Dysmorphophobia Treatment & Management

  • Author: Robert A Schwartz, MD, MPH; Chief Editor: Dirk M Elston, MD   more...
 
Updated: Mar 9, 2012
 

Medical Care

Individuals with body dysmorphic disorder (BDD) often refuse psychiatric referral because of poor insight into the underlying psychiatric illness.[26] Dermatologic or plastic surgery treatment frequently fails to improve dysmorphophobic symptoms. If provided routine treatment, most people with dysmorphophobia are displeased with therapy and may attest to increased preoccupation with the flaw.

Serotonin reuptake inhibitors (SRIs) and cognitive behavior therapy may be useful in treating such patients.[27]

SRIs have proven to be the most effective medications in the treatment of dysmorphophobia. The most widely used SRIs include clomipramine[28] (average dose approximately 175 mg/d), fluoxetine (approximately 50 mg/d), and fluvoxamine (approximately 260 mg/d). These drugs often require high doses and lengthy treatment periods before symptoms improve; drug trials should continue for several months after the target dose is reached. Increase the dose gradually to prevent possible adverse effects. Almost 58% of patients with dysmorphophobia achieve either partial improvement or complete resolution of symptoms with an SRI regimen.

Efficacy of clomipramine (SRI) versus desipramine (selective norepinephrine reuptake inhibitor) was compared in a study of body dysmorphic disorder. Superior results were noted with clomipramine treatment. Increased improvement occurred in obsessive characteristics, depression, insight, social performance, and general severity of the disorder.[29]

Selective serotonin reuptake inhibitors (SSRIs) also are used in the treatment of dysmorphophobia. Fluoxetine is used most frequently. People with delusional symptoms may benefit from a therapeutic regimen including pimozide (antipsychotic) in addition to an SSRI. Patient insight may improve using pimozide alone. A pimozide/clomipramine combination may lengthen the QT interval on ECG; therefore, close monitoring of the cardiogram is required.

Buspirone (30-60 mg/d) in addition to an SRI proves helpful to one third of patients who do not respond to SRI treatment alone.

In some situations, patients who show resistance to normal treatment may have positive results when treated with SSRIs in combination with clomipramine. In this case, monitor clomipramine levels because SSRIs increase clomipramine concentration in the blood.

If all other treatment modalities fail, monoamine oxidase inhibitors (MAOIs) may be used, although dietary and other restrictions are necessary (ie, avoiding foods containing tyramine, use of certain medications). These drugs probably should be prescribed only by experienced specialists.

The United Kingdom’s National Collaborating Centre for Mental Health guideline, Obsessive-compulsive disorder: core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder, may be of interest.[30]

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Consultations

A psychiatric consultation may be adviseable for patients seeking cosmetic treatment whether by orthodonists, plastic surgeons, or dermatologists.[31, 32]

Nonpharmacologic psychiatric treatment may prove effective in the treatment of people with body dysmorphic disorder; however, the patients are most likely to avoid psychiatric therapy. An on-site psychiatric liaison may be used to bridge the gap between dermatologic and psychological treatments.

Therapy using behavioral modification includes encouraging people with body dysmorphic disorder to discontinue or decrease compulsive behaviors such as skin picking. Gradual desensitization to social situations that cause anxiety also is helpful.

Cognitive behavioral therapy, including encouragement of self-esteem, modification of distorted thoughts, and formulation of coping strategies, may be most effective when used in conjunction with SRIs.

Therapy within a group setting and supportive psychotherapy may be adequate for people who are not truly delusional.

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Contributor Information and Disclosures
Author

Robert A Schwartz, MD, MPH  Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, University of Medicine and Dentistry of New Jersey-New Jersey Medical School

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi

Disclosure: Nothing to disclose.

Coauthor(s)

Wanda M Patterson, MD  Department of Dermatology, UMDNJ-New Jersey Medical School

Wanda M Patterson, MD is a member of the following medical societies: Sigma Xi

Disclosure: Nothing to disclose.

O Joseph Bienvenu III, MD, PhD  Assistant Professor, Department of Psychiatry, Johns Hopkins University School of Medicine

O Joseph Bienvenu III, MD, PhD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, and American Psychiatric Association

Disclosure: Nothing to disclose.

M Peter Chodynicki, MD  Staff Physician, Department of Psychiatry, Johns Hopkins University School of Medicine

M Peter Chodynicki, MD is a member of the following medical societies: American Psychiatric Association

Disclosure: Nothing to disclose.

Camila K Janniger, MD  Clinical Professor of Dermatology, Clinical Associate Professor of Pediatrics, Chief of Pediatric Dermatology, University of Medicine and Dentistry of New Jersey-New Jersey Medical School

Camila K Janniger, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Specialty Editor Board

James J Nordlund, MD  Professor Emeritus, Department of Dermatology, University of Cincinnati College of Medicine

James J Nordlund, MD is a member of the following medical societies: American Academy of Dermatology, Sigma Xi, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Richard P Vinson, MD  Assistant Clinical Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine; Consulting Staff, Mountain View Dermatology, PA

Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Association of Military Dermatologists, Texas Dermatological Society, and Texas Medical Association

Disclosure: Nothing to disclose.

Jeffrey Meffert, MD  Assistant Clinical Professor of Dermatology, University of Texas School of Medicine at San Antonio

Jeffrey Meffert, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, Association of Military Dermatologists, and Texas Dermatological Society

Disclosure: Nothing to disclose.

Joel M Gelfand, MD, MSCE  Medical Director, Clinical Studies Unit, Assistant Professor, Department of Dermatology, Associate Scholar, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania

Joel M Gelfand, MD, MSCE is a member of the following medical societies: Society for Investigative Dermatology

Disclosure: AMGEN Consulting fee Consulting; AMGEN Grant/research funds Investigator; Genentech Grant/research funds investigator; Centocor Consulting fee Consulting; Abbott Grant/research funds investigator; Abbott Consulting fee Consulting; Novartis investigator; Pfizer Grant/research funds investigator; Celgene Consulting fee DMC Chair; NIAMS and NHLBI Grant/research funds investigator

Chief Editor

Dirk M Elston, MD  Director, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

References

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