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Conservative use of drug therapy
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A psychological approach that emphasizes the present and future of the patient, rather than the past.
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Emphasis on nutrition and physical exercise
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Family participation, if appropriate
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Psychoeducation for patients and relatives
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WHAT IS BODY DYSMORPHIC DISORDER?
Body dysmorphic disorder (BDD) is a condition that involves an intense preoccupation with a particular aspect(s) of physical appearance in a normal appearing person. Although individuals can become preoccupied with any aspect of their appearance, concern with facial features is the most common. Patients may complain, for example, that their nose is too large nose, their hairline is receding, or they have facial blemishes.
BDD first appeared in the scientific literature in 1886 when researcher by the name of Morselli provided a detailed description of the disorder. He conceputalized BDD as a subjective feeling of ugliness terming it "dysmorphophobia." It was later referred to as "imagined ugliness." The current psychiatric diagnostic manual (DSM-IV) provides the following criteria for diagnosis of BDD:
- Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person's concern is markedly excessive.
- The preoccupation causes clinically significant distress or impairment in social, occupational or other important areas of functioning.
- The preoccupation is not better accounted for by another mental disorder, such as anorexia nervosa.
Recent research has provided evidence that BDD can be conceptualized as an "obsessive-compulsive spectrum disorder." The obsessive-compulsive spectrum refers to a series of major psychiatric conditions defined by the presence of obsessions and compulsions. Obsessions are intrusive ideas, thoughts, or images that cause much anxiety and distress. Compulsions are repetitive behaviors or mental acts performed to reduce the anxiety produced by obsessions. In the case of BDD, patients experience intrusive negative thoughts related to their appearance and perform many behaviors in order to cope with the imagined defect, such as repeated mirror checking. Other disorders that seem to fit into the spectrum include: obsessive compulsive disorder, trichotillomania, compulsive orective mutilative snydrome, self mutilation, hypochondriasis, anorexia nervosa, and Tourette's snydrome.
WHAT ARE THE SYMPTOMS OF BODY DYSMORPHIC DISORDER?
- Repetitive and intrusive thoughts about one's physical appearance. The preoccupation interferes with daily living and is very distressing to the individual. These repetitive thoughts often lead to certain behaviors meant to disguise or cope with the imagined defect.
- Common behaviors include:
- Spending many hours in a day examining the body part in mirrors and shiny surfaces.
- Avoidance of mirrors or shiny surfaces.
- Deliberate camouflaging of the "defect" using: hats, scarves or other articles of clothing as well as make-up or other cosmetic products.
- Altering of body posture to hide a profile etc.
- Constantly questioning family or friends about appearance, with the purpose of seeking reassurance.
- Repeatedly consulting with medical professionals, such as cosmetic surgeons or dermatologists in order to find ways to improve appearance.
- Repeated cosmetic surgery, such as rhinoplasty, is quite common.
- Compulsive skin picking can also occur as a symptom of BDD. Some individuals may use their nails or tweezers to remove supposed blemishes or hairs on their face and body. Ironically, repeated skin picking can lead to actual permanent scars.
- Avoidance of social situations is also quite prevalent.
- Going out in public or outdoors only when it is dark outside so that the "defect" is not as visible to others.
- In severe cases, individuals can eventually become housebound, without appropriate treatment.
- It is important to note that research has found that up to 80% of individuals with BDD think about or attempt to commit suicide.
- Individuals with BDD are usually very secretive about their preoccupation. They often feel a sense of shame or embarrassment or think that others will perceive their behavior as vain or silly. Often even treating medical professionals are unaware about the presence of BDD unless a thorough interview is conducted, with specific questions about BDD symptoms.
- Depression and low self-esteem are also common.
OVERVALUED IDEATION
Most patients' belief about their defect is quite strong. Family and friends are usually unable to convince the individual that their appearance is within normal limits. Often the belief is so strong that it can be classified as an "overvalued idea." The term "overvalued idea" means that the belief is quite strong and does not easily change with evidence that contradicts it. Professionals at our Institute have developed an interview based questionnaire ("The Overvalued Ideas Scale") to evaluate the strength of the belief.
BDD is often accompanied by other psychiatric conditions, such as depression, social phobia, or other anxiety disorders.
WHO SUFFERS FROM BODY DYSMORPHIC DISORDER?
BDD may affect up to 2% of the United States population. The ratio of males to females appears to be equal. BDD seems to begin in adolescence. Research at our Institute and other centers indicates that the age of onset is between 14 and 20. Cases that begin at an earlier or later age are not uncommon.
Since BDD has only recently gained the attention of researchers, no one specifically knows what causes it. BDD is commonly viewed as a medical illness in which certain chemicals (neurotransmitters) in the brain are influenced. Serotonin is thought to be the neurotransmitter most likely to be involved in BDD. Some researchers suggest that BDD is an abnormal response to the physical changes that occur in adolescence. The focus on the body continues into adulthood due to constant attention on physical appearance which leads to avoidance of social situations. Traumatic incidents, such as being teased about one's appearance, comments by acquaintances, repeated criticism by family members, and abuse have also been thought to trigger the disorder.
WHAT TREATMENTS ARE AVAILABLE?
Current research conducted at our Institute indicates that techniques used to treat obsessive compulsive disorder (OCD) are also effective for BDD. Cognitive therapy and exposure and response prevention (ERP) combined with medication are the current treatment of choice.
One study conducted at the Institute found that four out of five patients showed significant improvement after undergoing a combination of cognitive therapy and ERP. Intensive treatment, with sessions held more than once a week, seem to be the most beneficial.
Another one of our research projects found that ERP and cognitive therapy was effective in 12 out of 17 patients who also had personality disorders. Treatment consisted of intensive 90 minute sessions five times a week for four weeks. All of the subjects met criteria for at least one personality disorder and 13 out of the 17 had four or more. Treatment sessions consisted of 60 minutes of ERP and 30 minutes of cognitive therapy. No relationship between treatment response and number of personality disorders was found.
Cognitive therapy involves challenging and altering faulty thinking patterns. It is believed that faulty beliefs lead to negative emotions and behaviors. In cognitive therapy, patients learn to first identify faulty thinking patterns, challenge these thoughts and finally derive more constructive beliefs. It is believed that constructive thoughts lead to more positive emotions and behaviors. Common cognitive distortions include: "I must be perfect," "I must be noticed," "The only way to feel better is to look better," as well as "If I am not beautiful, then I must be ugly." It is the experience of our clinicians that cognitive therapy is more effective when done at the onset of treatment.
ERP is the specific behavioral technique implemented at our facility for BDD and numerous other disorders. ERP involves exposing patients to situations frequently avoided or feared while preventing the person from engaging in compulsive behaviors that artificially reduce the anxiety. Patients willingly engage in ERP sessions and are exposed to anxiety provoking situations at their own pace.
The following is an example of ERP treatment for a BDD patient with the belief that his/her nose is too large: The therapist first makes a list of situations avoided or feared by the individual from least to most anxiety provoking. This list is referred to as an "anxiety hierarchy." Common situations include: attending a party, going on a date, sitting very close to another person on public transportation, having photographs taken, and brightly lit places such as department stores. The therapist then takes the individual to these places and encourage him/her to interact in the situation while at the same time preventing rituals, such as mirror checking or hiding his/her nose. Patients are encouraged to stop all rituals outside of sessions as well. Often, mirrors are covered up in the home and cosmetic products are thrown out. Between session homework assignments are given for further exposure exercises. The goal of ERP is for the individual to experience a natural reduction in anxiety in previously feared situations.
The class of medications called "serotonin reuptake inhibitors" had been found to be effective. It is generally recommended that medication should be accompanied by cognitive therapy and ERP for the maximum benefit.
The following medications are most commonly used to treat BDD:
- Prozac
- Anafranil
- Zoloft
- Paxil
- Luvox
- Celexa and Lexapro
- Effexor
Adjunct Medications (Medications commonly used along with the Serotonin medications):
- Buspar
- Risperdal
- Seroquel
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