Psychiatric Manifestations of Body Dysmorphic Disorder Treatment & Management

  • Author: Iqbal Ahmed, MBBS, FRCPsych (UK); Chief Editor: David Bienenfeld, MD   more...
 
Updated: Feb 11, 2011
 

Medical Care

The primary treatment modalities for body dysmorphic disorder (BDD) include the use of selective serotonin reuptake inhibitors (SSRIs) and cognitive behavioral therapy. Both treatment modalities are supported by level 2 evidence, which includes at least 1 double-blinded randomized controlled trial with placebo or active comparison condition.[24] The use of pharmacologic agents remains off-label, as currently no FDA medication is approved for the treatment of BDD.

  • Evidence for SSRIs in the treatment of BDD supports the use of SSRIs such as fluoxetine, fluvoxamine, escitalopram, and citalopram.[24]
  • Other pharmacologic agents, such as neuroleptics, trazodone, lithium, benzodiazepines, tricyclics (excluding clomipramine), and anticonvulsants have been much less beneficial or ineffective.
  • In general, higher SSRI doses than those prescribed for depression appear to be needed. This is similar to the treatment of OCD. A review article by Phillips pointed out that most SSRI studies for body dysmorphic disorder have a mean time to treatment response of 6-16 weeks.[25]
  • In BDD, even when the perceptions are felt to be psychotic, the use of neuroleptics may not ameliorate the delusions. Some patients may still benefit from adjunctive antipsychotics.[1] However, when used at levels comparable to the treatment of OCD, SSRIs are effective at ameliorating symptoms.[22] The response to SSRIs is often partial rather than complete, and 40-50% of patients may not respond adequately to medication alone.[24]
  • Psychotherapy, especially cognitive-behavioral psychotherapy, and behavioral modification therapy are highly recommended in addition to treatment with SSRIs.[26]
    • Approaches include systematic desensitization, exposure techniques, self-confrontational techniques, and cognitive imagery.
    • A few studies have claimed successful results with behavior modification alone.
  • Strongly consider therapy with family members, spouses, or significant others to help improve the patient's outcome.
    • People who have a close relationship with the patient may agree with the patient's perception of the defect and may reinforce the patient's maladaptive beliefs and behaviors.
    • On the other hand, people with a close relationship to the patient may disagree with what the patient thinks is necessary for treatment.
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Surgical Care

Plastic or cosmetic surgery intended to correct the perceived defect in patients with body dysmorphic disorder is contraindicated. Studies have shown that more than 90% of patients report symptoms that are unchanged and often exacerbated following surgical procedures. Due to their underlying symptomology and motivation for seeking surgical care, these patients represent a significantly disproportionate litigious risk. Even more concerning for surgeons considering providing surgical treatment to these patients are reports of patients with BDD who postoperatively become violent, causing physical harm to their healthcare providers.[27]

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Consultations

  • Physicians should refer patients to a psychiatrist for a thorough psychiatric evaluation to confirm a suspected diagnosis of BDD as well as to evaluate the patient for possible comorbid psychiatric diagnoses and provide appropriate treatment recommendations.
  • As many of these patients present to cosmetic and plastic surgeons seeking surgical correction of the perceived defect, they may react negatively and angrily to such a referral.[27]
  • As mentioned earlier, the referring surgeon or other physician is advised to treat the referral to a psychiatrist as they would any other health professional. Treating the referral as a standard aspect of preoperative care increases the likelihood that the patient follows up with the referral and should mitigate the possibility of patient dissatisfaction with the referring surgeon or physician.
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Contributor Information and Disclosures
Author

Iqbal Ahmed, MBBS, FRCPsych (UK)  Faculty, Department of Psychiatry, Tripler Army Medical Center; Clinical Professor of Psychiatry, Clinical Professor of Geriatric Medicine, University of Hawaii, John A Burns School of Medicine

Iqbal Ahmed, MBBS, FRCPsych (UK) is a member of the following medical societies: Academy of Psychosomatic Medicine, American Association for Geriatric Psychiatry, American Neuropsychiatric Association, American Psychiatric Association, American Society of Clinical Psychopharmacology, and Royal College of Psychiatrists

Disclosure: Nothing to disclose.

Coauthor(s)

Lawrence Genen, MD, MBA  Child & Adolescent Psychiatry Fellow, Division of Child & Adolescent Psychiatry, Department of Psychiatry, Keck School of Medicine, University of Southern California

Disclosure: Nothing to disclose.

Thomas Cook, MD  Resident Physician, Department of Psychiatry, University of Hawaii, John A Burns School of Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Denis F Darko, MD  Executive Director, Clinical Research and Development, Global Neuroscience, AstraZeneca

Denis F Darko, MD is a member of the following medical societies: American College of Physicians and American Psychiatric Association

Disclosure: AstraZeneca Salary Management position

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Harold H Harsch, MD  Program Director of Geropsychiatry, Department of Geriatrics/Gerontology, Associate Professor, Department of Psychiatry and Department of Medicine, Froedtert Hospital, Medical College of Wisconsin

Harold H Harsch, MD is a member of the following medical societies: American Psychiatric Association

Disclosure: lilly Honoraria Speaking and teaching; Forest Labs None None; Pfizer Grant/research funds Speaking and teaching; Northstar None None; Novartis Grant/research funds research; Pfizer Honoraria Speaking and teaching; Sunovion Speaking and teaching; Otsuke Grant/research funds reseach; GlaxoSmithKline Grant/research funds research; Merck Honoraria Speaking and teaching

Chief Editor

David Bienenfeld, MD  Professor of Psychiatry, Vice-Chair and Director of Residency Training, Department of Psychiatry, Wright State University, Boonshoft School of Medicine

David Bienenfeld, MD is a member of the following medical societies: American Medical Association, American Psychiatric Association, and Association for Academic Psychiatry

Disclosure: Nothing to disclose.

References

  1. Castle DJ, Rossell SL. An update on body dysmorphic disorder. Curr Opin Psychiatry. Jan 2006;19(1):74-8. [Medline].

  2. Phillips KA, Menard W, Fay C, Pagano ME. Psychosocial functioning and quality of life in body dysmorphic disorder. Compr Psychiatry. Jul-Aug 2005;46(4):254-60. [Medline]. [Full Text].

  3. Didie ER, Walters MM, Pinto A, Menard W, Eisen JL, Mancebo M, et al. A comparison of quality of life and psychosocial functioning in obsessive-compulsive disorder and body dysmorphic disorder. Ann Clin Psychiatry. Jul-Sep 2007;19(3):181-6. [Medline].

  4. Phillips KA, Diaz SF. Gender differences in body dysmorphic disorder. J Nerv Ment Dis. Sep 1997;185(9):570-7. [Medline].

  5. Phillips KA, Menard W, Fay C. Gender similarities and differences in 200 individuals with body dysmorphic disorder. Compr Psychiatry. Mar-Apr 2006;47(2):77-87. [Medline]. [Full Text].

  6. Phillips KA, Menard W. Suicidality in body dysmorphic disorder: a prospective study. Am J Psychiatry. Jul 2006;163(7):1280-2. [Medline]. [Full Text].

  7. Otto MW, Wilhelm S, Cohen LS, Harlow BL. Prevalence of body dysmorphic disorder in a community sample of women. Am J Psychiatry. Dec 2001;158(12):2061-3. [Medline].

  8. Rief W, Buhlmann U, Wilhelm S, Borkenhagen A, Brähler E. The prevalence of body dysmorphic disorder: a population-based survey. Psychol Med. Jun 2006;36(6):877-85. [Medline].

  9. Koran LM, Abujaoude E, Large MD, Serpe RT. The prevalence of body dysmorphic disorder in the United States adult population. CNS Spectr. Apr 2008;13(4):316-22. [Medline].

  10. Haas CF. Champion A. Secor D. Motivating factors for seeking cosmetic surgery: a synthesis of the literature. Plastic Surgical Nursing. Oct-Dec 2008;28(4):177-82. [Medline].

  11. Phillips KA. Body dysmorphic disorder: the distress of imagined ugliness. Am J Psychiatry. Sep 1991;148(9):1138-49. [Medline].

  12. Cleveland WL, DeLaPaz RL, Fawwaz RA, Challop RS. High-dose glycine treatment of refractory obsessive-compulsive disorder and body dysmorphic disorder in a 5-year period. Neural Plast. 2009;2009:768398. [Medline].

  13. Feusner JD, Moody T, Hembacher E, Townsend J, McKinley M, Moller H. Abnormalities of visual processing and frontostriatal systems in body dysmorphic disorder. Arch Gen Psychiatry. Feb 2010;67(2):197-205. [Medline].

  14. Feusner JD, Yaryura-Tobias J, Saxena S. The pathophysiology of body dysmorphic disorder. Body Image. Mar 2008;5(1):3-12. [Medline].

  15. Deckersbach T, Savage CR, Phillips KA. Characteristics of memory dysfunction in body dysmorphic disorder. J Int Neuropsychol Soc. Sep 2000;6(6):673-81. [Medline].

  16. Buhlmann U, Teachman BA, Naumann E, Fehlinger T, Rief W. The meaning of beauty: implicit and explicit self-esteem and attractiveness beliefs in body dysmorphic disorder. J Anxiety Disord. Jun 2009;23(5):694-702. [Medline].

  17. Phillips KA, Didie ER, Feusner J, Wilhelm S. Body dysmorphic disorder: treating an underrecognized disorder. Am J Psychiatry. Sep 2008;165(9):1111-8. [Medline]. [Full Text].

  18. Grieve FG. A conceptual model of factors contributing to the development of muscle dysmorphia. Eat Disord. Jan-Feb 2007;15(1):63-80. [Medline].

  19. Phillips KA, Kaye WH. The relationship of body dysmorphic disorder and eating disorders to obsessive-compulsive disorder. CNS Spectr. May 2007;12(5):347-58. [Medline].

  20. Phillips KA, Hollander E, Rasmussen SA, Aronowitz BR, DeCaria C, Goodman WK. A severity rating scale for body dysmorphic disorder: development, reliability, and validity of a modified version of the Yale-Brown Obsessive Compulsive Scale. Psychopharmacol Bull. 1997;33(1):17-22. [Medline].

  21. Butler Hospital. Butler Hospital Screening Questionnaire for Adolescents: Do I have BDD. Butler Hospital. Available at http://www.butler.org/body.cfm?id=237. Accessed 6.6.10.

  22. Yutzy, SParish, B. Somatoform Disorders. In: Tasman, A, Kay, J, Lieberman, J, First, M, Maj, M. Psychiatry. 2. Third. London: John Wiley & Sons; 2008:1538-1542/74.

  23. Didie ER, Kuniega-Pietrzak T, Phillips KA. Body image in patients with body dysmorphic disorder: evaluations of and investment in appearance, health/illness, and fitness. Body Image. Jan 2010;7(1):66-9. [Medline].

  24. Ravindran AV, da Silva TL, Ravindran LN, Richter MA, Rector NA. Obsessive-compulsive spectrum disorders: a review of the evidence-based treatments. Can J Psychiatry. May 2009;54(5):331-43. [Medline].

  25. Phillips KA. Body dysmorphic disorder: clinical aspects and treatment strategies. Bull Menninger Clin. Fall 1998;62(4 Suppl A):A33-48. [Medline].

  26. [Guideline] National Collaborating Centre for Mental Health. Obsessive-compulsive disorder: core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder. London (UK): British Psychological Society, Royal College of Psychiatrists; 2006. 350 p. (National clinical practice guideline; no. 31).

  27. Crerand CE, Infield AL, Sarwer DB. Psychological considerations in cosmetic breast augmentation. Plast Surg Nurs. Jul-Sep 2007;27(3):146-54. [Medline].

  28. Arehart-Treichel J. Do Abnormal Visual Processes Underlie Body Dysmorphic Disorder?. Psychiatric News. January 18, 2008;Volume 43, Number 2Eating Disorders Centerhttp://www.emedicinehealth.com/collections/CO1589.aspDepression Centerhttp://www.emedicinehealth.com/collections/CO1588.aspAnorexia Nervosa Overviewhttp://www.emedicinehealth.com/articles/12688-1.aspDepression Overviewhttp://www.emedicinehealth.com/articles/10289-1.asp: 29. Available at http://pn.psychiatryonline.org/content/43/2/29.full.

  29. Pavan C, Simonato P, Marini M, Mazzoleni F, Pavan L, Vindigni V. Psychopathologic aspects of body dysmorphic disorder: a literature review. Aesthetic Plast Surg. May 2008;32(3):473-84. [Medline].

 
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