Body Dysmorphic Disorder Diagnosis and Treatment
Katharine Phillips, MD
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Q: What is BDD or Body Dysmorphic Disorder?
A: BDD is a disorder in which people worry in some way that they look abnormal, deformed or flawed when in reality they look just fine. They are preoccupied with some part of their body whether it is their skin, hair or nose. They obsess at least an hour, normally 3-8 hours a day over their perceived flaw. These thoughts cause clinically significant distress, anxiety, depression, suicidal thinking or impairment in functioning in school, work or social life. In addition, all patients perform compulsive behaviors which are usually intended to alleviate their distress. They can spend hours and hours in front of a mirror trying to fix their perceived problem such as compulsive grooming, hair combing, applying heavy make-up, skin picking or repeatedly seeking reassurance from others.
Q: How is BDD different from Obsessive Compulsive Disorder?
A: We think it is related to OCD but differs from OCD in ways that are important for clinicians to be aware of. BDD focuses on appearance whereas OCD can focus on many other things. People with BDD have a much poorer insight than people with OCD. Most people with BDD are certain that they really do look ugly or flawed in some way. The opposite is true with OCD. BDD patients are also more likely to have delusions of reference, thinking other people are laughing at them, staring at them or making fun of them which I think contributes to the social morbidity since you are less likely to go out and be around people. This is not as common in OCD. It is hard to engage BDD patients in treatment because they don’t recognize they have BDD. They truly believe they are ugly and thus more likely to see a surgeon or a dermatologist. They do come to see us but for depression over the problem. Suicide attempts also seem to be more common in BDD than in OCD.
Q: How would a clinician sort between Anorexia Nervosa, which in many ways is OCD also, and BDD when the focus is abdomen and thighs, which many people with BDD have those concerns as well?
A: The typical BDD case is easy to differentiate from eating disorders. The majority of BDD patients do not have abnormal eating patterns. Where it really becomes difficult is the grey zone, which is more difficult for eating disorders than any other disorder. Some people might say that the core disturbance of eating disorders is distorted body image. The treatments are quite different for eating disorders and BDD so it is really important to diagnose correctly. We need to study these patients where some patients think they are a little overweight, they think their stomach is too big and have a little abnormal eating behavior and figure out how to characterize them. Compare them to a classic BDD group and compare them to a classic eating disorder group and get a sense of how we should diagnose them.
Q: How do you treat BDD and what kinds of therapies do you do?
A: First of all, there is a lot of ground work to be done to get the patient interested in treatment. A fair amount of psycho education should be done first and because of the poor insight, a lot of patients may or may not want treatment for BDD. If a patient is reluctant to get into treatment, focusing on the suffering and impact of these concerns on their life and the amount of time they are spending on these rituals and obsessions, it is often a way to get the patient to try the treatment that you have to offer. Two forms of treatment appear to be efficacious for the majority of patients. First, SRIs (serotonin reuptake inhibitor) and it appears you need pretty high doses, higher than you would need if you were just treating depression. A common problem with BDD is that patients are often depressed; the depression is diagnosed and treated but the BDD is missed. The medication is often not pushed high enough and we recommend a trial of 12-14 weeks to see if it is going to work. Secondly, Cognitive Behavior Therapy (CBT) is currently the psychotherapy of choice. The components of CBT are (1) cognitive restructuring to identify distorted and negative thinking to help the patient develop more accurate and helpful beliefs about their appearance and (2) ritual prevention to get the rituals under better control and (3) exposure. We also work with mirrors, so the patient can see themselves in a less judgmental way. We do work with core beliefs with BDD. Once you deal with the surface beliefs, with how they look, we can identify the deeper level beliefs such as, I am unworthy or I am unlovable.
Q: Is there a genetic predisposition for BDD?
A: We don’t know much about that. We have preliminary data from a small candidate gene study on the GABA (A) Gamma 2 receptor gene which has been implicated in mouse models in depression and anxiety like symptoms but this is just one small preliminary study. There is some evidence that BDD does run in families and that first degree relatives are 3 times more likely to have BDD than members of the general population.
Q: How prevalent is BDD in the general population?
A: There have been three nationwide probability based studies that have found current prevalence in the range of 2% making it about as common as OCD but more common than Schizophrenia, more common than anorexia so this is not a rare disorder. I think it is often assumed to be rare. BDD is pretty well known among the public. Studies have shown that in the U.S., 13-15% of in-patients on general in-patient units have BDD. So, it is out there, just under recognized.
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