Treatment for Body Dysmorphic Disorder
By Jennifer L. Greenberg, Psy.D.
and Sabine Wilhelm, Ph.D.
Most people are dissatisfied with some aspect of their appearance. However, some individuals are so distressed about the way they look that it interferes with their daily life. Body dysmorphic disorder (BDD) is a severe and impairing disorder characterized by a preoccupation with an imagined or slight flaw in appearance. Any area of the body can be the focus of concern, but concerns involving the face or head (e.g., skin, hair, or nose) are most common. BDD occurs about equally in men and women, or slightly more often among women. Some gender differences have been found; however, clinical features appear generally similar in males and females. Although BDD has been described in the literature for more than a century it remains an underrecognized disorder.
BDD usually begins in early adolescence and affects about 0.7% to 2.4% of the general population. The prevalence is higher when examined in dermatology and plastic surgery settings, suggesting that individuals with BDD do not often seek psychological help. Rather, individuals, including adolescents, often shop around for doctors hoping to fix the flaw cosmetically. Those who suffer from BDD are most likely to seek treatment from dermatologists, plastic surgeons, or dentists because of the urge to fix the perceived flaw or because they are too ashamed and embarrassed to seek help from mental health professionals. However, those who pursue costly surgical, dermatologic and other medical treatments are typically left feeling the same or worse than before the procedure. If left untreated, BDD symptoms typically persist for years.
Individuals with BDD experience significant distress about their perceived flaw and are often plagued by unwanted thoughts or images about the flaw for several hours a day. Nearly all individuals with BDD perform repetitive, compulsive behaviors in an effort to improve their appearance or alleviate distress. Common rituals include frequent mirror checking, excessive grooming (e.g., hair combing or shaving), comparing with others, reassurance seeking, skin picking, and camouflaging (e.g., with a hat, makeup, or clothes). Rituals provide only short-term relief and can make symptoms worse over time. Some individuals are convinced that others take special notice of them (e.g., talk about or mock them) because of their perceived appearance flaw. Individuals who are completely convinced that their concerns are due to real physical flaws are thought to have a delusional variant of the disorder.
For most individuals with BDD, a fear of being evaluated negatively by others, difficulty concentrating and poor self-esteem make it difficult to keep up with daily life. Consequently, everyday functioning and quality of life are compromised. Individuals may avoid daily activities, including dating and other social activities, school and work. In extreme cases individuals may become housebound. When compared to the general U.S. population, and individuals with depression or recent heart disease, individuals with BDD report a significantly poorer quality of life. Of those individuals who do seek psychiatric or psychological services, it is often for depressive and anxious symptoms associated with their BDD. It is important that patients with BDD are assessed for depression and suicidality. BDD sufferers are at an increased risk for psychiatric hospitalization, suicidal ideation, suicide attempts and completed suicide. Suicide risk factors, including high rates of psychiatric hospitalization, being single or divorced, psychiatric comorbidity (including anxiety, depression and impulsive aggression), poor social supports and poor self-esteem, have all been associated with BDD.
Although data from children and adolescents are limited, symptoms appear to be generally similar to those in adults in that they are extremely upsetting, time consuming, and commonly involve the face or head. However, children and adolescents with BDD are less likely to identify their concerns as part of a psychological disorder. Adolescents are more likely to be convinced that they are physically “ugly, disfigured, monstrous,” and that others are judging them based on these flaws. Children and adolescent may also be at greater risk for developing additional disorders (e.g., substance abuse, social phobia, depression); this may be due in part to the disorder’s interference with social and academic functioning during a critical developmental period. Unfortunately, during adolescence, when symptoms typically emerge, BDD may be overlooked or mistaken for normal adolescent concerns about appearance. One way to distinguish normative concerns from BDD is to observe the time-consuming and distressing nature of the appearance concerns. For example, if appearance-related thoughts or behaviors take up more than 1 hour per day and result in significant distress, tardiness to school or social events, difficulty concentrating, withdrawal from friends, family or school, or drop in grades, further evaluation may be warranted.
Although many individuals with BDD, including children and adolescents, obtain multiple, costly surgical, dermatologic, and other cosmetic procedures, the outcome is usually poor. These treatments rarely improve BDD symptoms. More commonly, individuals report an increase in appearance concerns (e.g., feeling “disfigured”) or new areas of preoccupation (e.g., from a concern with nose size to hair texture) following cosmetic (medical or non-medical) procedures. In severe cases, distress following cosmetic procedures has resulted in suicide and violent/homicidal acts against the treating physician.
Over the past decade, promising psychological and pharmacological treatments have emerged to help those with BDD. Most medication studies have examined serotonin reuptake inhibitors (SRIs) while psychological studies have focused primarily on behavior therapy or cognitive behavioral therapy. Treatments for BDD aim to improve quality of life and overall functioning through the reduction of compulsive behaviors and distress associated with appearance concerns.
Although patients with BDD may receive various psychotropic medications, including antidepressants (e.g., tricyclic antidepressants, monoamine oxidase inhibitors [MAOIs]) and neuroleptics, evidence for the effectiveness of non-SRI antidepressants or neuroleptics in treating BDD symptoms has not been adequately demonstrated. SRIs (e.g., clomipramine) and selective SRIs (SSRIs; e.g., fluoxetine, fluvoxamine, citalopram) are the first-line medication treatment for BDD. SRIs have been found to be more effective than non-SRI antidepressants or sugar pill placebo. Relatively high SRI doses over a longer period are indicated than for SRI use in depression. Interestingly, patients with delusional BDD tend to respond as favorably as those with the nondelusional variant to high dose SRI treatment.
Preliminary findings from clinical case reports suggest that SRIs may also be effective in children and adolescents. The potential effectiveness of SRIs in this population is promising given its similarities to adult BDD and pediatric OCD. SRIs are already indicated for the treatment of pediatric and adult OCD.
Cognitive behavioral therapy (CBT) is a present-focused, short-term, goal-directed approach that has been shown to be helpful in treating BDD symptoms in both individual and group formats. Currently, there is no empirical basis for any other psychological treatment in the treatment of BDD; insight-oriented psychotherapy alone has not been shown to be effective in reducing BDD symptoms. The CBT model focuses on cognitive and behavioral factors involved in the development and maintenance of BDD symptoms. The model proposes that individuals with BDD selectively pay attention to certain, small aspects of appearance (e.g., minor appearance flaws). This theory is based on clinical observations and neuropsychological findings that patients with BDD over-focus on small details in lieu of seeing the big picture. Similar patterns have been observed among individuals with OCD. Individuals with BDD place an excessive value on physical attractiveness (and sociocultural ideals) in determining self-worth. Moreover, they rely almost exclusively on their specific area(s) of concern to determine their body image and self-esteem. In addition, persons with BDD tend to underestimate their own physical attractiveness and overestimate others’ attractiveness. Thus, negative beliefs and interpretations about appearance lead to feelings of anxiety, sadness, and shame, and make persons with BDD more likely to engage in compulsive or avoidant behavior to try to improve appearance or reduce distress. Rituals and avoidance are negatively reinforced because they may provide a temporary decrease in distress. However, these behaviors maintain BDD symptoms over time.
In CBT, the therapist and patient work as a team to identify and challenge current thought and behavior patterns maintaining a patient’s individual BDD symptoms. Specifically, CBT involves helping patients identify distorted or unhelpful appearance-related thoughts and developing more accurate, adaptive beliefs. Patients are also gradually exposed to anxiety-provoking situations. Patients learn strategies to help them eliminate avoidance (e.g., avoiding eye contact) and ritual behaviors (e.g., comparing self to others in the room) initially intended to decrease anxiety or distress associated with trigger situations. Patients are asked to repeat exposure exercises until the accompanying anxiety or discomfort decreases (i.e., habituation). In addition, patients learn to “see the big picture.” For example, patients learn to view themselves more holistically and nonjudgmentally—e.g., when in front of the mirror.
CBT strategies are practiced in session and as homework assignments between sessions in order to facilitate mastery of new skills in multiple environments. Family members may be involved. For example, when a patient comes in for treatment, it is not uncommon for parents or significant others to be involved in rituals (e.g., by providing reassurance about appearance); this is understandable as it difficult to watch a loved one suffer. However, therapists can be helpful in providing information about the disorder and in instructing family members in more adaptive, supportive strategies. In summary, CBT for adults with BDD is effective in improving BDD symptoms and has also been shown to improve related symptoms, such as depressive symptoms, insight, body image, self-esteem and social anxiety.
Whereas both medication and psychological treatment studies have obtained promising results, additional clinical and research attention should focus on developing more effective treatment strategies for BDD. In addition, given its early onset and chronic, devastating course, early identification and treatment of the disorder are crucial. Appearance concerns associated with BDD are more than a matter of vanity. The serious psychological impact on individuals with BDD and their loved ones calls for increased public and professional awareness of the disorder and the development of more effective interventions.
Body Dysmorphic Disorder Program/OCD Program at Massachusetts General Hospital
Offers several no-cost treatment studies for Cognitive Behavior Therapy as well as Pharmacotherapy for BDD and related disorders.
Toll free: 877- 4-MGH BDD
Brown Body Image Program
For a comprehensive source on BDD and its treatment readers are directed to:
“The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder” by Katharine Phillips (Oxford University Press, 2005).
“Feeling Good about the Way You Look: A Program for Overcoming Body Image
Problems” by Sabine Wilhelm (The Guilford Press, 2006) is recommended to help individuals understand their body image concerns and decide whether they should be evaluated for BDD. It offers a CBT-based self-help approach with step-by-step guidelines for overcoming appearance-related thoughts and behaviors.
Jennifer Greenberg is a Clinical Research Fellow at the Massachusetts General Hospital (MGH) and the Harvard Medical School in Boston, MA. Dr. Wilhelm is Associate Professor at the Harvard Medical School and the Director of the Body Dysmorphic Disorder Program and the OCD Program at MGH.
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