Beyond the mirror: Treating body dysmorphic disorder
A multimodal approach appears most effective for this distressing disorder of imagined ugliness.
Identifying which came first—body dysmorphic disorder (BDD) or comorbid anxiety or depressive disorders—can be as complex as treating the disorder’s delusional thinking and high suicide risk. To help you when working alone or with a psychotherapist, we offer strategies we have found useful for:
- diagnosing BDD
- educating patients and families about it
- choosing and dosing medications
- addressing inaccurate perceptions with targeted cognitive-behavioral therapies.
Though many recommendations are based on published data, we also draw on our clinical experience because research on effective BDD treatments is limited.
What is body dysmorphic disorder?
Body dysmorphic disorder (BDD) is preoccupation with an imagined defect in physical appearance or excessive concern about a slight physical anomaly that causes significant distress or impairs social, occupational, or other functioning.1 BDD patients have obsessive thoughts about their “flaws” and engage in compulsive behaviors and avoidances related to how they perceive their appearance, similar to behavior seen in obsessive-compulsive disorder. BDD causes great distress and disability, often accompanied by depression and suicidality.2
BDD occurs in an estimated 0.7% of the general population3 and in 6 to 14% of persons receiving treatment for anxiety or depressive disorders.4,5 These estimates may be low, however, as persons with BDD often do not seek treatment. Men and women are equally affected.6 Average age of onset is 16, although diagnosis often doesn’t occur for another 10 to 15 years.7
BDD causes patients great distress and disability—often accompanied by major depression—but is easy to miss or misdiagnose (Box).1-7 Even when suicidal, BDD patients often do not reveal their symptoms to clinicians,2 probably because of poor insight or shame about their appearance. When a patient describes being unable to stop thinking about specific aspects of his or her appearance, assess further for BDD.
BDD patients’ conviction that their appearance is defective ranges from good insight to mildly overvalued ideation to frankly delusional.8 They often have ideas of reference (such as thinking others may be looking at their “defective” body part) and delusions of reference (such as being convinced others are talking about their “defective” body part). Asking a patient the questions in Table 1 can help establish the diagnosis. BDD also is included in the Structured Clinical Interview for DSM-IV (SCID). Useful assessment tools include:
- Body Dysmorphic Disorder Questionnaire,9 a 5-minute, patient-rated scale for screening
- Body Dysmorphic Disorder Examination,10 to diagnose BDD, survey BDD symptoms, and measure severity
- Yale-Brown Obsessive-Compulsive Scale modified for Body Dysmorphic Disorder (BDD-YBOCS),11 for measuring symptom severity and changes over time.
Comorbidity. Psychiatric comorbidity is common in BDD (Table 2),6,7,12-14 and deciding which disorder to address first can be difficult. If there is acute mania or non-BDD psychosis, we suggest that you stabilize these before treating BDD. Suicidality or severe substance dependence or abuse may result from BDD and therefore needs to be treated in conjunction with BDD.
If comorbid obsessive-compulsive disorder (OCD) or social phobia symptoms are interconnected with the patient’s BDD, treat concurrently; if not, address sequentially, starting with the more-severe symptoms. For example, symptoms that suggest social phobia (such as fear of public speaking) may be related to BDD, and treatment should focus on BDD. A patient with obsessive fears about how “contaminants” will affect her skin’s appearance may need to have the OCD and BDD addressed concurrently.
For other comorbidities, the treatment hierarchy is less clear. Major depression, for example, may be caused by severe BDD and might not improve until BDD improves. Even when a patient has several concurrent Axis I disorders, don’t over-look treating BDD; otherwise, the patient may remain quite impaired.
Assess suicide risk, as ≥ 25% of BDD patients may attempt suicide in their lifetimes.2 Safety measures include frequent monitoring, medication, family involvement, and—if necessary—hospitalization.
Patient interview: Questions to help diagnose BDD
Are you concerned about specific parts of your appearance that you believe are ugly or defective?
Do you find it difficult to stop thinking about parts of your appearance?
Do you avoid certain situations, places, or being seen in general because of your appearance?
Do you feel anxious, ashamed, disgusted, or depressed by specific aspects of your appearance?
Are any of your behaviors influenced by your appearance, such as trying to hide parts of your appearance or taking a long time getting ready to leave your residence?
Does your preoccupation cause you a lot of distress, anxiety, disgust, and/or shame?
Is preoccupation with your appearance interfering with your social life, ability to work, job performance, or other important areas of your life?
Do you tend to use mirrors very often or avoid them?
Does what you see in the mirror determine your mood that day?
How important do you think appearance is in life?
Do you use any oral or topical medications for dermatologic reasons or to prevent hair loss?
Have you ever had cosmetic surgery? If so, how satisfied were you with the outcome? Did you have any revisions?
Lifetime prevalence (%) of comorbid Axis I disorders in BDD
Substance use disorders
Gunstad and Phillips (2003)*12
Zimmerman and Mattia (1998)14
Perugi et al (1997)13
Veale et al (1996)7
Hollander et al (1993)6
N: number of study subjects
OCD: obsessive-compulsive disorder
* Phenomenology group
† not reported
Source: Adapted and reprinted with permission from reference 12.
Improving insight. Educate patients that BDD is a brain disorder that creates faulty, inaccurate thoughts and perceptions about appearance. Many patients initially resist a BDD diagnosis; delusional thinking and poor insight lead them to assume the “flaw” they see is an accurate perception. They may need to hear about other persons with similar concerns to realize that a psychiatric disorder is causing their distress.
Other helpful resources for improving insight include:
- group therapy
- The Broken Mirror, by Katharine A. Phillips, MD,15 which contains case examples to which BDD sufferers may relate
- Websites and online forums (see Related resources).
Explaining BDD. Discuss possible causes of BDD, giving patients alternate explanations for the physical defects they perceive. Contributing factors may include:
- neurobiological abnormalities and genetic factors16
- a history since childhood of shyness, perfectionism, or anxious temperament
- being teased, abused, or in poor family and peer relationships.17
Emphasize that multiple, different, converging factors cause BDD for each individual.
The obsessive-compulsive cycle. Explain that thoughts create distressing emotions, and that persons with BDD try to relieve or prevent these emotions by performing compulsive behaviors. Compulsions then strengthen the association between intrusive thoughts about appearance “defects” and negative feelings about appearance.
Review a list of common compulsions (Table 3) with BDD patients, as many have engaged in these behaviors for years without realizing they are compulsions.
Common BDD compulsions and avoidances
Excessive checking or avoidance of mirrors and other reflective surfaces
Asking for reassurance about appearance
“Camouflaging” (hiding or covering up) supposed defects
Scrutinizing the appearance of other people and comparing to oneself
Avoiding social interactions
Avoidance of certain lighting conditions
Skin-picking to “fix” perceived flaws
Having repeated cosmetic or dermatological procedures, such as dermabrasion, cosmetic surgery, etc.
BDD is a severe and complex disorder that often requires multimodal treatment using cognitive-behavioral therapy (CBT) and medication (algorithm).18 In our experience, most BDD patients need medication for the disorder and for common comorbidities. We recommend starting medications before or when beginning CBT for patients with moderate to severe BDD (BDD YBOCs ≥ 20).
Serotonin reuptake inhibitors (SRIs) have reduced BDD symptoms in open-label19,20 and controlled trials.21,22 As first-line treatments, SRIs decrease distress, compulsions, and frequency and intensity of obsessions about perceived defects; they also can improve insight.21-24 SRIs appear equally effective for delusional and nondelusional patients;21,23 whether CBT is similarly effective is unclear.
Relatively high dosages are usually necessary, according to published flexible-dosing trials in BDD,19-23 a retrospective chart review24 and our experience. Try dosages similar to those used for OCD (Table 4) as tolerated, and monitor for side effects. Twelve to 16 weeks of treatment are often needed for a full therapeutic effect.20-21
Augmentation. Consider adding another agent if a full SRI trial achieves partial symptom relief. One open-label trial of 13 BDD patients found that 6 (46%) improved when buspirone (mean dosage 48.3 mg/d) was added to SRI therapy.25 In a chart review, Phillips et al24 reported variable response rates of BDD patients treated with augmentation trials of clomipramine (4/9), buspirone (12/36), lithium (1/5), methylphenidate (1/6), and antipsychotics (2/13).
Very few studies have examined antipsychotic use in BDD. Placebo-controlled data are available only for pimozide.27 Conventional antipsychotics are unlikely to be effective, either as monotherapy26 or augmentation.27 As for the atypicals, olanzapine augmentation showed little to no efficacy in one small trial, although the average dosage used was low (4.6 mg/d).28 In our experience, atypicals—such as aripiprazole, 5 to 30 mg/d; quetiapine 100 to 300 mg/d; olanzapine, 7.5 to 15 mg/d; or risperidone, 1 to 3 mg/d—can improve BDD core symptoms and improve insight.
Benzodiazepines can be useful for acute anxiety or agitation. Carefully monitor benzodiazepine use, however, as substance abuse is relatively common in BDD patients.29
Recommended SRI dosages for treating BDD*†
Dosage range (mg/d)
40 to 100
150 to 250
20 to 50
40 to 100
200 to 400
40 to 100
150 to 400
* Off-label use.
† May exceed FDA-recommended maximum dosages.
Specialized cbt techniques
Cognitive restructuring. Trying to convince BDD patients there is nothing wrong with their appearance will not be successful. Instead, we use cognitive restructuring to challenge the rationality of their thoughts and beliefs and to find alternate, more rational ones:
Therapist: “I know I cannot convince you that your (body area) is not defective, but can you give me evidence of how this ‘defect’ has affected your life?”
BDD patient: “Well, I haven’t had a date for a long time. I think this is evidence that my (body part) must be ugly, and that no one wants to date me because of it.”
Therapist: “What are some other possible reasons why you haven’t had a date in a long time? You admitted that you have barely left your house for many months. Is it possible that you have not had a date for a long time because you rarely go outside?”
With cognitive restructuring, patients learn to:
- identify automatic thoughts and beliefs that provoke distress
- examine evidence supporting or refuting these beliefs
- de-catastrophize (such as “What is the worst thing that could happen if you left the house today without checking your [body part]? Do you think you would eventually be able to cope with that?”)
- learn to more accurately assess the probability of feared negative consequences
- arrive at rational responses.
In our experience—which is supported by OCD literature—participating in CBT is very hard for patients with frank delusions, and insight determines how effective cognitive restructuring can be.30 If a patient is convinced a body part is defective, she is unlikely to stay in treatment—much less be open to restructuring her thoughts. Even unsuccessful attempts can help you gauge the intensity of patients’ beliefs, however.
During cognitive restructuring, it is important to uncover patients’ core beliefs (underlying, organizing principles they hold about themselves, others, and the world). BDD patients commonly believe that appearance is of utmost importance and that no one could love them because of their “defect.” The therapist can then help the patient challenge the rationality of those core beliefs.
Behavioral therapy. Basic behavioral therapy attempts to normalize excessive response to appearance concerns and to prepare patients for exposure and response prevention therapy (ERP). Having identified their compulsions, the next step is to guide patients in changing these behaviors, such as by:
- decreasing reassurance-seeking
- reducing avoidance of social situations
- decreasing opportunities to use the mirror
- reducing time spent on the Internet seeking cosmetic solutions
- increasing eye contact in social situations
- decreasing scanning of others’ physical features.
For example, suggest that BDD patients stand at least an arm’s length away when using a mirror for normal grooming. Then, instead of focusing on their body part, they will view it within the context of their entire face and body.