Psychiatric Annals

CME Article 

Update on Body Dysmorphic Disorder: Clinical Features, Epidemiology, Pathogenesis, Assessment, and Treatment

Megan M. Kelly, PhD; Katharine A. Phillips, MD

Abstract

Body dysmorphic disorder (BDD) is common and characterized by distressing or impairing preoccupations with perceived defects in one's bodily appearance as well as repetitive, compulsive behaviors aimed at hiding, improving, checking, or coping with appearance concerns. Avoidance of social situations is common. BDD is associated with high rates of suicidal ideation and behavior, co-occurring depression and substance use disorders, psychiatric hospitalization, and notably poor psychosocial functioning. Despite BDD's prevalence, severity, and morbidity, this disorder is often underrecognized and undertreated. Cosmetic treatment is often sought but not recommended. First-line treatments consist of serotonin-reuptake inhibitors (often at high doses) and cognitive-behavioral therapy that is tailored to BDD's unique symptoms. This review presents up-to-date information on the clinical features, epidemiology, pathogenesis, assessment, and treatment of BDD. [Psychiatr Ann. 2017;47(11):552–558.]

Abstract

Body dysmorphic disorder (BDD) is common and characterized by distressing or impairing preoccupations with perceived defects in one's bodily appearance as well as repetitive, compulsive behaviors aimed at hiding, improving, checking, or coping with appearance concerns. Avoidance of social situations is common. BDD is associated with high rates of suicidal ideation and behavior, co-occurring depression and substance use disorders, psychiatric hospitalization, and notably poor psychosocial functioning. Despite BDD's prevalence, severity, and morbidity, this disorder is often underrecognized and undertreated. Cosmetic treatment is often sought but not recommended. First-line treatments consist of serotonin-reuptake inhibitors (often at high doses) and cognitive-behavioral therapy that is tailored to BDD's unique symptoms. This review presents up-to-date information on the clinical features, epidemiology, pathogenesis, assessment, and treatment of BDD. [Psychiatr Ann. 2017;47(11):552–558.]

Body dysmorphic disorder (BDD) is characterized by distressing or impairing preoccupations with nonexistent or slight defects in physical appearance and compulsive behaviors performed in response to body image concerns.1 BDD is common, and in fact it is more common than obsessive-compulsive disorder (OCD), schizophrenia, or anorexia nervosa.2 BDD is associated with high rates of suicidality, psychiatric hospitalizations, and comorbid depression and substance use, as well as notably poor psychosocial functioning.3–6 In the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), BDD is classified as an obsessive-compulsive and related disorder.1 Despite its prevalence and severity, BDD is underrecognized in clinical settings.2–4

Clinical Features

Bodily Preoccupations

BDD is characterized by intrusive and persistent preoccupations that one or more aspects of one's appearance are unattractive, ugly, hideous, or deformed. In reality, the perceived flaws are nonexistent or only slight.1 Multiple appearance concerns are the norm.3–6 The preoccupations are difficult to resist or control, and they often interfere with attention and concentration.3,4 The most common concerns focus on skin (eg, acne, wrinkles, lines, pale skin), hair (eg, too thin or thick, balding, excessive body hair), and nose (eg, shape or size).3–6 Asymmetry concerns affect about one-quarter of people with BDD.4

Muscle dysmorphia—preoccupation with a “small” and insufficiently muscular body build—is associated with increased suicidality, impairment in psychosocial functioning, and substance use disorders (particularly anabolic steroid use) compared to other forms of BDD.7 Use of anabolic steroids may lead to adverse health effects (eg, cardiovascular) and may trigger aggressive or violent behavior.8

Repetitive (Compulsive) Behaviors

At some point during the disorder, people with BDD engage in excessive repetitive behaviors (ie, compulsions, rituals) that aim to improve, examine, seek reassurance about, or hide disliked body areas.1 They are usually time consuming (3 to 8 hours a day on average) and difficult to control, and they may increase, rather than decrease, distress.3,4

Common repetitive behaviors include checking one's reflection in mirrors and other reflective surfaces, excessive grooming rituals (eg, combing or getting hair “just right”), tanning, comparing oneself to others, reassurance seeking, and skin picking to try to improve perceived skin flaws.3–6

Insight/Delusionality of BDD Beliefs

Appearance beliefs span a range of insight, from excellent to absent (ie, delusional beliefs—complete conviction that the person looks ugly, abnormal, or deformed).3,4,9,10 Prior to treatment, insight is absent or poor in more than 70% of people with BDD.9 BDD's delusional form (absent insight) and its nondelusional form (ie, excellent, good, fair, or poor insight) appear to have far more similarities than differences; importantly, delusional BDD appears to respond well to serotonin-reuptake inhibitor (SRI) monotherapy as does nondelusional BDD (see below).10 Thus, those with delusional BDD beliefs are diagnosed with BDD with the absent insight specifier rather than a psychotic disorder.1

Many people with BDD have ideas or delusions of reference, believing that others take special notice of them (eg, make fun of them, stare at them) because they look so abnormal.3,4 This symptom is consistent with evidence that BDD is associated with misperception of neutral facial expressions as threatening or contemptuous.11 These symptoms may contribute to social isolation and trigger aggressive behavior.3,4

Age at Onset and Course

BDD begins before age 18 years in two-thirds of people with the disorder.3,4 Unless it is appropriately treated, the course is usually chronic.12 A greater severity and a longer duration of BDD symptoms is predictive of a lower likelihood of remission.12

Comorbidity

Major depressive disorder is the most common comorbid disorder (lifetime prevalence of about 75%).5,6 Other common comorbid disorders include substance use disorders (lifetime prevalence of 30%–50%), social anxiety disorder (lifetime prevalence of 37%–39%), and OCD (lifetime prevalence of 32%–33%).5,6 Substance use appears to reflect an attempt to cope with the severe emotional distress that BDD often causes.13

Quality of Life and Psychosocial Functioning

Quality of life and psychosocial functioning are usually poor across many domains, including social, occupational, academic, and physical functioning.3,4,14 Impairment ranges from moderate to extreme, with most people experiencing severe impairment in functioning and poor quality of life. Time-consuming appearance preoccupations and compulsive behaviors usually interfere with the ability to concentrate, work, attend school, and maintain or form relationships3,4,14(Table 1). Social situations are often avoided or endured with anxiety and distress due to fears of being negatively judged because of how they look.3,4,14 People with more severe BDD may be completely housebound and unable to hold a job or attend school.3,4,14 More severe BDD symptoms are associated with greater functional impairment and poorer quality of life.3,4,14

Questions to Diagnose Body Dysmorphic Disorder According to DSM-5 Diagnostic Criteria

Table 1:

Questions to Diagnose Body Dysmorphic Disorder According to DSM-5 Diagnostic Criteria

Suicidality

In clinical samples and samples of convenience, 78% to 81% of participants report lifetime suicidal ideation, and 24% to 28% have attempted suicide.15,16 In a sample of 100 veterans in a primary care behavioral health clinic, those with BDD had a lifetime suicide attempt rate of 58% compared to 19% for veterans without BDD.17 In a nationwide probability study of 2,510 people, 31% of those with BDD versus 3.5% of those without BDD had experienced suicidal ideation due to appearance concerns, and 22.2% versus 2.1% had attempted suicide because of appearance concerns.2

Factors independently associated with suicidal ideation and/or suicide attempts in BDD include greater BDD symptom severity as well as comorbid substance use disorder, major depressive disorder, and posttraumatic stress disorder.15 Additional correlates include onset of BDD before age 18 years, unemployment, comorbid social phobia or OCD, three or more comorbid Axis I disorders, perceived childhood maltreatment (abuse or neglect), and BDD-related restrictive food intake.16

The rate of completed suicide appears markedly elevated and perhaps higher than for major depressive disorder, bipolar disorder, or eating disorders.16 In a prospective longitudinal study of BDD, the annual suicide rate was 45 times higher than in the general United States population; over a longer follow-up period of up to 6 years, the rate of confirmed suicides was 22 times higher than in the US population; including probable suicides, it was 36 times higher.16

BDD in Youth

Youth with BDD typically experience very poor quality of life and impaired psychosocial functioning.18 School refusal is common, and school dropout due to BDD symptoms occurs in 18% to 22% of youth.18 Youth are more likely than adults to have delusional BDD beliefs (as opposed to nondelusional beliefs) and attempt suicide.18

Epidemiology

Five population-based probability samples found a point prevalence of 1.7% to 2.9%.2 In these studies, BDD was slightly more common in women than in men (about a 3:2 ratio).2 BDD was associated with a lower likelihood of being in a committed relationship, less education, lower household income, and greater unemployment.2

Etiology and Pathophysiology

Both genetic and environmental factors, including a genetic link to OCD, contribute to the development of BDD.19 Evolutionary pressures (eg, physical appearance judgments in the context of efforts to attract and secure reproductively healthy mates) may also be relevant. Visual processing abnormalities involving overfocus on details and deficits in holistic (“big picture”) visual processing are present; these abnormalities appear similar to, but of a greater magnitude than, those that occur in anorexia nervosa.19,20 BDD is also characterized by deficits in executive functioning as well as information-processing biases, emotion-recognition deficits and biases, and selective processing of appearance-related information.21 Environmental factors may include perceived childhood maltreatment and a history of teasing.4

Diagnosis and Assessment

To diagnose BDD, DSM-5 criteria should be assessed and met. Table 1 outlines these criteria and provides questions for clinicians to ask. Regarding criterion A, it is best to start with a general question about appearance concerns, such as “Are you very worried about your appearance in any way?” or “Are you unhappy with how you look?” Criterion B specifies that repetitive behaviors (comparing oneself to others, grooming rituals, reassurance seeking, skin picking, mirror checking) have been present at some point during the course of the disorder (not necessarily currently). To fulfill DSM-5 criterion C, appearance preoccupations must cause clinically significant distress and/or impairment in social, occupational, academic, or other areas of functioning. To fulfill Criterion D, the appearance concerns cannot be better explained by an eating disorder, although weight concerns may occur as a symptom of BDD. Two specifiers—insight (good, fair, poor, or absent/delusional BDD beliefs) and muscle dysmorphia—should be assessed. The DSM-5 panic attack specifier, which can be used for any disorder, should be noted if BDD symptoms trigger panic attacks.

Although BDD is common, it is commonly underdiagnosed or misdiagnosed. People with BDD are often reluctant to discuss their appearance concerns unless directly asked. Reasons include embarrassment and shame, not wanting to draw more attention to their perceived appearance flaws, lack of recognition that their appearance concerns are psychiatric in nature, and preferring cosmetic to psychiatric treatment. Thus, clinicians need to proactively assess for BDD. BDD is often mistaken for comorbid disorders, including depression, social anxiety disorder, and OCD. It may be misdiagnosed as a psychotic disorder because BDD beliefs may be delusional and delusions of reference may be present.

Treatment

Surgery, Dermatologic Treatment, and Other Cosmetic Treatments

Because many people with BDD consider their problem a physical issue rather than a body image problem, they pursue cosmetic treatments to “fix” their appearance. About three-quarters of those with BDD seek, and two-thirds actually receive, cosmetic procedures for their BDD concerns.22 Dermatologic treatment is most often received (by nearly half of patients) followed by surgery (20%–40%).22 Other types of cosmetic procedures (eg, dental, electrolysis, hair plugs) may also be obtained.22 Cosmetic treatments for BDD rarely reduce BDD symptoms, and most people are dissatisfied with them.22 After such procedures, appearance preoccupations may shift from the initial area, and appearance concerns are sometimes exacerbated.22 A sizable proportion of patients with BDD threaten surgeons legally or physically because they are dissatisfied with the surgical outcome. Thus, cosmetic treatments are currently contraindicated for BDD.23

Pharmacotherapy

SRIs are the first-line medication for BDD, including delusional BDD. Controlled trials as well as methodologically rigorous open-label trials have shown that optimal SRI treatment significantly improves BDD symptoms, depression, anger/hostility, suicidal ideation, other associated symptoms, psychosocial functioning, and quality of life.24–26 Within 12 to 14 weeks of starting treatment, and with proper dosing, BDD symptoms typically decrease by about 50%; in addition, by this time a majority of patients are considered responders (at least a 30% decrease in symptoms), and about one-quarter achieve full remission.26

As is the case for OCD, SRIs appear more efficacious than other medications for BDD.24,26 SRI monotherapy is as effective for delusional BDD as for nondelusional BDD.24–26 Thus, an SRI, rather than a neuroleptic, is recommended as initial treatment for delusional BDD (although a neuroleptic can be started concurrently with an SRI when treating more severely ill, agitated, or aggressive patients).

High SRI doses are often needed. Rigorous dose-finding studies have not been done, but mean daily doses and maximum doses that the second author (K.A.P.) has used in clinical practice since the early 1990s are: escitalopram: 29.2 + 12 mg (up to 60 mg); fluoxetine: 67 ± 24 mg (up to 120 mg); sertraline: 202 ± 46 mg (up to 400 mg); fluvoxamine: 308 ± 49 mg (up to 450 mg); paroxetine: 55 ± 13 mg (up to 100 mg); and clomipramine: 203 ± 53 mg (up to 250 mg).26 These doses are similar to those recommended for OCD.27 US Food and Drug Administration (FDA)-approved dosing limits can be exceeded for escitalopram, fluoxetine, fluvoxamine, sertraline, and paroxetine if needed and tolerated, with close patient monitoring. Suggested maximum doses for children and adolescents are somewhat lower. An electrocardiogram is recommended when exceeding 30 mg/day of escitalopram. Citalopram is no longer recommended for BDD due to postmarketing FDA dosing limits.26

A general recommendation is to attempt to reach the maximum manufacturer-recommended SRI dose (30 mg for escitalopram) by week 5 to 9 of treatment, if tolerated, unless a lower dose is efficacious.26 A full SRI trial of 12 to 16 weeks, while reaching a high dose if necessary and staying on the maximum tolerated dose for at least 3 to 4 of those 12 to 16 weeks, is recommended to determine whether the SRI is improving symptoms.26 If the dose is raised more slowly, or a higher dose is needed, a longer trial than the typical 12 to 16 week trial will be needed before evaluating efficacy.

If an optimal 12- to 16-week SRI trial improves BDD symptoms by at least 30%, the SRI should usually be continued, because BDD symptoms may further improve.26 If an SRI at a high enough dose does not produce sufficient improvement in BDD symptoms (eg, <30%) after an optimal 12- to 16- week trial, medication adherence should be evaluated; improving adherence may convert medication nonresponse to response. At this point, alternatives are (1) further increasing the SRI dose until the maximum doses noted above are reached, (2) augmenting the SRI with a medication such as buspirone (up to 60 mg/day if needed and tolerated) or a low dose of an atypical neuroleptic such as aripiprazole, (3) adding cognitive-behavioral therapy (CBT), or (4) switching to another SRI. No studies have evaluated the relative efficacy of these approaches, although all may be effective.26 Options 1, 2, and 3 are usually preferred if the SRI has partially improved symptoms.26

Serotonin-norepinephrine reuptake inhibitors may be considered if multiple SRI trials are ineffective.26 Electroconvulsive therapy (in combination with an SRI) can be considered for severely depressed and highly suicidal patients, although its efficacy for BDD is unknown.26 For SRI responders, continued SRI treatment is recommended for at least several years, and indefinite treatment is recommended for severely ill, high-risk patients.26 More detailed recommendations can be found elsewhere.4,26

Psychosocial Treatment

CBT is the first-line psychosocial treatment for BDD. CBT must be tailored to BDD's unique clinical features. Such treatment is often effective, as evidenced by controlled trials.28,29 Improvement in BDD symptoms appears to often be long-lasting.

CBT for BDD typically includes (1) doing initial groundwork for treatment, including setting valued goals and developing a cognitive-behavioral model of the patient's BDD; (2) cognitive restructuring to identify maladaptive patterns of thinking and develop more accurate and helpful BDD-related thoughts and beliefs; (3) exposure for situations that are commonly avoided (often social activities, because these are typically avoided due to fear of rejection); (4) behavioral experiments to test whether BDD beliefs are accurate (eg, asking a patient to go to the grocery store to test whether 70% of people are the store are indeed looking at them), which are combined with exposures; (5) ritual (response) prevention to stop compulsive behaviors in response to appearance concerns (eg, limiting time spent styling hair or applying makeup, stopping excessive mirror checking, or comparing oneself to others); (6) advanced cognitive strategies to change problematic core beliefs (eg, “I am unlovable”); (7) perceptual retraining and mindfulness, which involves learning to globally see oneself in a mindful and nonjudgmental way, rather than focusing in a negative way on disliked details of appearance; and (8) relapse prevention to sustain progress.30 CBT for BDD may also address skin picking, muscle dysmorphia, and weight/shape concerns, cosmetic treatment seeking behavior, and mood management for people with relevant symptoms.30 Because insight is usually poor or absent, motivational interviewing is often needed to engage and retain patients in treatment.30

We recommend that patients not be told to stare in the mirror for any length of time, because BDD symptoms may worsen and the ritual of mirror checking is reinforced. Instead, ritual prevention should be used to refrain from mirror checking, and perceptual retraining (see above) can be taught. We also suggest not doing more extreme behavioral exposures (eg, painting big red dots on one's face and going out in public). Although the intent might be to help patients learn that they can tolerate their feared outcomes, such as being noticed by other people because of perceived acne, such exposures can potentially destabilize patients, trigger suicidal thinking or aggressive behavior, or intensify delusional beliefs (because the feared outcome of being stared at may actually occur).

CBT needs to be individualized to the concerns of the patient. Treatment for BDD generally involves weekly hour-long sessions for 6 months (which is longer than other treatments due to the severity and complexity of BDD symptoms);30 however, some patients may improve with fewer sessions, whereas others need longer and more intensive treatment. Because BDD can be challenging to treat, we recommend use of an empirically based CBT treatment manual for BDD.30,31

Conclusions

BDD is common, impairing, and associated with substantial morbidity and mortality. However, BDD is underdiagnosed, misdiagnosed, and undertreated. It is important to recognize and screen patients for BDD because effective pharmacotherapy (ie, SRI treatment) and psychosocial approaches (ie, CBT for BDD) are available. When appropriately implemented they usually profoundly improve BDD symptoms, functioning, and quality of life.

References

  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013.
  2. Hartmann AS, Buhlmann U. Phenomenology and epidemiology of BDD. In: Phillips KA, ed. Body Dysmorphic Disorder: Advances in Research and Clinical Practice. New York, NY: Oxford University Press; 2017:49–60.
  3. Phillips KA. The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder. New York, NY: Oxford University Press; 1996.
  4. Phillips KA. Understanding Body Dysmorphic Disorder: An Essential Guide. New York, NY: Oxford University Press; 2009.
  5. Phillips KA, Diaz S. Gender differences in body dysmorphic disorder. J Nerv Ment Dis. 1997;185:570–577. doi:10.1097/00005053-199709000-00006 [CrossRef]
  6. Phillips KA, Menard W, Fay C, Weisberg R. Demographic characteristics, phenomenology, comorbidity, and family history in 200 individuals with body dysmorphic disorder. Psychosomatics. 2005;46:317–325. doi:. doi:10.1176/appi.psy.46.4.317 [CrossRef]
  7. Pope HG, Gruber AJ, Choi P, et al. Muscle dysmorphia: an underrecognized form of body dysmorphic disorder. Psychosomatics. 1997;38:548–557. doi:. doi:10.1016/S0033-3182(97)71400-2 [CrossRef]
  8. Trenton AJ, Currier GW. Behavioural manifestations of anabolic steroid use. CNS Drugs. 2005;19:571–595. doi:10.2165/00023210-200519070-00002 [CrossRef]
  9. Eisen JL, Phillips KA, Coles ME, Rasmussen SA. Insight in obsessive-compulsive disorder and body dysmorphic disorder. Compr Psychiatry. 2004;45:10–15. doi:. doi:10.1016/j.comppsych.2003.09.010 [CrossRef]
  10. Phillips KA, Menard W, Pagano M, Fay C, Stout RL. Delusional versus nondelusional body dysmorphic disorder: clinical features and course of illness. J Psychiatr Res. 2006;40:95–104. doi:. doi:10.1016/j.jpsychires.2005.08.005 [CrossRef]
  11. Buhlmann U, Etcoff NL, Wilhelm S. Emotion recognition bias for contempt and anger in body dysmorphic disorder. J Psychiatr Res. 2006;40:105–111. doi:. doi:10.1016/j.jpsychires.2005.03.006 [CrossRef]
  12. Phillips K, Menard W, Quinn E, Didie E, Stout R. A 4-year prospective observational follow-up study of course and predictors of course in body dysmorphic disorder. Psychol Med. 2013;43:1109–1117. doi: . doi:10.1017/S0033291712001730 [CrossRef]
  13. Grant JE, Menard W, Pagano ME, Fay C, Phillips KA. Substance use disorders in individuals with body dysmorphic disorder. J Clin Psychiatry. 2005;66:309–311. doi:10.4088/JCP.v66n0306 [CrossRef]
  14. Kelly MM, Brault M, Didie ER. Psychosocial functioning and quality of life in body dysmorphic disorder. In: Phillips KA, ed. Body Dysmorphic Disorder: Advances in Research and Clinical Practice. New York, NY: Oxford University Press; 2017:139–154.
  15. Phillips KA, Coles M, Menard W, et al. Suicidal ideation and suicide attempts in body dysmorphic disorder. J Clin Psychiatry. 2005;66:717–725. doi:10.4088/JCP.v66n0607 [CrossRef]
  16. Phillips KA. Suicidality and aggressive behavior in body dysmorphic disorder. In: Phillips KA, ed. Body Dysmorphic Disorder: Advances in Research and Clinical Practice. New York, NY: Oxford University Press; 2017:155–172.
  17. Kelly MM, Zhang J, Phillips KA. The prevalence of body dysmorphic disorder and its clinical correlates in a VA primary care behavioral health clinic. Psychiatry Res. 2015;228:162–165. doi:. doi:10.1016/j.psychres.2015.04.007 [CrossRef]
  18. Phillips KA, Didie ER, Menard W, Pagano ME, Fay C, Weisberg RB. Clinical features of body dysmorphic disorder in adolescents and adults. Psychiatry Res. 2006;141:305–314. doi:. doi:10.1016/j.psychres.2005.09.014 [CrossRef]
  19. McCurdy-McKinnon D, Feusner JD. Neurobiology of body dysmorphic disorder: heritability/genetics, brain circuitry, and visual processing. In: Phillips KA, ed. Body Dysmorphic Disorder: Advances in Research and Clinical Practice. New York, NY: Oxford University Press; 2017:253–276.
  20. Li W, Lai TM, Bohon C, et al. Anorexia nervosa and body dysmorphic disorder are associated with abnormalities in processing visual information. Psychol Med. 2015;45(10):2111–2122. doi:. doi:10.1017/S0033291715000045 [CrossRef]
  21. Buhlmann U, Hartmann AS. Cognitive and emotional processing in body dysmorphic disorder. In: Phillips KA, ed. Body Dysmorphic Disorder: Advances in Research and Clinical Practice. New York, NY: Oxford University Press; 2017:285–298.
  22. Crerand CE, Sarwer DB, Ryan M. Cosmetic medical and surgical treatments and body dysmorphic disorder. In: Phillips KA, ed. Body Dysmorphic Disorder: Advances in Research and Clinical Practice. New York, NY: Oxford University Press; 2017:431–448.
  23. Ishii LE, Tollefson TT, Basura GJ, et al. Clinical practice guideline: improving nasal form and function after rhinoplasty. Otolaryngol Head Neck Surg. 2017;156(suppl):S1–S30. doi:. doi:10.1177/0194599816683153 [CrossRef]
  24. Hollander E, Allen A, Kwon J, et al. Clomipramine vs desipramine crossover trial in body dysmorphic disorder: selective efficacy of a serotonin reuptake inhibitor in imagined ugliness. Arch Gen Psychiatry. 1999;56:1033–1039. doi:10.1001/archpsyc.56.11.1033 [CrossRef]
  25. Phillips KA, Albertini RS, Rasmussen SA. A randomized placebo-controlled trial of fluoxetine in body dysmorphic disorder. Arch Gen Psychiatry2002;59:381–388. doi:10.1001/archpsyc.59.4.381 [CrossRef]
  26. Phillips KA. Pharmacotherapy and other somatic treatments for body dysmorphic disorder. In: Phillips KA, ed. Body Dysmorphic Disorder: Advances in Research and Clinical Practice. New York, NY: Oxford University Press; 2017:333–356.
  27. Koran LM, Hanna GL, Hollander E, Nestadt G, Simpson HB. Practice Guideline for the Treatment of Patients with Obsessive-Compulsive Disorder. Arlington, VA: American Psychiatric Association; 2007.
  28. Veale D, Anson M, Miles S, Pieta M, Costa A, Ellison N. Efficacy of cognitive behaviour therapy versus anxiety management for body dysmorphic disorder: a randomised controlled trial. Psychother Psychosom. 2014;83:341–353. doi:. doi:10.1159/000360740 [CrossRef]
  29. Wilhelm S, Phillips KA, Didie E, et al. Modular cognitive-behavioral therapy for body dysmorphic disorder: a randomized controlled trial. Behav Ther. 2014;45:314–327. doi:. doi:10.1016/j.beth.2013.12.007 [CrossRef]
  30. Wilhelm S, Phillips KA, Steketee G. Cognitive-Behavioral Therapy for Body Dysmorphic Disorder: A Treatment Manual. New York, NY: Guilford Press; 2013.
  31. Veale D, Neziroglu F. Body Dysmorphic Disorder: A Treatment Manual. Hoboken, NJ: Wiley-Blackwell; 2010. doi:10.1002/9780470684610 [CrossRef]

Questions to Diagnose Body Dysmorphic Disorder According to DSM-5 Diagnostic Criteria

Questions to evaluate diagnostic criteria Criterion A: Preoccupation with nonexistent or slight appearance defects or flaws <list-item>

“Are you very worried about your appearance in any way?” OR “Are you unhappy with how you look?”

</list-item><list-item>

Invite the patient to describe his or her concern by asking “What don't you like about how you look?” OR “Can you tell me about your concern?” Listen to the patient's description; do not provide reassurance about or comment on his or her appearance.

</list-item><list-item>

Ask if there are other disliked body areas—for example, “Are you unhappy with any other aspects of your appearance, such as your face, skin, hair, nose, or the shape or size of any other body area?”

</list-item><list-item>

Ascertain that the patient is preoccupied with these perceived flaws by asking “How much time would you estimate that you spend each day thinking about your appearance, if you add up all the time you spend?” OR “Do these concerns preoccupy you?”

Criterion B: Repetitive behaviors in response to the appearance concerns

</list-item><list-item>

Ask “Is there anything that you do over and over again in response to your appearance concerns?” ...“For example, do you compare yourself with others, check your appearance in mirrors or other reflecting surfaces, ask other people if you look okay or what they think of your appearance, touch the disliked areas, or pick at your skin?” ...“Do you do anything else to try to check, fix, hide, or be reassured about your (fill in disliked body areas)?”

Criterion C: Clinically significant distress or impairment in functioning resulting from appearance concerns

</list-item><list-item>

Ask “How much distress do these concerns cause you?” Ask specifically about resulting anxiety, social anxiety, depression, panic, shame, hopelessness, guilt, and suicidal thinking.

</list-item><list-item>

Ask about effects of the appearance preoccupations on the patient's life—for example: “Do these concerns interfere with your life or cause problems for you in any way?” Ask specifically about effects on work, school, other aspects of role functioning (eg, caring for children), relationships, intimacy, family and social activities, household tasks, and other types of interference. Examples of interference include: <list-item>

Decreased focus and concentration

</list-item><list-item>

Being late for or missing school or work

</list-item><list-item>

Interruption of school, work, or household routines by body dysmorphic disorder rituals (for example, leaving class to check the bathroom mirror or reapply makeup)

</list-item><list-item>

Dropping or failing grades

</list-item><list-item>

Dropping out of school

</list-item><list-item>

Quitting a job or being fired; being unemployed

</list-item><list-item>

Not dating

</list-item><list-item>

Marital conflict or divorce

</list-item><list-item>

Sexual difficulties

</list-item><list-item>

Not seeing friends as often or at all

</list-item><list-item>

Missing family events

</list-item><list-item>

Turning down or avoiding social gatherings

</list-item><list-item>

Difficulty caring for children or managing a household, going shopping, or doing chores

</list-item><list-item>

Avoiding activities like going to the gym

</list-item><list-item>

Using drugs or alcohol to cope with body dysmorphic disorder

</list-item>

Criterion D: The appearance preoccupation is not better explained by concerns with body fat or weight if these symptoms meet diagnostic criteria for an eating disorder

</list-item><list-item>

People who have excessive and problematic concerns with the belief that they weigh too much or that their overall body or parts of their body are too fat should be evaluated for the presence of an eating disorder (anorexia nervosa, bulimia nervosa, and binge eating disorder). If one of these disorders explains these body image concerns, then the concerns do not count toward a diagnosis of body dysmorphic disorder.

</list-item>
Questions to evaluate specifiers <list-item>

With muscle dysmorphia, ask “Are you preoccupied with the idea that your body build is too small or that you're not muscular enough?”

</list-item><list-item>

Insight: Elicit a global belief about the perceived defect(s) (rather than asking about specific body areas): “What word would you use to describe how bad all of these areas (fill in all disliked areas) look?” If the patient has difficulty choosing a word (often because of embarrassment), ask

</list-item><list-item>

“Some people use words like unattractive, ugly, deformed, hideous”; do you think any of these apply to you?” Then ask, “How convinced are you that these body areas look (fill in patient's global descriptor)?”

</list-item>
Authors

Megan M. Kelly, PhD, is the Bedford Site Director, Veterans Integrated Service Network 1 (VISN 1) New England Mental Illness Research, Education, and Clinical Center, Edith Nourse Rogers Memorial Veterans Hospital; and an Assistant Professor, Department of Psychiatry, University of Massachusetts Medical School. Katharine A. Phillips, MD, is a Professor of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University; a Senior Research Scholar, the Director of the Body Dysmorphic Disorder Program, and the Director of Research for Adult Psychiatry, Rhode Island Hospital.

Address correspondence to Megan M. Kelly, PhD, Veteran Affairs, VISN 1 New England Mental Illness Research, Education, and Clinical Center, 200 Springs Road, Bedford, MA 01730; email: megan.kelly1@va.gov.

Disclaimer: No medications are approved by the US Food and Drug Administration (FDA) for the treatment of body dysmorphic disorder. Some of the dosing recommendations exceed maximum FDA-approved doses for other uses, although these recommendations are consistent with the American Association Practice Guideline for the treatment of obsessive-compulsive disorder.

Disclosure: The authors have no relevant financial relationships to disclose.

10.3928/00485713-20171004-02

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