How to Recognize, Treat Body Dysmorphic Disorder

Max, a 23-year-old single, unemployed white male who lived with his parents had consulted with 12 surgeons across the United States about his concerns over his looks. He was scheduled for a cranioplasty to widen his skull, which he believed was too narrow, even though measurements showed that it was within the normal range. He also believed that he had severe acne, a receding hairline, and a large nose, and he was planning a future rhinoplasty.

Max looked normal, but he was convinced that he looked “deformed,” and he was certain that people laughed at him and mocked him because he looked so “strange.” He obsessed about his perceived defects for 8 to 10 hours a day and spent 6 to 8 hours a day checking disliked areas in mirrors, comparing his appearance with that of other people, and searching online for information about cosmetic surgery and skin treatments.

Because Max was so ashamed of and preoccupied with his “horrible” appearance, he spent most of his time alone in his house and did not work. He left the house only at night, when it was harder to be seen. He avoided most social situations and relationships. He had attempted suicide multiple times because, as he described, “I was feeling repulsed by what I saw in the mirror.”

With a current prevalence of about 2 percent, body dysmorphic disorder (BDD)—a distressing or impairing preoccupation with perceived defects in appearance—is more common than schizophrenia or anorexia nervosa. Yet BDD usually goes unrecognized and undiagnosed in both youth and adults.

Many patients with BDD are too embarrassed and ashamed to volunteer their concerns to their clinician. Thus, to detect BDD, clinicians often must screen patients for this disorder.

There are several core features of BDD:

• Preoccupation with one or more perceived defects or flaws in one’s appearance, which are not observable or appear only slight to others. Patients look normal but nonetheless believe that they look ugly, unattractive, deformed, or even monstrous. Concerns may focus on any part of the body but often involve the face or head—most often, skin, hair, or nose.

• The appearance preoccupations trigger excessive repetitive behaviors that focus on checking, fixing, hiding, or obtaining reassurance about the perceived defects. Behaviors may include mirror checking, excessive grooming, or skin picking.

• The appearance preoccupations cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

BDD has some features in common with obsessive-compulsive disorder (OCD), and DSM-5 classifies it as an obsessive-compulsive and related disorder. However, it is typically characterized by poorer insight, more frequent comorbid major depressive disorder and substance use disorders, and greater suicidality than OCD.

People with BDD appear to have abnormalities in visual processing in which they over-focus on tiny details of a visual stimulus and have difficulty “seeing the big picture” (that is, they have deficits in holistic visual processing). BDD is not diagnosed if the patient’s only appearance concerns focus on weight or body fat and qualify for an eating disorder diagnosis.

There are several key points to consider when assessing and treating patients with BDD:

• Screen all patients, including children and adolescents, for BDD. Two-thirds of cases onset before age 18.

• A good screening question is whether the patient has any concerns or worries about how they look. Subsequent questions should assess the key features noted above.

• Carefully monitor suicidality, which is common in patients with BDD.

• Attend to the therapeutic alliance, and focus on engaging and retaining patients in treatment. Because most patients have poor or absent BDD-related insight, they may resist psychiatric care. It may be helpful to focus on their excessive preoccupation, distress, effects of symptoms on functioning, and the potential for treatment to improve these symptoms. It is usually not helpful to try to talk patients out of their appearance concerns.

• Discourage cosmetic treatment, such as surgical, dermatologic, or dental treatment. It does not appear to be helpful and can worsen BDD symptoms. Risks include lawsuits and even violent behavior toward surgeons and other physicians who provide such care.

• The first-line pharmacotherapy for BDD is an SRI. High doses are often needed. SRIs are also recommended for patients with delusional BDD beliefs (complete conviction that they look abnormal or ugly).

• The first-line psychosocial treatment is cognitive-behavioral therapy that is tailored to BDD’s unique clinical features. Because BDD is often difficult to treat, use of a manualized treatment for BDD is recommended; several treatment manuals are available.

With a combination of motivational interviewing and pressure from his family, Max agreed to delay surgery and first try psychiatric treatment. After three months of treatment with escitalopram (up to 30 mg/day) and use of manualized BDD-focused cognitive-behavioral therapy, his BDD symptoms were much improved.

After six months of both treatments, Max reported thinking about his appearance for only one hour a day, was socializing more and looking for a job, and no longer desired surgery. ■