has been studied in various psychological disorders. However, research examining experiential avoidance in individuals with body dysmorphic disorder (BDD) is limited and inconsistent. The present study compared experiential avoidance in individuals with primary BDD (n = 23) to healthy controls (n = 22). Standardized measures were used to assess baseline clinical characteristics as well as experiential avoidance. Compared to healthy controls, individuals with BDD presented with significantly greater experiential avoidance (p < .001, d = −2.51). In BDD, experiential avoidance was positively correlated with depressive symptoms (p < .01) and avoidant coping strategies (p < .01). Clinician sensitivity to experiential avoidance may serve to improve the course of treatment for BDD.     

Body dysmorphic disorder and appearance enhancing medical treatments

This article reviews the literature on body dysmorphic disorder (BDD) in persons who seek appearance enhancing medical treatments such as cosmetic surgery and dermatological treatment. We begin with a discussion of the growing popularity of cosmetic surgical and minimally invasive treatments. The literature investigating the psychological characteristics is briefly highlighted. Studies investigating the rate of BDD among persons who seek appearance enhancing treatments are detailed and, collectively, suggest that approximately 5–15% of individuals who seek these treatments suffer from BDD. Retrospective reports suggest that persons with BDD rarely experience improvement in their symptoms following these treatments, leading some to suggest that BDD is a contraindication to cosmetic surgery and other treatments. The clinical management of patients with BDD who present for these treatments is briefly described and directions for future research are provided.     

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.     

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.     

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.     

Clinical features of muscle dysmorphia among males with body dysmorphic disorder

Muscle dysmorphia – a pathological preoccupation with muscularity – appears to be a form of body dysmorphic disorder (BDD) with a focus on muscularity. However, little is known about muscle dysmorphia in men with BDD, and no study has compared men with BDD who do and do not report muscle dysmorphia. To explore this issue, we reviewed the histories of 63 men with BDD; we compared those rated as having a history of muscle dysmorphia with those who had BDD but not muscle dysmorphia in several domains. The 14 men with muscle dysmorphia resembled the 49 comparison men in demographic features, BDD severity, delusionality, and number of non-muscle-related body parts of concern. However, those with muscle dysmorphia were more likely to have attempted suicide, had poorer quality of life, and had a higher frequency of any substance use disorder and anabolic steroid abuse. Thus, muscle dysmorphia was associated with greater psychopathology.     

Mirror, mirror on the wall, who is the ugliest of them all? The psychopathology of mirror gazing in body dysmorphic disorder

Patients with Body Dysmorphic Disorder (BDD) may spend many hours in front of a mirror but little is known about the psychopathology or the factors that maintain the behaviour. A self-report mirror gazing questionnaire was used to elicit beliefs and behaviours in front of a mirror. Two groups were compared, which consisted of 55 controls and 52 BDD patients. Results: Prior to gazing, BDD patients are driven by the hope that they will look different; the desire to know exactly how they look; a belief that they will feel worse if they resist gazing and the desire to camouflage themselves. They were more likely to focus their attention on an internal impression or feeling (rather than their external reflection in the mirror) and on specific parts of their appearance. They were also more likely to practise showing the best face to pull in public or to use “mental cosmetic surgery” to change their body image than controls. BDD patients invariably felt worse after mirror gazing and were more likely to use ambiguous surfaces such as the backs of CDs or cutlery for a reflection. Conclusion: Mirror gazing in BDD consists of a series of complex safety behaviours. It does not follow a simple model of anxiety reduction that occurs in the compulsive checking of obsessive–compulsive disorder. The implications for treatment are discussed.     

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.     

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.     

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.     

Pharmacologic treatment of body dysmorphic disorder: review of the evidence and a recommended treatment approach

Research on effective pharmacotherapy for body dysmorphic disorder (BDD) has rapidly increased in recent years, with emerging data consistently indicating that serotonin reuptake inhibitors (SRIs) are often efficacious for this disorder. Although data are limited, it appears that higher SRI doses and longer treatment trials than those used for many other psychiatric disorders are often needed to treat BDD effectively. Approaches to treatment-resistant BDD have received little investigation, but available data indicate that switching to another SRI and several SRI-augmentation strategies may be helpful. This article reviews the empirical literature on BDD and offers a recommended approach to the pharmacotherapy of this distressing and often disabling disorder.     

Rates of abuse in body dysmorphic disorder and obsessive-compulsive disorder

Body dysmorphic disorder (BDD) continues to challenge professionals due to symptom severity, co-morbidity, suicidal ideation, and overvalued ideation. Despite the disorder's severity, little research exists. Clinical observation suggests a noteworthy history of abuse; therefore the present study investigated the reported rate of physical, sexual, and emotional abuse in BDD patients. OCD patients were chosen as a comparison group because BDD is considered to be an obsessive-compulsive spectrum disorder. A group survey design was used (N = 50 for each group). Results show significantly higher levels of emotional and sexual abuse in the BDD sample versus the OCD sample. No significant differences were found in physical abuse. Abuse may be a contributing factor in BDD, but not in OCD.     

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.     

Facial asymmetry detection in patients with body dysmorphic disorder

Cognitive-behavioral models of body dysmorphic disorder (BDD) propose that individuals with BDD may possess a better or more developed sense of aestheticality than do individuals without BDD. Evidence for this proposition, however, is limited. One perceptual process that could contribute to heightened aestheticality is the ability to detect differences in symmetry. In this experiment we tested whether individuals with BDD (n = 20), relative to individuals with obsessive compulsive disorder (OCD; n = 20) and healthy controls (n = 20), show an enhanced ability to detect differences in the symmetry of others’ faces, symmetry of dot arrays, and/or show a greater preference for symmetrical faces. Individuals with BDD were not significantly more accurate in detecting differences in facial symmetry or dot arrays relative to individuals with OCD and healthy controls. Individuals with OCD took longer to make facial symmetry judgments than did individuals in the other two groups. All participants, regardless of diagnostic group, preferred more symmetrical faces than nonsymmetrical ones. Taken together, our results do not support a heightened perceptual ability or evaluative preference for symmetry among individuals with BDD.     

The relationship of hypercompetitiveness and gender roles with body dysmorphic disorder symptoms in a nonclinical sample

This study examined whether hypercompetitiveness was a moderator between body dysmorphic disorder (BDD) symptoms and gender roles in 345 college students. To test this, the Body Dysmorphic Disorder Examination-Self Report (BDDE-SR), the Hypercompetitive Attitude Scale, and the Personal Attributes Questionnaire (PAQ) were used. Significant positive correlations were found between BDD symptoms and hypercompetitiveness in men and women. For men and women, no significant correlation was found between female-valued items on the PAQ and the BDDE-SR. A statistically significant negative correlation was found between male-valued items on the PAQ and the BDDE-SR for both genders. Hypercompetitiveness, however, was found not to be a moderator between BDD symptoms and gender roles.     

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.     

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.