Body Dysmorphic Disorder : Recognizing and Treating Imagined Ugliness

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Body Dysmorphic Disorder: Recognizing and Treating Imagined Ugliness by Katharine A. Phillips, M.D.

Peter, a 23-year-old single white male, was often suicidal over his hair. He thought about his supposedly receding hairline for more than eight hours a day, and described his distress as extreme and devastating. Peter frequently combed his hair and checked it in mirrors, asked his parents whether it was thinning and used hair spray and gel to "increase its size." He also searched his pillow each morning for hair, saved his hairs in a plastic bag and developed complex math formulas to determine the rate of hair loss.

Sophie was excessively preoccupied with her nose, which she thought was toolarge. Although she'd often been asked to work as a model, she believed these requests were motivated by pity for her ugliness. After three rhinoplasties, she thought her nose looked even worse, and she contemplated suing the surgeon. Eventually, she was hospitalized after attempting suicide because of her "atrocious" appearance.

Both of these patients had body dysmorphic disorder (BDD), a preoccupation with an imagined or slight defect in appearance. Although BDD is becoming increasingly familiar to clinicians, it remains an underdiagnosed, often secretive, disorder. Its underrecognition is problematic because BDD appears to be relatively common. In addition, emerging data, while preliminary, suggest that psychiatric treatment (serotonin reuptake inhibitors [SRIs] and cognitive-behavioral therapy) are promising for BDD. And while the symptoms might sound trivial, BDD is associated with significant suffering and impairment in functioning. In extreme cases, patients may commit suicide; others attempt their own surgery.

Body dysmorphic disorder, previously known as dysmorphophobia, is classified in DSM-IV as a somatoform disorder; its delusional variant is a type of delusional disorder, somatic type. To qualify for the diagnosis, the preoccupation must cause clinically significant distress or impairment in functioning and it must not be better accounted for by another mental disorder, such as anorexia nervosa.

Although it was added to DSM as recently as 1987, BDD was first described more than 100 years ago by Enrique Morselli, an Italian psychiatrist who saw 78 patients with BDD (Phillips 1991). In 1891 he wrote: "The dysmorphophobic patient is really miserable; in the middle of his daily routines, talks, while reading, during meals, everywhere and at any time, he is caught by the doubt of deformity..."

Pierre Janet also described BDD, which he considered relatively common. Like Morselli, he considered it a close relative of obsessive-compulsive disorder. In 1903, he described a 27-year-old woman he called Nadia, a gifted and intelligent woman who worried about many aspects of her appearance, including her red and spotted skin, her feet and supposed tallness, and her "long and ridiculous" hands. Nadia worried that no one years she confined herself to a tiny apartment that she rarely left. "If they saw me in plain light, people would be disgusted," Nadia told Janet. Despite its long historical tradition, for a number of reasons BDD continues to be underrecognized: many clinicians are still unfamiliar with the disorder; many patients pursue surgical, dermatologic and other nonpsychiatric treatment; and patients are often too ashamed and embarrassed
to reveal their concerns. Often, to make the diagnosis, the physician must inquire about the symptoms. The following case illustrates many of BDD's clinical features.

Lisa, 22, an attractive, single white college student, had been preoccupied since age 18 with her "pale, blotchy and oily" skin, "horrible" facial acne and freckles, and her "curly and thick" hair. She thought about these perceived defects for more than eight hours a day, and at times considered suicide because she felt so ugly.

Lisa spent hours each day checking her "defects" in mirrors, comparing herself with other people and models in magazines, asking others whether she looked OK, picking her skin with tweezers, putting on makeup and styling her hair. She avoided dating and many social situations because of her self-consciousness and fear that people stared at and mocked her flaws. She also avoided going to the library because she worried that walking there would "mess up [her] looks." Because Lisa's preoccupation and associated
behaviors interfered with her concentration, her grades dropped. Past treatment with Accutane had improved her mild acne but not her preoccupation because she feared her skin would worsen again, and she worried more about her hair.

Lisa was treated with fluvoxamine (Luvox) up to 300 mg per day, and after six weeks her BDD was considered very much improved. After 16 weeks of treatment, she thought about her appearance for less than one hour per day and had stopped all BDD-related behaviors. She reported only mild distress over her appearance and no interference with functioning. She became very socially active, started dating and performed notably better in school. Her insight also improved, changing from poor (being "pretty certain" about the accuracy of her beliefs) to good. In addition, she no longer perceived her defects, stating, "I look much better now. I look completely different, like
a different person. My skin looks clearer, and my face is more proportionate. I don't notice the rashiness or blemishes anymore. I look normal, but I didn't used to...What I see now is the correct view."

Subsequent discontinuation of fluvoxamine led to relapse, and reinitiation of the medication again resulted in near remission of her symptoms.

Obsessional Preoccupations

BDD preoccupations commonly involve the face or head, although any body part can be the focus of concern (Phillips and others 1993). As shown in Table 1,the skin, hair and nose are most often disliked-examples of complaints are wrinkles, acne, scarring, other blemishes or pale skin; thinning hair; or alarge or misshapen nose. Concern with bodily asymmetry is also relatively common. Over time, most people are concerned with more than one aspect of their appearance.

Appearance preoccupations may be expressed in more unusual ways. Some patients, for example, say that they look like a gorilla or as ugly as the Elephant Man. One woman worried that her "face was falling." And some individuals have "BDD by proxy"-an obsession with supposed flaws in someone else's appearance, which may involve insistence that the other person have surgery to correct the perceived problem. Relatively common associated features of BDD are low self-esteem, shame and fear of rejection by others.

BDD preoccupations are distressing and usually difficult to resist or control. Patients typically think about their perceived deformity for at least an hour a day (the mean time is three to eight hours a day). A majority experience ideas or delusions of reference, thinking others are taking special notice of the supposed defect and perhaps talking about it or mocking it. This, too, can take unusual forms. A man who sang in a choir thought the entire audience was staring at a scar barely visible on his neck, and a woman thought that other people stared at her minor skin blemishes through binoculars.

Whereas some people with BDD realize that their view of the defect may be distorted-that the flaw may not be as ugly, grotesque or noticeable as they think it is-others are completely convinced of the accuracy of their view.Individuals in the latter group receive a diagnosis of delusional disorder, which may be double-coded with BDD. Double-coding reflects available data suggesting that the nondelusional and delusional variants of BDD may be the same disorder (with the delusional form a more severe variant) (Phillips and others 1994). Insight in BDD spans a spectrum from good to absent and may change over time, sometimes fluctuating between nondelusional and delusional

Compulsive Behaviors

More than 90% of patients with BDD perform one or more repetitive and often time-consuming behaviors, usually to examine, improve or hide the perceived defect. They may frequently check the supposed flaw in mirrors or other reflecting surfaces (83%); e.g., car bumpers, watch faces, backs of spoons, groom excessively (34%); e.g., style or cut their hair for hours a day, compare themselves with others (91%), pick their skin (28%), ask for reassurance (41%) or try to convince others of the defect's ugliness, or
repeatedly seek dermatologic or surgical treatment.

A majority (83%) camouflage the perceived deformity with such things as clothing, hair, makeup, or body position, for example, wearing six layers of T-shirts to "build up" a supposedly small body or constantly jutting out a "wimpy-looking" jaw.

While these behaviors are particularly common, there is no limit to the strategies patients devise to try to alleviate their suffering. One man tied up his calves with rope while he slept to make them smaller. A teenage boy who thought his facial features were asymmetric tried to "straighten them out" by tying socks around his head, sometimes so tightly that he hurt himself. To make his face look fuller, another patient slept without a pillow, ate lots of food and drank more than three gallons of water a day.


Consequences of BDD

Level of functioning in BDD spans a very broad spectrum. Some people, despite their distress, manage to function well although often below their capacity. An accountant, for example, performed her job well but had to spend extra hours at work to make up for time lost to her obsessions and mirror-checking. Many with BDD, however, are severely impaired by their symptoms. They may perform their job or school work poorly, drop out of with BDD whom I have evaluated, 10% were on disability because of BDD.

Some degree of social impairment is nearly universal. Individuals with BDD may have few friends, avoid dating and other social interactions, or get divorced because of their symptoms. They often avoid specific situations or activities-such as restaurants, beaches or stores-in which they feel particularly self-conscious about how they look. Of those 176 patients with BDD, 30% had been housebound for at least one week, more than half had been hospitalized for psychiatric disorders and one-quarter had made a suicide
attempt. Some patients complete suicide. There are many other consequences of BDD-for example, a car accident resulting from checking the defect in the rearview mirror. Some patients, trying to remove facial blemishes, pick their skin so deeply that they damage major blood vessels and require emergency surgery.

Occasionally people with BDD are so desperate to fix the perceived defect that they attempt their own surgery. One man was unable to find a surgeon who would do a rhinoplasty, so to eradicate a small bump he smashed his nose with a hammer. Another man with likely BDD thought the fingers on his left hand were too long, so he cut them off. And another disliked his nose so intensely that he cut it open and attempted to replace his own cartilage Demographics, Course of Illness

The male-to-female ratio in BDD has generally been found to be approximately 1-to-1 or 3-to-2, although one series contained more women than men. The clinical features of BDD in men and women appear generally similar. A notably large percentage (nearly three-fourths) of patients have never been married. BDD usually begins during adolescence (Phillips and others 1995) and can occur in children, although it remains underrecognized in this age group. Data suggest that the disorder is generally chronic, with waxing and waning symptom severity, although prospective studies are needed to confirm these findings.


Major depression appears to be the disorder most often comorbid with BDD, with a current rate of about 60% and a lifetime rate of more than 80%. In my series of patients, onset of BDD usually preceded that of depression. Other commonly comorbid disorders are social phobia (occurring in nearly 40%), OCD (occurring in about one-third), and substance use disorders (with a lifetime history of about 40%).

Treatment Approaches

A majority of patients with BDD seek often-costly nonpsychiatric treatment (Phillips and others 1993). Dermatologists and surgeons are most often consulted, but patients consult virtually any type of physician. Ophthalmologists may be asked to correct "cross-eyed" eyes, endocrinologists to evaluate "excessive" body hair or urologists to fix "small" genitals.

While prospective studies are lacking, it appears that most patients with BDD are dissatisfied with such treatment; many dislike their appearance even more or develop new appearance preoccupations. Multiple procedures may be received in the search for a cosmetic solution to a psychiatric problem. Some dissatisfied patients, despite an acceptable treatment outcome, sue the physician, and occasionally patients are violent toward the treating physician.

Although BDD has been said to be extremely difficult to treat, preliminary data suggest that psychiatric treatment-in particular, the serotonin reuptake inhibitors (SRIs) and cognitive-behavioral therapy-may be effective for many patients. Hollander and colleagues first reported that five patients with BDD who had failed to respond to a variety of medications responded to SRIs (Hollander and others 1989). In a series of 130 patients (who had received a total of 316 medication trials) in whom I assessed
treatment response retrospectively, 42% of 65 SRI trials (fluoxetine [Prozac], clomipramine [Anafranil], fluvoxamine, sertraline [Zoloft] or paroxetine [Paxil]) resulted in much or very much improvement, in contrast to 30% of 23 trials with monoamine oxidase inhibitors, 15% of 48 trials with non-SRI tricyclics, 3% with neuroleptics, 6% with a variety of other medications (e.g., benzodiazepines and mood stabilizers), and 0% of electrotherapy trials. Of 45 patients whom I or my colleagues treated with an SRI in an open fashion, 70% (43 of 61) of SRI trials resulted in much or very much improvement (Phillips and others 1994).

Similarly, in a retrospective study of 50 patients with BDD, Hollander and colleagues (1994) found that 35 SRI trials resulted in much improvement, whereas 18 non-SRI tricyclic trials resulted in no overall improvement in BDD symptoms.

Two open-label studies of an SRI have been done, both with fluvoxamine. In one such study, which I am conducting with Susan McElroy, M.D., of the University of Cincinnati, 26 subjects with DSM-IV BDD have thus far completed a 16-week study, two-thirds of whom responded to the medication. Five responders discontinued fluvoxamine after completing the study, all of whom relapsed, with BDD symptoms significantly improving when an SRI was restarted. Similarly, in another open-label study of fluvoxamine, two-thirds of 15 subjects were considered responders (Perugi G, personal communication).

While these data are promising, they are limited because they are uncontrolled. Two controlled treatment trials are in progress, one of which is a placebo-controlled trial of fluoxetine (conducted by Ralph Albertini, M.D., Steven Rasmussen, M.D., and myself). The other, by Hollander and colleagues at Mount Sinai School of Medicine in New York City, is a crossover trial of clomipramine and desipramine (Norpramin). Preliminary results from this study indicate a significantly higher response rate with clomipramine than desipramine (Hollander E, personal communication); like available retrospective data, these findings suggest that SRIs may be preferentially effective for BDD.

Response to medication usually results in decreased distress and less time spent preoccupied with the "defect," as well as improvement in functioning. Associated compulsive behaviors usually diminish as well. Many SRI responders also experience improved insight and a decrease in referential thinking. However, insight does not always improve with treatment, and in some cases (like Lisa's) in which it does improve, the patient nonetheless maintains that the defect was indeed present and ugly prior to treatment. As
Lisa's case also illustrates, improved insight with an SRI sometimes appears due to resolution of an apparent visual illusion-that is, the patient reports that the defect is no longer visually detectable. This outcome is increasing, given that serotonin appears to modulate the visual system.

It is worth noting that available data also suggest that patients with BDD (delusional disorder, somatic type) are as likely as those with nondelusional BDD to respond to SRIs (Phillips and colleagues 1994). While requiring confirmation in controlled treatment trials, this finding suggests that SRIs may be effective for some delusional patients.

Available data suggest that patients should receive an SRI for at least 12 weeks before concluding that the medication is ineffective. Although dose-finding studies have not been done, many patients require relatively high SRI doses; the highest dose tolerated or recommended by the manufacturer should be reached before concluding the medication is ineffective.

Although formal medication discontinuation studies have not been done, clinical experience suggests that a majority of patients relapse with SRI discontinuation and that long-term treatment is often needed, with efficacy usually sustained over time.

Augmentation of an SRI with buspirone (BuSpar) or pimozide (Orap), or perhaps other antipsychotics such as risperidone (Risperdal), is a promising strategy for patients who do not respond or respond only partially to an SRI (Phillips 1996). Another option is to combine clomipramine with a selective SRI when an adequate trial of one of these medications alone has been ineffective. In addition, patients who fail one adequate SRI trial may respond to another SRI. If none of these strategies is effective, a
monoamine oxidase inhibitor may be worth trying. It is important to note that doses of pimozide greater than 0.2 mg per kg per day or more than 10 mg per day are not recommended, and that pimozide should not be combined with clomipramine, as the addition to pimozide of any medication with the potential to prolong the QT interval (such as tricyclics) is contraindicated. In addition, clomipramine blood levels should be monitored when combined with a selective SRI because of the latter drugs' potential to
increase clomipramine levels. (The Physicians Desk Reference warns that pimozide prolongs the QT interval of the electrocardiogram and is contraindicated in patients with congenital long QT syndrome, patients with a history of cardiac arrhythmias or patients taking other drugs that y of bipolar disorder. Epidemiological data suggest that many genes are involved in the genetic transmission of bipolar disorder. They may be a complex combination of genes of large effect and small effect, as well as autosomal dominant, recessive and X-linked transmission.

Multiple Genes?

In many families the susceptibility to illness may require the interaction of multiple genes. Other factors also complicate the problem. The twin studies indicate that some individuals may inherit genes for the disordering compulsive behaviors, such as mirror-checking and reassurance-seeking, are effective for a majority of patients.

Examples of helpful strategies are advising patients to cover or remove mirrors, limit grooming time, avoid covering makeup and to advise family members not to reassure the patient about the defect. Some patients, however, are too severely depressed, suicidal or delusional to meaningfully engage in such treatment. Clinical experience suggests that combining medication and cognitive-behavioral therapy is often effective. While supportive and insight-oriented psychotherapy may be useful in some cases as adjunctive approaches, or to treat associated problems, they generally do not appear to decrease BDD symptoms per se.

Diagnosing BDD

Making the diagnosis of BDD can be challenging; sufferers often keep their symptoms secret because of embarrassment or shame. They may volunteer only their depression, anxiety or discomfort in social situations. Clinicians often need to ask directly about BDD symptoms, using questions such as those in Table 2. Clues to the diagnosis include the presence of characteristic behaviors such as mirror checking, skin picking, excessive grooming, reassurance-seeking or camouflaging (for example, always wearing a hat).
Other clues include social avoidance (which may be misdiagnosed as social phobia or agoraphobia), panic attacks (which may occur, for example, after looking in the mirror, and may be misdiagnosed as panic disorder), or ideas or delusions of reference, which patients may describe as paranoia.

Clinicians should be particularly alert to the possible presence of BDD in patients with atypical major depression, social phobia and OCD, as BDD appears to be relatively common in these patients (Phillips and others 1996, Brawman-Mintzer and others, Simeon and others). BDD should also be asked about with patients with minimal appearance flaws who seek surgery or dermatologic treatment such as dermabrasion.

It is essential that BDD be taken seriously and treated psychiatrically. Well-intentioned attempts to reassure sufferers or to convince them that the defect is minimal or doesn't exist are generally ineffective. While definitive statements about treatment efficacy await the completion of controlled treatment trials, it appears that many patients with this
distressing and sometimes disabling disorder respond well to psychiatric treatment.

Dr. Phillips is chief of outpatient services, director of the Body Dysmorphic Disorder and Body Image Program at Butler Hospital, and assistant professor of psychiatry and human behavior at Brown University School of Medicine in Providence, RI.

Her book, The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder, is available through Oxford University Press.


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