57CHAPTER 3

Body Dysmorphic Disorder

Katharine A. Phillips, M.D.

Body dysmorphic disorder (BDD) is a common yet very underrecognized disorder. Because patients are typically ashamed of and embarrassed by their symptoms, they usually do not reveal them to clinicians unless specifically asked. It is important to screen patients for BDD and to identify this disorder when present, because it usually causes tremendous suffering and substantial impairment in psychosocial functioning. In addition, rates of suicidal ideation, suicide attempts, and completed suicide appear markedly high.

BDD has many similarities to obsessive-compulsive disorder (OCD), as noted by Pierre Janet more than a century ago (Phillips 1991). Since then, numerous studies that have directly compared BDD to OCD have elucidated their many similarities, and BDD is widely considered one of the disorders that is most closely related to OCD. Thus, BDD’s inclusion in DSM-5’s new chapter of obsessive-compulsive and related disorders (OCRDs) is well supported (American Psychiatric Association 2013). Nonetheless, BDD and OCD have some important differences; for example, BDD is characterized by poorer insight, more comorbid major depressive disorder and perhaps substance use disorders, and higher rates of suicidality, and it requires a different 58cognitive-behavioral therapy (CBT) approach. In addition, in a prospective longitudinal study, BDD symptoms persisted in a sizable proportion of participants whose comorbid OCD remitted, suggesting BDD is not simply a symptom of OCD. Thus, it is important to recognize BDD’s and OCD’s similarities while also differentiating them in clinical settings.

BDD has received far less investigation than OCD; systematic research has been conducted only during the past few decades. Yet recently, research on BDD has dramatically increased. It is worth noting that as the research literature on BDD increases, constructs that are not the same as BDD but may overlap with it are sometimes equated with BDD. These include “dysmorphic concern” and “BDD symptoms”; the latter appears to often reflect subclinical BDD or body image dissatisfaction. Studies that use these constructs are generally not included in this chapter. Regarding research on BDD (this chapter’s focus), the substantial increase in this area of investigation has yielded many new and important findings—on course of illness, neuroimaging, visual processing abnormalities, information processing abnormalities, and other areas. Importantly, recent advances in the development and testing of effective CBT approaches, along with the availability of effective medication options, offer great hope to patients with this often-debilitating disorder.

Diagnostic Criteria and Symptomatology

Before it was included in the classification system for the first time as a separate disorder, in DSM-III-R in 1987 (American Psychiatric Association 1987), BDD was known as “dysmorphophobia.” This term, coined in the 1800s by the Italian psychiatrist Enrico Morselli, comes from the Greek word dysmorphia, which refers to “misshapenness” or “ugliness” (Phillips 1991). Individuals with BDD are preoccupied with one or more perceived defects or flaws in their appearance that are not observable or appear only slight to others (see Criterion A in Box 3–1; American Psychiatric Association 2013). In other words, patients incorrectly perceive themselves as looking ugly, deformed, unattractive, or even grotesque or monstrous when they actually look normal. Examples of these preoccupations are “I look hideous,” “I look ugly, and everyone is staring at me,” or “My face is horribly red and looks disgusting.” Often, the physical “defects” that the patient perceives are not visible to others. If appearance defects or flaws are present, they are only slight. In this case, others do not notice the “defects” unless the patient points them out, and even then they are minimal and within the normal range. For DSM-5, only minor wording changes were made to Criterion A. For example, the word imagined, which DSM-IV (American Psychiatric Association 1994) used to describe the physical defects, is no longer used because it was confusing for some patients, especially those with poor or absent insight. 59Preoccupation with appearance defects that are clearly noticeable and observable by others (e.g., at conversational distance) is diagnosed as “other specified OCRD,” not as BDD (see Chapter 7, “Other Obsessive-Compulsive and Related Disorders in DSM-5”).

BOX 3–1.   DSM-5 Diagnostic Criteria for Body Dysmorphic Disorder

A. Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others.

B. At some point during the course of the disorder, the individual has performed repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (e.g., comparing his or her appearance with that of others) in response to the appearance concerns.

C. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. The appearance preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder.

Specify if:

With muscle dysmorphia: The individual is preoccupied with the idea that his or her body build is too small or insufficiently muscular. This specifier is used even if the individual is preoccupied with other body areas, which is often the case.

Specify if:

Indicate degree of insight regarding body dysmorphic disorder beliefs (e.g., “I look ugly” or “I look deformed”).

With good or fair insight: The individual recognizes that the body dysmorphic disorder beliefs are definitely or probably not true or that they may or may not be true.

With poor insight: The individual thinks that the body dysmorphic disorder beliefs are probably true.

With absent insight/delusional beliefs: The individual is completely convinced that the body dysmorphic disorder beliefs are true.

Reprinted from American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. Arlington, VA, American Psychiatric Association. Copyright 2013, American Psychiatric Association. Used with permission.

Most commonly, disliked areas involve the face and head; more specifically, they most often focus on the skin (e.g., perceived acne, scarring, color, wrinkles), nose (e.g., too large or misshapen), and hair (e.g., too little head hair or too much facial or body hair) (Phillips and Diaz 1997; Phillips et al. 2005b). However, any body part can be the focus of preoccupation (e.g., eyes, teeth, jaw, ears, head size or shape, breasts, thighs, stomach, hands, body build). A common misconception is that BDD can be diagnosed only 60if the patient is preoccupied with just one body area, such as a large and misshapen nose. However, areas of preoccupation may range from just one area to virtually every aspect of the person’s appearance; on average, patients are preoccupied with five to seven body areas over the course of their illness (Phillips et al. 2005b). More than 25% of patients with BDD have at least one concern that involves symmetry (e.g., asymmetrical eyebrows or uneven hair) (Hart and Phillips 2013). Symmetry concerns that involve physical appearance should be diagnosed as BDD, not as OCD.

The appearance preoccupations are intrusive and time consuming. To be diagnosed as BDD, these preoccupations should occur for about 1 hour a day or more (as for OCD obsessions). On average, patients are preoccupied with their perceived appearance defects for 3–8 hours a day, and some are preoccupied for the entire day. The appearance preoccupations are unwanted and not pleasurable; they usually cause substantial, and sometimes extreme, distress. BDD preoccupations are also usually difficult to resist and control (Phillips 2009).

The appearance preoccupations usually trigger intense dysphoria, distress, anxiety, depressed mood, shame, and other painful emotions (Phillips 2009; Phillips et al. 2010b). These distressing emotions in turn drive patients to perform repetitive compulsive behaviors that typically focus on checking, fixing, or hiding the perceived flaws and are intended to alleviate emotional distress. These behaviors are not pleasurable, and they often do not decrease—and may even increase—distress (Phillips 2009). All individuals with BDD, at some time during the course of the disorder, perform such repetitive behaviors in response to the appearance concerns, as reflected in a new criterion (Criterion B) in DSM-5 (see Box 3–1; Phillips et al. 2010b). These behaviors have many similarities to OCD compulsions, and thus they are often referred to as compulsions or rituals; a possible difference, however, is that BDD compulsions may be less likely to reduce anxiety and distress.

Criterion B was added to DSM-5 to provide a fuller description of BDD’s key clinical features; these behaviors (e.g., comparing and mirror checking) are usually a prominent and problematic aspect of the clinical presentation. The addition of Criterion B also helps clinicians differentiate BDD from major depressive disorder, social anxiety disorder, and other disorders with which it may be confused. Furthermore, when a patient with BDD is being treated with CBT, these behaviors need to be targeted with ritual prevention. The very small number of individuals who meet all diagnostic criteria for BDD except Criterion B should be diagnosed with “other specified OCRD” rather than BDD.

Common repetitive behaviors, which must be excessive, and lifetime rates of these behaviors are as follows (Phillips and Diaz 1997; Phillips et al. 2005b):

61 Comparing disliked body parts with the same areas on others: 88%

Checking disliked body parts in mirrors or other reflecting surfaces: 87%

Grooming (e.g., applying makeup; cutting, styling, shaving, or removing head hair, facial hair, or body hair): 59%

Seeking reassurance about the perceived defects or questioning others about how they look (e.g., “Do I look okay?”): 54%

Touching the disliked areas to check their appearance: 52%

Changing clothes (e.g., to more effectively camouflage disliked areas or to find a flattering outfit that distracts others from the “defects”): 46%

Dieting (e.g., to make a “wide” face narrower): 39%

Skin picking to improve perceived skin flaws: 38%

Tanning (e.g., to darken “pale” skin): 25%

Exercising: 21%

Lifting weights: 18%

Additional repetitive behaviors include compulsive hair plucking/pulling (e.g., to make “crooked” eyebrows more symmetrical) and excessive shopping (e.g., for makeup, skin or hair products, or clothes to minimize the perceived flaws). Although most behaviors are observable by others, some repetitive acts—such as comparing oneself with others—may be mental, as noted by Criterion B. Camouflaging one’s perceived flaws (e.g., with a hat, makeup, sunglasses, hair, clothes, body position), which more than 90% of patients with BDD do, has some features of a safety-seeking behavior (the goal of which is to avoid or escape unpleasant feelings or to prevent a feared event, such as being ridiculed by others); however, camouflaging can also be done repeatedly (e.g., reapplying makeup 30 times a day) and thus may fulfill Criterion B (Phillips 2009). The repetitive behaviors that patients may engage in are unlimited. For example, they may tie their calves tightly with rope to try to make them smaller, develop complex counting rituals to track loss of individual hairs, or make and repeatedly watch videos to track the perceived worsening of hair loss, acne, or wrinkles.

Some of these repetitive behaviors can be risky and harm patients. For example, skin picking can occur for hours a day and involve use of sharp implements such as pins, needles, or razor blades; thus it can cause considerable skin damage, which may require sutures or surgery. Picking through and damaging major blood vessels, such as the carotid artery, can be life threatening (Phillips 2009). Compulsive mirror checking can cause car accidents (e.g., if the rearview mirror is checked while driving) or dangerous falls (e.g., if a reflecting mirror is checked while on a ladder). Tanning may increase the risk of skin cancer. Most patients with BDD seek cosmetic procedures for BDD concerns, some repeatedly, which involve anesthesia risks. In 62addition, some dissatisfied patients sue or physically attack or even murder the treating physician (Sarwer and Crerand 2008).

It should be noted that skin picking as a symptom of BDD occurs in response to a preoccupation with perceived skin defects; the picking intends to fix or improve a perceived skin flaw. In contrast, picking that occurs in excoriation (skin-picking) disorder is not triggered by thoughts about appearance. Similarly, hair plucking/pulling as a symptom of BDD is triggered by preoccupation with perceived defects in the hair’s appearance (e.g., asymmetry), which the pulling/plucking attempts to improve. In contrast, hair pulling that occurs in trichotillomania (hair-pulling disorder) is not triggered by appearance preoccupations.

For DSM-5 criteria for BDD to be met, the appearance preoccupations and resulting repetitive behaviors must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion C). In addition, if the patient’s only appearance concerns involve excessive body fat or weight, and these concerns meet diagnostic criteria for an eating disorder, they should be diagnosed as an eating disorder rather than BDD (Criterion D). However, eating disorders and BDD (involving preoccupations with other body areas) often co-occur (Phillips et al. 2005b).

DSM-5 has two new specifiers that should be considered after ascertaining that a patient’s symptoms meet all diagnostic criteria for BDD.

1. With muscle dysmorphia: This specifier identifies individuals, most of whom are men, who are preoccupied with the idea that their body build is too small or not muscular enough. These patients may describe themselves as looking “puny,” “tiny,” or “too small.” Most actually look normal, although some are unusually muscular as a result of excessive weight lifting or use of potentially dangerous anabolic steroids, which can increase muscle mass. Some, but not all, patients with muscle dysmorphia have abnormal eating behavior (e.g., eating large amounts of food or high-protein meals). In samples of men ascertained for BDD, most of those with muscle dysmorphia also have other more typical BDD concerns (e.g., involving skin or facial features). Compared with other forms of BDD, muscle dysmorphia appears to be associated with higher rates of suicidality, substance-related disorders, and anabolic steroid use as well as poorer quality of life (Phillips 2009; Phillips et al. 2010b).

2. Insight: An insight specifier has been added to BDD, OCD, and hoarding disorder in DSM-5. The specifier for BDD indicates insight regarding BDD beliefs (e.g., “I look ugly”). Levels of insight are as follows:

“With good or fair insight”: Patients recognize that their beliefs about their appearance are definitely or probably not true or that they may or may not be true.

63 “With poor insight”: Patients think their BDD beliefs probably are true.

“With absent insight/delusional beliefs”: Patients are completely convinced that their BDD beliefs are true.

Insight regarding the perceived appearance defects (e.g., “I look ugly”) is usually absent or poor; most individuals are completely or mostly convinced that their view of their perceived deformities is accurate (Eisen et al. 2004; Phillips et al. 2012). This is one important way in which BDD differs from OCD. In OCD, only about 2%–4% of patients have delusional OCD beliefs; about 85% have excellent, good, or fair insight into the beliefs that underlie their obsessions (e.g., whether the house really will burn down if they do not check the stove 30 times). In contrast, about one-third of patients have delusional BDD beliefs, and only about one-quarter have excellent, good, or fair insight (Phillips et al. 2012). The poorer insight that is typically characteristic of BDD may largely explain why those with BDD tend to be more reluctant to accept and engage in mental health treatment than those with OCD. Research evidence indicates that delusional and nondelusional BDD (i.e., BDD characterized by good, fair, or poor insight) are the same disorder, with insight spanning a spectrum from good to absent, as reflected in the new specifier (Phillips et al. 2014). Individuals with the delusional form of BDD tend to have greater morbidity than those with some insight, but this difference appears accounted for by their tendency to have more severe BDD symptoms (Phillips et al. 2014).

DSM-5’s new insight specifier is important for several reasons (Phillips et al. 2014):

1. It clarifies that individuals who are completely convinced that their BDD belief is true should be diagnosed with “BDD with absent insight/delusional beliefs” rather than a psychotic disorder, as was done in DSM-IV.

2. It implies that delusional and nondelusional BDD should be treated similarly; indeed, both delusional and nondelusional BDD respond to serotonin reuptake inhibitor (SRI) monotherapy and to CBT.

3. Specifying level of insight allows clinicians to identify patients with poor or absent insight who may be more reluctant to accept the idea that they have a mental disorder (BDD) rather than actual physical deformities; such patients may require more motivational interviewing and attention to the therapeutic alliance in order to engage and retain them in mental health treatment.

Nearly 30% of patients with BDD experience panic attacks that are triggered by BDD symptoms (e.g., when looking at perceived defects in the mirror or feeling that others are scrutinizing them, or when under bright lights). Such panic attacks are not diagnosed as panic disorder because they do not 64“come out of the blue.” The DSM-5-wide panic attack specifier may be used in such cases.

A majority of patients with BDD have ideas or delusions of reference, falsely believing that others take special notice of them in a negative way because of how they look (e.g., mock, talk about, or stare at them) (Phillips et al. 2005b, 2012). Referential thinking, which is more common in BDD than in OCD, may contribute to social avoidance. BDD is associated with high levels of social anxiety and avoidance, anxiety, depressed mood, neuroticism, and rejection sensitivity as well as low self-esteem (Phillips 2009). Many patients are ashamed of how they look and the fact that they worry so much about their appearance; they may conceal their concerns because they do not want to be considered vain. It is also worth mentioning BDD by proxy, a form of BDD in which an individual is preoccupied with perceived flaws in another person’s appearance (e.g., a spouse or child) and meets diagnostic criteria for BDD.

Case Example: Scott

Scott, a 21-year-old single white male, had been obsessed since age 13 with perceived acne, a “big” head, and his “small” body build. When he presented for treatment, his chief complaint was “I keep thinking about how ugly I look, and it’s ruining my life.” Although other people told him that he was handsome and did not have the defects he perceived, Scott was convinced that he looked “ugly and disgusting,” stating, “I know what I see when I look in the mirror.” He thought about his perceived defects for 6–8 hours a day, which caused severe distress. He believed that when people looked at him they thought he looked repulsive and that others singled him out of the crowd because he looked so strange. Scott spent 5–6 hours a day performing repetitive behaviors, such as comparing his skin, head size, and body build with those of other people and with celebrities online, checking mirrors, asking his parents if he looked okay (while never accepting their reassurance), repeatedly washing and scrubbing his face, and picking his skin to remove tiny blemishes. Scott also lifted weights for several hours a day and took five types of supplements to increase his muscle mass. He spent several hours a day obtaining information about supplements and anabolic steroids online.

As a result of his appearance concerns, Scott became depressed, anxious, and socially withdrawn. He stopped dating because he thought he was so ugly that no one would want to be with him. He missed many classes because his symptoms made it difficult to focus on schoolwork, he did not want others to see him, and he believed his classmates ridiculed him because of how he looked. For these reasons, he dropped out of high school during his senior year. He subsequently spent most of his time alone in his bedroom, despite his family’s efforts to persuade him to attend school, participate in family events, and see his friends. He had considered suicide many times and had attempted suicide once because he thought that life wasn’t worth living if he looked like a “freak.”

65Epidemiology

The point (current) prevalence of DSM-IV BDD in nationwide epidemiological studies of adults is 2.4% in the United States and 1.7%–1.8% in Germany (Buhlmann et al. 2010; Koran et al. 2008; Rief et al. 2006). Thus, although BDD used to be considered rare, it appears to be about twice as common as anorexia nervosa, schizophrenia, and OCD. In epidemiological samples, those with BDD are less likely to be living with a partner or employed and more likely to report suicidal ideation and suicide attempts due to appearance concerns (Rief et al. 2006). Although epidemiological data are not available in youths, a study of 566 U.S. high school students found a current prevalence of DSM-IV BDD of 2.2% (Mayville et al. 1999).

Two U.S. studies found a prevalence of 13% and 16% among general adult psychiatric inpatients (Conroy et al. 2008; Grant et al. 2001). In one study, BDD was more common than many other disorders, including schizophrenia, OCD, posttraumatic stress disorder, and eating disorders; patients with BDD had significantly lower scores on the Global Assessment of Functioning Scale and twice the lifetime rate of suicide attempts as patients without BDD (Grant et al. 2001). In the other inpatient study, a high proportion of patients reported that their BDD symptoms were a major reason or “somewhat of a reason” for their suicidal thinking (50% of subjects), suicide attempts (33%), or substance use (42%) (Conroy et al. 2008). In studies of adolescent psychiatric inpatients, 6.7%–14.3% of subjects had current BDD (Dyl et al. 2006; Grant et al. 2001). BDD also appears fairly common among adults in dermatology settings (9%–15%), cosmetic surgery settings (7%–15% in most studies), and orthodontia settings (8%) and among patients presenting for oral or maxillo-facial surgery (10%) (Phillips 2009).

In epidemiological samples, BDD is slightly more common in females than in males (Buhlmann et al. 2010; Koran et al. 2008; Rief et al. 2006). In clinical samples of individuals ascertained for BDD, the gender ratio has differed somewhat, possibly reflecting different ascertainment methods. The largest samples contained an equal proportion of males and females or a slight preponderance of females (Phillips and Diaz 1997; Phillips et al. 2005b).

Comorbidity

Major depressive disorder is the most common comorbid disorder, with a lifetime rate of about 75% (Phillips and Diaz 1997; Phillips et al. 2005b). BDD usually has its onset before major depressive disorder, and many patients attribute their depressive symptoms to the distress caused by BDD symptoms (Phillips 2009). Other commonly co-occurring disorders are social anxiety disorder (social phobia), which affects nearly 40% of patients (lifetime), and 66OCD, which affects about one-third of patients with BDD (lifetime) (Phillips and Diaz 1997; Phillips et al. 2005b).

Lifetime substance use disorders are also common, occurring in about 30%–50% of those with BDD (Grant et al. 2005; Phillips and Diaz 1997). Alcohol and marijuana use are most common. In one study, nearly 70% of individuals with a comorbid substance use disorder attributed their substance use, at least in part, to the distress caused by BDD symptoms; 30% cited BDD as the main reason or a major reason for their substance use disorder (Grant et al. 2005). Many patients appear to use substances to self-medicate in an effort to diminish social anxiety or emotional pain caused by BDD symptoms.

About 20% of men with muscle dysmorphia abuse potentially dangerous anabolic steroids in an attempt to become more muscular (Phillips et al. 2010b). These drugs may cause abuse or dependence, and they carry a risk of adverse physical and psychiatric effects, which include depressive symptoms when discontinuing use as well as aggressive behavior (“roid rage”).

Course and Prognosis

BDD usually has its onset in early adolescence. The most common age at onset is 12 or 13 years, and two-thirds of individuals have onset of BDD before age 18 (Bjornsson et al. 2013). The mean age at BDD onset is 16 or 17 (Bjornsson et al. 2013). Subclinical BDD symptoms (mean onset at age 12–13 years) often precede onset of the full disorder (Phillips et al. 2006a). Earlier age at BDD onset may be associated with greater morbidity (see “Developmental Considerations” later in this chapter). In one study, subjects with onset before age 18 were more likely to have been psychiatrically hospitalized (Bjornsson et al. 2010). In two studies, those with BDD onset before age 18 had more comorbidity and were more likely to have attempted suicide (Bjornsson et al. 2013).

The only prospective naturalistic study of the course of BDD found that BDD tended to be chronic (Phillips et al. 2013a). In this 4-year follow-up study of a broadly ascertained sample of individuals with BDD, the cumulative probability was only 0.20 for full remission and 0.55 for full or partial remission from BDD (remission required as little as 8 consecutive weeks of minimal or no BDD symptoms for full remission and less than DSM-IV criteria for partial remission). A lower likelihood of full or partial remission was predicted by more severe BDD symptoms at intake into the study, a longer lifetime duration of BDD, and being an adult. Among subjects whose BDD partially or fully remitted at some point during the follow-up period, the cumulative probability of subsequent full relapse was 0.42; for subsequent full or partial relapse, it was 0.63. More severe BDD at intake and earlier age at BDD onset predicted full or partial relapse. It should be noted that 67although most study subjects received treatment in the community, relatively few received what is considered adequate treatment; BDD usually improves when evidence-based treatments are implemented (see “Treatment” section later in this chapter).

Psychosocial Impairment and Suicidality

BDD is associated with markedly poor psychosocial functioning and mental health-related quality of life across a broad range of domains (Phillips et al. 2005c). On standardized measures, differences between individuals with BDD and norms are very large and typically several standard deviation units below normative scores (Phillips et al. 2005c). Scores on the Short Form Health Survey (SF-36; Ware 1993) mental health subscales are 0.4–0.7 standard deviation units poorer than for depression. Impairment in functioning can range from moderate to extreme. A patient with moderate functional impairment due to BDD may, for example, avoid dating and some but not all social events; she may be able to attend school but be late and miss some classes. A patient with extreme and incapacitating BDD may quit his job, avoid all social contact, and stay in his bedroom at all times. More severe BDD symptoms are associated with poorer functioning and quality of life (Phillips et al. 2005c). Males tend to have somewhat greater functional impairment than females (Phillips et al. 2005c).

Among individuals with BDD that is moderate in severity, nearly one-third have been completely housebound for at least 1 week because of BDD symptoms; some have been housebound for years because they feel too ugly to be seen. Nearly 40% have been psychiatrically hospitalized, and more than one-quarter attribute at least one psychiatric hospitalization primarily to BDD (Phillips and Diaz 1997; Phillips et al. 2005b).

Perhaps the most concerning aspect of BDD is the high rate of suicidality. From a clinical perspective, reasons for suicidality may include hopelessness about being “deformed”; feeling angry and hopeless because rituals do not improve the “defects”; feeling rejected by others because of being “ugly”; social isolation (which overlaps with the concept of “thwarted belongingness”); ideas/delusions of reference, which may increase social isolation; negative core beliefs (e.g., unlovability, worthlessness); a high prevalence of comorbid major depressive disorder; and a belief that a cosmetic procedure made the patient look even worse.

Rates of suicidal ideation and suicide attempts are high in both clinical and epidemiological samples and in adults as well as youth (Buhlmann et al. 2010; Phillips and Diaz 1997; Phillips et al. 2005a). In samples of convenience or in clinical samples of individuals ascertained for BDD, about 80% have experienced suicidal ideation, and 24%–28% have attempted suicide (Phillips 68and Diaz 1997; Phillips et al. 2005a; Veale et al. 1996a). In a study of psychiatric inpatients, the suicide attempt rate among those with BDD was double the rate among inpatients without BDD (Grant et al. 2001), and among inpatients with anorexia nervosa, those who had BDD in addition to anorexia had triple the number of suicide attempts compared with those without BDD (Grant et al. 2002). In a retrospective study in two dermatology practices over 20 years, most of the patients who committed suicide had had acne or BDD (Cotterill and Cunliffe 1997). Individuals with BDD appear more likely to experience suicidality than those with OCD (Phillips et al. 2007).

Suicidality rates also appear markedly elevated in epidemiological samples, where rates might be expected to be lower. In an epidemiological study from Germany, 31% of subjects with BDD reported thoughts about committing suicide specifically due to appearance concerns, and 22% had actually attempted suicide due to appearance concerns (Buhlmann et al. 2010).

Greater BDD severity independently predicts suicidal ideation and suicide attempts (Phillips et al. 2005a). In addition, suicidal ideation is associated with lifetime comorbid major depressive disorder, and suicide attempts are associated with lifetime comorbid substance use disorder and posttraumatic stress disorder (Phillips et al. 2005a).

There are only limited data on completed suicide, but the rate appears markedly elevated compared with the general population and perhaps even higher than in disorders with high suicide rates, such as bipolar disorder and major depressive disorder (Phillips and Menard 2006).

Developmental Considerations

A clinically important and underrecognized aspect of BDD is that it is a disorder of childhood and adolescence. As noted earlier, a majority of cases have their onset before age 18. Available data, although limited, suggest that many of BDD’s clinical features appear largely similar in youths and adults (Albertini and Phillips 1999; Phillips et al. 2006a). However, youths may be even more severely ill than adults: they appear to have poorer insight regarding their appearance, and they are more likely than adults to have delusional BDD beliefs (59% vs. 33%; Phillips et al. 2006a). Their poorer insight may possibly reflect adolescents’ poorer metacognitive skills, which may mediate poor insight in some psychiatric disorders. At a trend level, youths are more likely than adults to have more severe BDD and to have been psychiatrically hospitalized (43% vs. 24%). Of note, youths are significantly more likely than adults to have attempted suicide (44% vs. 24%) (Phillips et al. 2006a). A study in a psychiatric adolescent inpatient setting found that compared with youths with no significant body image concerns, those with BDD had significantly 69higher levels of anxiety and depression and significantly higher scores on a standardized measure of suicide risk (Dyl et al. 2006). These findings are consistent with data indicating that greater body image dissatisfaction more generally in adolescents is associated with higher suicide risk.

School refusal and dropout are particularly concerning consequences of BDD in youths. In one study, 18% of youths with BDD had dropped out of school primarily because of BDD symptoms (Albertini and Phillips 1999). In another study, 22% of youths had dropped out of school primarily because of psychopathology, and 29% more had not attended school for at least a week in the past month because of psychopathology (for most, BDD was the primary diagnosis) (Phillips et al. 2006a). Thus, youths who refuse to attend school should be carefully assessed for BDD.

BDD typically has profound and detrimental effects on family functioning. BDD in youths, especially when untreated, often adversely affects the development trajectory, impeding completion of developmental transitions and tasks, such as completing school, dating, and developing social competence. Not uncommonly, these deficits persist well into adulthood and may even be lifelong.

Case Example: Maria

Maria, a 16-year-old Hispanic high school student, presented with a chief complaint of “I look really ugly, and everyone at school is laughing at me because I look so bad.” Maria thought that she had “horrible” acne and facial scarring and that her hair looked “ridiculous and hideous.” She also believed that her stomach “stuck out too much.” Maria thought about her appearance for 3–4 hours a day, and she spent about 3 hours a day styling her hair to make it look “presentable,” checking mirrors, asking her parents if she looked okay, shopping for makeup and hair products, and sucking in her stomach to make it look flatter. When possible, she covered her stomach with her hand and turned “the really bad” side of her face away from people when talking with them. Maria was “pretty certain” that she really did look ugly.

As a result of these concerns, Maria sometimes avoided being with her friends, and she turned down social opportunities. She was often late for school because she got “stuck” in the mirror styling her hair and coating her skin with makeup to cover her perceived scars. She often left class to check her appearance and groom in the bathroom mirror. She avoided dating and talking with boys because this made her feel especially self-conscious about how she looked.

Gender-Related Issues

BDD appears to have largely similar features in females and males, including similar demographic characteristics, disliked body areas, types of compulsive BDD behaviors, BDD severity, suicidality, and comorbidity. Both genders 70appear equally likely to seek and receive cosmetic treatment for their BDD concerns (Phillips and Diaz 1997; Phillips et al. 2006b).

Some gender differences are apparent; however, many may reflect cultural preferences and concerns regarding appearance in men and women (Phillips and Diaz 1997; Phillips et al. 2006b). Men are more likely to be preoccupied with supposedly thinning hair, genitals (usually focusing on “small” penis size), and small body build (muscle dysmorphia), which affects men nearly exclusively. In contrast, women appear more likely to be preoccupied with weight (usually thinking that they weigh too much), breasts, hips, legs, and excessive body hair. Women are more likely than men to camouflage their bodies to hide disliked areas, check mirrors, and pick their skin. They are also more likely to have a comorbid eating disorder, and men are more likely to have a comorbid substance use disorder, consistent with gender-related findings in the general population. Men may be more likely to be single, and they may experience somewhat greater impairment in psychosocial functioning (e.g., unemployed and receiving disability payments).

Cultural Aspects of Phenomenology

Although most studies of BDD have focused on patients in Western settings, an increasing number have been done around the world. No studies have directly compared BDD’s clinical features across different countries or cultures, but a qualitative descriptive comparison of case reports and case series from around the world suggested more similarities than differences in terms of demographic and clinical features (Phillips 2005). Thus, BDD may be largely invariant across cultures.

However, this comparison also suggested that cultural values and preferences may influence and shape BDD symptoms to some degree. For example, concerns about eyelids and having a small, rather than a large, nose may be more common in Asian countries than in Western countries. Indeed, culturally related concerns about physical appearance and the importance of physical appearance might influence or amplify preoccupations with perceived physical deformities. Nonetheless, there is a growing literature on the universality of certain concepts of beauty, and the extent to which cultural factors impact BDD’s pathogenesis or clinical expression remains unclear.

Taijin kyofusho, or anthropophobia (fear of people), literally meaning a fear of interpersonal relations, is a construct in the Japanese diagnostic system that includes a BDD-like variant known as shubo-kyofu (“phobia of a deformed body”). However, shubo-kyofu appears more prominently focused on a fear that one’s ugliness will offend other people.

71Assessment and Differential Diagnosis

Assessment

Screening for and Diagnosing Body Dysmorphic Disorder

In clinical settings, BDD usually goes undiagnosed (Conroy et al. 2008; Grant et al. 2001; Phillips 2009). Patients usually do not spontaneously reveal their appearance concerns to a mental health clinician or family members because they are too embarrassed, fear they will be negatively judged (e.g., considered vain), worry that their concerns will not be understood, or do not know that their symptoms are treatable by a mental health clinician (Conroy et al. 2008). However, most patients want clinicians to ask about them (Conroy et al. 2008). Thus, to detect BDD, clinicians should ask patients about BDD symptoms, especially patients with another OCRD, major depressive disorder, or social anxiety disorder. Questions are provided in Table 3–1.

It is important to consider the following when screening patients for and diagnosing BDD:

Express empathy and do not trivialize the patient’s concerns. Keep in mind that patients usually suffer tremendously because of their symptoms; it is best not to minimize their concerns or express surprise or skepticism about their symptoms.

Do not use the word “imagined”: DSM-IV used this term, but it has been removed in DSM-5 because many patients consider their flaws to be real, not imagined.

Avoid using words such as “defect” or “deformity” when initially asking about BDD symptoms. Although terms such as these are very fitting for some patients’ concerns, they may be too harsh for others to initially endorse. Terms such as “appearance concerns” may be more acceptable to patients.

Do not simply ask patients if they think there is something wrong with their bodies; this question may be interpreted to refer to bodily functioning, and it may miss BDD.

Do not require that the patient have sought medical advice about the perceived defects; some patients do not do this because they are too embarrassed to reveal their concerns to anyone. Also, not all individuals have access to health care.

Do not argue with patients about how they actually look. Because patients typically have poor or absent insight, this approach is usually unsuccessful, and providing reassurance about their appearance may actually reinforce the ritual of reassurance seeking.

72TABLE 3–1. Questions to diagnose body dysmorphic disorder

Criterion A: Preoccupation

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

If yes, 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?”

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?”

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

Ask “Is there anything you feel an urge to do over and over again in response to your appearance concerns?” Give examples of repetitive behaviors.

Criterion C: Clinically significant distress or impairment in functioning

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

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 (e.g., caring for children), relationships, intimacy, family and social activities, household tasks, and other types of interference.

Criterion D: Concerns not better explained by an eating disorder

Ask diagnostic questions for anorexia nervosa, bulimia nervosa, and binge-eating disorder.

Muscle dysmorphia specifier

Ask “Are you preoccupied with the idea that your body build is too small or that you’re not muscular enough?”

Insight specifier

Elicit a global belief about the perceived defect(s): “What word would you use to describe how bad your [fill in disliked areas] look?” Optional: “Some people use words like ‘unattractive,’ ‘ugly,’ ‘deformed,’ ‘hideous.’ The global belief must be inaccurate. Do not use beliefs that are true, such as “I don’t look perfect” or “I want to be prettier.”

Ask “How convinced are you that these body areas look [fill in patient’s global descriptor]?”

73Screening, Diagnostic, Severity, and Insight Measures

Scales that can be used for clinical or research purposes are provided in Table 3–2 and are freely available at www.bodyimageprogram.com (Eisen et al. 1998; Phillips 2005; Phillips et al. 1997).

Differential Diagnosis

Other Psychiatric Disorders

Table 3–3 summarizes key mental disorders to consider in the differential diagnosis and approaches to accurately diagnosing BDD. Regarding the OCRDs, as previously discussed, BDD has both similarities to and differences from OCD. If preoccupations/obsessions focus on appearance concerns, including symmetry concerns, BDD should be diagnosed rather than OCD. If skin picking or hair plucking/pulling is done in response to appearance concerns and is intended to improve perceived appearance flaws, BDD should be diagnosed rather than excoriation (skin-picking) disorder or trichotillomania (hair-pulling disorder).

Perhaps the most difficult differential diagnosis is between certain presentations of BDD and an eating disorder. Studies that have directly compared BDD to eating disorders indicate that those with BDD are concerned with more body areas (typically not weight) and have more negative self-evaluation and self-worth, more avoidance of activities, and poorer functioning and quality of life due to appearance concerns (Hrabosky et al. 2009; Rosen and Ramirez 1998).

Although it is easy to differentiate an eating disorder from BDD when BDD concerns focus on non-weight and non–body shape concerns (e.g., hair or nose), the differential diagnosis is more difficult when BDD concerns do focus on weight or body shape. As indicated by BDD Criterion D, if appearance concerns focus on being too fat or thoughts that parts of the body (e.g., stomach, arms, and thighs) are too fat, and these concerns qualify for a diagnosis of anorexia nervosa, bulimia nervosa, or binge-eating disorder, then BDD is not diagnosed. However, when eating disorder symptoms are present but do not meet full diagnostic criteria for one of these disorders, it may be difficult to determine whether such a presentation should be diagnosed as “other specified eating disorder” or as BDD. In such cases, careful patient questioning and clinical judgment are needed to make the correct diagnosis. From a treatment perspective, it is important to address abnormal eating behavior that may jeopardize one’s physical health; psychosocial treatments for BDD do not address such behaviors.

74TABLE 3–2. Screening, diagnostic, severity, and insight measures for body dysmorphic disorder (BDD)

Body Dysmorphic Disorder Questionnaire (BDDQ; Phillips 2005)	Screens for the presence of BDD. (The BDDQ is not meant to diagnose BDD. An in-person evaluation is recommended for diagnosis.)
	Brief self-report questionnaire that maps onto DSM-IV diagnostic criteria for BDD. (The current version does not include repetitive behaviors as required by DSM-5 diagnostic criteria, but it is expected to have adequate sensitivity and specificity for DSM-5 BDD.)
	Adolescent and adult versions are available.
	Takes 1–5 minutes to administer.
	Scoring: Visit www.bodyimageprogram.com or see Phillips 2005.
	Measure has good sensitivity and specificity.
BDD Diagnostic Module (Phillips 2005)	Diagnoses BDD. (The Structured Clinical Interview for DSM [SCID] can also be used to diagnose BDD; it is probably preferable to use the SCID for DSM-5 when it becomes available, as it will include DSM-5’s new Criterion B.)
	Rater-administered, semistructured instrument modeled after the format used in the SCID. Maps onto DSM-IV diagnostic criteria for BDD.
	Adolescent and adult versions are available.
	Takes 10–15 minutes to administer.
	Scoring: BDD is present if diagnostic criteria are met.
	Measure has good interrater reliability.
75Yale-Brown Obsessive Compulsive Scale Modified for Body Dysmorphic Disorder (BDD-YBOCS; Phillips 2005; Phillips et al. 1997)	Rates current (past week) severity of BDD; should not be used as a diagnostic measure and should not be used in individuals who have not been diagnosed with BDD.
	Rater-administered, 12-item, semistructured instrument modeled after the Yale-Brown Obsessive Compulsive Scale for obsessive-compulsive disorder (OCD).
	Adolescent and adult versions are available.
	Takes 15 minutes to administer.
	Scoring: Scores range from 0 to 48, with higher scores indicating more severe BDD. A score of 20 or higher is the cut point for a diagnosis of BDD. Scores lower than 20 reflect subclinical, or subthreshold, BDD.
	Measure has good interrater and test-retest reliability, strong internal consistency, and good convergent and discriminant validity, and is sensitive to change.
Brown Assessment of Beliefs Scale (BABS; Eisen et al. 1998; Phillips et al. 2013b)	Assesses current (past week) insight/delusionality of inaccurate beliefs. Can be used to assess inaccurate beliefs in a variety of disorders, such as OCD, psychotic depression, eating disorders, olfactory reference syndrome, and schizophrenia. In BDD, the BABS assesses the person’s insight regarding his or her beliefs about the perceived appearance flaws—for example, “I look ugly.”
	76Seven-item, rater-administered, semistructured scale.
	Adolescent and adult versions are available.
	Takes 10 minutes to administer.
	Scoring: Provides a dimensional score that ranges from 0 to 24, with higher scores reflecting poorer insight/greater delusionality; also categorizes beliefs according to different levels of insight/delusionality:
	Score of 4 on item 1 (conviction) plus a total score of 18 or higher on items 1–6 equals absent insight/delusional beliefs.
	Total score of 13–17 on items 1–6 equals poor insight (a total score of 18 or higher plus a score of 0–3 on item 1 also equals poor insight).
	Total score of 8–12 on items 1–6 equals fair insight.
	Total score of 4–7 on items 1–6 equals good insight.
	Total score of 0–3 on items 1–6 equals excellent insight.
	Item 7 is NOT included when scoring this scale.
	Measure has good interrater and test-retest reliability, strong internal consistency, and good convergent and discriminant validity, and is sensitive to change.

77TABLE 3–3. Considerations in the differential diagnosis of body dysmorphic disorder (BDD)

Disorder in differential	Why BDD may be misdiagnosed	When BDD should be diagnosed
Obsessive-compulsive disorder	Both disorders are characterized by obsessions, preoccupations, and repetitive behaviors.	Obsessions (preoccupations) and behaviors focus on appearance.
Eating disorders	Both involve dissatisfaction with one’s appearance and distorted body image.	If appearance concerns focus only on being too fat or on body shape (being fat) and qualify for an eating disorder diagnosis, then BDD is not diagnosed. However, eating disorders and BDD commonly co-occur (with BDD symptoms typically focusing on non-weight concerns), in which case both disorders should be diagnosed.
Social anxiety disorder (social phobia)	Fear of rejection and humiliation, social anxiety, and social avoidance are very common symptoms of BDD.	In BDD, these symptoms are due to embarrassment and shame about perceived appearance flaws; if diagnostic criteria for BDD are met, BDD should be diagnosed rather than social anxiety disorder.
Agoraphobia	Some people with BDD avoid going out of the house or to public places because they think they are too ugly to be seen.	Diagnose BDD if avoidance is due to feeling too ugly to be seen or worry that other people will stare at or mock the patient because of how he or she looks.
Generalized anxiety disorder (GAD)	Excessive anxiety and worry—core features of GAD—are often seen in BDD.	Diagnose BDD if anxiety and worry are caused by concerns about perceived defects in one’s appearance.
78Major depressive disorder	Many patients with BDD have depressive symptoms, which often appear to be secondary to the distress and impairment that BDD causes. Often, depressive symptoms that coexist with BDD are diagnosed, but BDD is missed, or BDD symptoms are considered a symptom of depression, and BDD is not diagnosed.	BDD is characterized by prominent preoccupation with one’s appearance and compulsive repetitive behaviors. BDD should be diagnosed in depressed individuals if diagnostic criteria for BDD are met.
Psychotic disorders	BDD may be characterized by delusional appearance beliefs and BDD-related delusions of reference.	Patients whose symptoms meet diagnostic criteria for BDD and whose only psychotic symptoms consist of delusional appearance beliefs or related delusions of reference should receive a diagnosis of BDD with absent insight/delusional beliefs. BDD is not characterized by other psychotic symptoms, disorganized speech or behavior, or negative symptoms.
Gender dysphoria	Disliking and wishing to get rid of sex characteristics often involves their appearance.	BDD should not be diagnosed if the patient is preoccupied with only his or her genitals and/or secondary sex characteristics and the patient’s symptoms meet other diagnostic criteria for gender dysphoria.
79Excoriation (skin-picking) disorder	Skin picking is a common symptom of BDD.	If skin picking is triggered by a preoccupation with perceived skin flaws and is intended to improve the skin’s appearance, BDD should be diagnosed.
Trichotillomania (hair-pulling disorder)	Some patients with BDD remove their hair (body, facial, head) to try to improve their appearance.	If hair pulling is triggered by a preoccupation with hair that is considered ugly or abnormal in appearance and the hair pulling is intended to improve appearance, BDD should be diagnosed.
Olfactory reference syndrome (ORS)	Both BDD and ORS involve bodily preoccupation.	If the preoccupation focuses on body odor, ORS should be diagnosed. If it focuses on appearance, BDD should be diagnosed.
Panic disorder	Patients with BDD can have panic attacks that are cued by BDD concerns or behaviors (e.g., mirror checking, feeling scrutinized by others, bright lights).	For panic disorder to be diagnosed, panic attacks must “come out of the blue.” If a BDD thought or behavior triggers the attack, BDD should be diagnosed; the DSM-5-wide panic attack specifier may be used.

80Normal Appearance Concerns

Unlike normal appearance concerns, BDD is characterized by time-consuming and excessive appearance-related preoccupations (Criterion A) and excessive repetitive behaviors (Criterion B). BDD must also cause clinically significant distress or impairment in functioning (Criterion C). Body image dissatisfaction or other subclinical appearance concerns should not be considered equivalent to BDD.

Clearly Noticeable Physical Defects

Preoccupation with appearance defects or flaws that are clearly noticeable or observable (e.g., at conversational distance) is not diagnosed as BDD. If such defects cause preoccupation as well as clinically significant distress or impairment in functioning, they may be diagnosed as “other specified OCRD.” BDD-related skin picking, which is triggered by appearance concerns, can cause noticeable skin lesions and scarring; BDD should nonetheless be diagnosed in such cases.

Etiology and Pathophysiology

BDD’s etiology and pathophysiology are likely multifactorial and complex. Like other psychiatric disorders, BDD likely results from a complex array of many distal genetic and environmental factors as well as many more-proximal factors (e.g., abnormalities in visual processing). Although emerging research in this area is exciting and is beginning to shed some light on possible underlying mechanisms, limitations include the fact that studies are few, some findings are inconsistent across studies, and few replication studies have been done. In addition, some studies have examined constructs that differ somewhat from BDD (e.g., dysmorphic concern and subclinical BDD). Furthermore, it is unclear whether some of the factors discussed in the following sections may contribute to, and increase the risk for, BDD’s development or are a consequence of BDD. Nonetheless, these findings indicate that BDD is a neurobiologically based disorder and is not simply vanity.

Genetic Factors

Genes likely play a role in BDD’s etiology, although they remain to be elucidated. Preliminary data indicate that the prevalence of BDD is higher in first-degree relatives of BDD probands than in the general population (Phillips 2005; Phillips et al. 2005b). In addition, BDD is more common in first-degree relatives of OCD probands than in control probands, suggesting shared etiology and pathophysiology (genetic and/or environmental; Bienvenu et al. 2012) with OCD. Several twin studies similarly suggest a genetic overlap between 81BDD and OCD (although they examined the broader concept of “dysmorphic concern” rather than the disorder BDD) (Monzani et al. 2012). These findings require replication.

Evolutionary Perspective

The application of evolutionary theory to disorders such as BDD is at a very preliminary stage. However, it might be argued that concerns with body appearance may in part have an evolutionary basis (i.e., a desire to attract mates or avoid social ostracism; Phillips 2009). Indeed, in animals, the absence of facial defects or greater symmetry of body parts, for example, may signal reproductive health and fitness or the absence of disease. Moreover, in the animal world, large body size confers some advantages. Certain abnormal behaviors in animals may be relevant to repetitive BDD behaviors—for example, compulsive grooming behaviors such as acral lick syndrome in dogs and compulsive feather plucking in birds.

Neurobiological Factors

What do patients with BDD actually see? There are currently no firm answers to this intriguing question. However, emerging findings from functional magnetic resonance imaging (fMRI) and other studies indicate that BDD is associated with abnormal visual processing. These abnormalities consist of a bias for encoding and analyzing details at the expense of holistic visual processing strategies (i.e., seeing “the big picture”) (Feusner et al. 2010, 2011). Individuals with BDD appear to excessively focus on details of faces as well as non-face objects such as houses. These findings are consistent with clinical observations that people with BDD focus excessively on tiny details of their appearance while ignoring global aspects of how they look. Preliminary data also suggest abnormalities in executive functioning (e.g., Dunai et al. 2010), although findings differ somewhat across studies.

One structural magnetic resonance imaging study found no volumetric differences between BDD subjects and healthy control subjects; however, two studies found greater total white matter volume in BDD subjects (Phillips et al. 2010a). One of the latter two studies also found a leftward shift in caudate asymmetry, and the other found smaller orbitofrontal cortex and anterior cingulate and larger thalamic volumes (Phillips et al. 2010a). More recently, a small study found that BDD may be characterized by compromised white matter fibers (reduced organization) and inefficient connections—or poor integration of information—between different brain areas (Buchanan et al. 2013). Another study did not find this (although statistical power was somewhat limited) but did find a relationship between fiber disorganization and impairment in insight in tracts connecting visual with emotion/memory 82processing systems (Feusner et al. 2013). In addition, an fMRI study found relative hyperactivity in the left orbitofrontal cortex and bilateral head of the caudate when subjects viewed their own faces, which may possibly reflect obsessional preoccupation (Feusner et al. 2010). Although BDD subjects were not directly compared with OCD subjects, this activation pattern is also characteristic of OCD. Given the efficacy of SRIs for BDD (see “Treatment” later in the chapter), the neurotransmitter serotonin, as well as other neurotransmitters, may play an important role in BDD.

Emotion- and Information-Processing Biases

Individuals with BDD appear to have difficulty identifying emotional facial expressions and to have a bias toward interpreting neutral faces as contemptuous and angry (Buhlmann et al. 2006), consistent with their belief that others mock them because they look “deformed.” Persons with BDD also have threatening interpretations of ambiguous scenarios; compared with individuals with OCD, they interpret ambiguous appearance-related and social information as more threatening (Buhlmann et al. 2002), which is also consistent with the frequent occurrence of ideas and delusions of reference in BDD.

Sociocultural and Environmental Factors

BDD appears to be associated with lower-than-average levels of parental care, a history of teasing, and childhood neglect or abuse (Buhlmann et al. 2007; Phillips 2009). In one study, patients with BDD reported higher rates of emotional and sexual abuse (but not physical abuse) than patients with OCD (Neziroglu et al. 2006). Regarding personality characteristics and temperament (which have both environmental and genetic determinants), BDD appears associated with very high levels of neuroticism and low levels of extroversion (Phillips 2005). Although all these factors are associated with other psychiatric disorders and are not specific to BDD, they are consistent with this disorder’s clinical features. It is also likely that sociocultural factors focusing on the importance of appearance play a role in causing and maintaining BDD.

Treatment

General Approaches to Treatment and Special Considerations

Engaging and Retaining Patients in Treatment

One of the most challenging problems that clinicians face when treating patients with BDD is their poor BDD-related insight. Many believe not only that 83they truly are ugly or deformed, but also that their appearance concerns do not have a psychiatric or psychological cause, such as BDD (Phillips et al. 2012). As a result, many are reluctant to accept a diagnosis of BDD or psychiatric care, which they doubt can help them.

Thus, before clinicians discuss or offer treatment, it is important to lay some groundwork, such as the following, which may help patients to recognize that they have BDD and to accept psychiatric treatment:

Attend to the therapeutic alliance and instill hope. Strive to build rapport and trust by expressing empathy for patients’ suffering. Be nonjudgmental so patients do not feel that their concerns are trivial or that they are vain. Many patients, especially those who are more severely ill, feel hopeless and desperate about their symptoms; thus it is important to instill hope by conveying that most patients get better with the right treatment.

Avoid trying to talk patients out of their appearance beliefs or arguing with them about how they look. Just as it is usually not helpful to try to talk a patient with schizophrenia out of a delusional belief, this approach also does not usually work with patients with BDD. Instead, the clinician might note that individuals with BDD see themselves very negatively and very differently from how others see them, for reasons that are not well understood; this mismatch in perception may involve abnormalities in visual perception and overfocusing on details, which may possibly be reinforced by BDD rituals such as mirror checking. It may not be helpful to say that the patient is pretty, beautiful, or handsome, because some patients negatively interpret positive words such as these.

Focus on the patients’ suffering and the effect of BDD on their lives. It is often helpful to discuss how the patients’ concerns are causing them to suffer and are interfering with their functioning, which most patients can readily agree with.

Provide psychoeducation about BDD and its treatment. Explain the disorder’s clinical features and that it is a common and usually treatable disorder. Many patients are relieved to learn this. Patients may benefit from reading about BDD (e.g., Phillips 2009).

Provide information about recommended treatments and a rationale for these treatments.

Address any misconceptions about recommended treatments. For example, some patients are fearful of CBT exposures, worrying that the therapist will push them to do exposures they find too frightening. The clinician can explain that doable exposure exercises can be developed and that learning cognitive approaches first may make exposures easier to do. Fears or misconceptions about medication treatment should 84also be addressed. For more reluctant patients, it can be helpful to frame a medication trial as an “experiment” in which patients can try the medication, assess its pros and cons after an optimal trial, and then make a decision, in collaboration with the physician, about whether to continue it.

Focus on the potential benefits of psychiatric treatment.

Discourage patients from getting dermatological, surgical, dental, and other cosmetic treatments for BDD concerns. Convey that such treatment is not recommended because available data indicate that it is almost never effective for BDD and can even make symptoms worse (Crerand et al. 2005; Phillips et al. 2001b; Sarwer and Crerand 2008). Encourage patients to try medication and/or CBT first, because such treatments appear to be helpful for a majority of patients.

Involve family members if appropriate and potentially helpful, especially if they have brought the patient for treatment. They may be an important source of support for the patient and an ally for the clinician during the treatment process.

Consider use of motivational interviewing strategies that are modified for BDD. These strategies may help to engage and retain reluctant patients in treatment.

Addressing Suicidality

Clinicians must carefully assess and monitor suicidal ideation. Suicidal patients should always receive an SRI trial that is adequate for BDD. SRIs often decrease suicidality and also protect against worsening of suicidality in patients with BDD (Phillips 2009; Phillips and Kelly 2009). Suicidal patients should also be strongly encouraged to participate in CBT for BDD, especially if suicidality appears largely BDD related. For more highly suicidal patients, clinicians should consider incorporating cognitive-behavioral approaches for suicidality into treatment (e.g., Wenzel et al. 2008). Higher-risk patients may need a higher level of care, although many refuse such care because they do not want other people to see them, in which case the clinician must determine whether commitment standards are met.

Using Body Dysmorphic Disorder–Specific Treatments

It is critically important to recognize that effective treatment for BDD—especially CBT for BDD—differs in some important ways from treatments for other disorders, such as OCD, social anxiety disorder, major depressive disorder, or schizophrenia. Because BDD differs from other disorders, it requires treatment that targets its unique symptoms. For example, compared with patients with OCD, those with BDD typically require more intensive 85strategies to engage them in treatment and ongoing motivational interventions. Cognitive interventions are more complex and intensive for BDD than for OCD, because many BDD patients have delusional beliefs and delusions of reference. Unlike with OCD, exposure exercises and behavioral experiments are needed to address prominent social avoidance in BDD. In addition, CBT for BDD includes a mindfulness/perceptual retraining intervention that targets visual processing abnormalities. Furthermore, treatment must target problematic behaviors that are unique to BDD, such as surgery seeking and skin picking or hair pulling due to appearance concerns.

Surgical, Dermatological, Dental, and Other Cosmetic Treatment

A majority of patients with BDD seek and receive cosmetic treatment. The surgery literature has referred to such patients as “polysurgery addicts.” Studies from psychiatric settings indicate that about two-thirds of patients with BDD receive surgical, dermatological, dental, or other cosmetic treatment for their perceived appearance flaws (Crerand et al. 2005; Phillips et al. 2001b). Dermatological treatment is most often received (most often topical acne agents, but also treatments such as dermabrasion and isotretinoin [Accutane]), followed by surgery (most often rhinoplasty) (Crerand et al. 2005; Phillips et al. 2001b). The treatment outcome appears to usually be poor. One study (N=50) found that 81% of subjects were dissatisfied with past medical consultation or surgery (Veale et al. 1996a). In two other studies (N=250 and N=200), only 4%–7% of such treatments led to overall improvement in BDD (Crerand et al. 2005; Phillips et al. 2001b). BDD symptoms may be exacerbated by cosmetic treatment. Findings from these larger studies concur with those from a small prospective surgery study (Tignol et al. 2007) and with observations in the surgery and dermatology literature that patients with BDD may consult numerous physicians, pressure them to prescribe unsuitable treatments, and are often dissatisfied with the outcome (e.g., Sarwer and Crerand 2008). Such outcomes are perhaps not unexpected, given that individuals with BDD actually look normal but are prone to perceive “defects” where none actually exist and to become preoccupied with and distressed by them.

In a survey of cosmetic surgeons, 43% of respondents reported BDD patients were even more preoccupied with the treated “defects” and only 1% were free of their preoccupation after surgery (Sarwer 2002). In 39% of cases, the patient was free of his or her preoccupation but then focused on a different perceived defect. Of concern, 40% reported that a dissatisfied BDD patient had threatened them legally and/or physically. Occasional dissatisfied patients commit suicide or murder the physician (Phillips 1991, 2009). Thus, 86patients should be discouraged from seeking cosmetic treatment for BDD symptoms.

Pharmacotherapy

Serotonin Reuptake Inhibitors as First-Line Pharmacotherapy

SRIs are currently considered the medication of choice for BDD, including for patients with delusional BDD beliefs (Ipser et al. 2009; National Collaborating Centre for Mental Health 2006; Phillips 2009; Phillips and Hollander 2008). However, no medications are approved by the U.S. Food and Drug Administration (FDA) for the treatment of BDD because no pharmaceutical companies have sought this indication.

Prior to the 1990s, no treatment studies were done, and BDD was generally considered untreatable (Phillips 1991). However, early case series suggested that SRIs might have efficacy, consistent with BDD’s similarities to OCD and the high co-occurrence of depressive symptoms (Phillips and Hollander 2008). Subsequently, four methodologically rigorous open-label SRI trials—two with fluvoxamine, one with citalopram, and one with escitalopram (N=15–30)—found that SRIs improved BDD and associated symptoms in 63%–83% of patients (intention-to-treat analyses; Phillips and Hollander 2008). In a clinical series of 33 children and adolescents with BDD, 53% of 19 subjects who received an SRI had improvement in BDD, whereas non-SRI medications were not efficacious for BDD (Albertini and Phillips 1999).

In a randomized, double-blind crossover study, 29 randomized subjects were treated for 8 weeks with the SRI tricyclic antidepressant clomipramine or the non-SRI tricyclic antidepressant desipramine (Hollander et al. 1999). Clomipramine was superior to desipramine for BDD symptoms and functional disability. These results suggested that SRIs may be preferentially efficacious for BDD, which is similarly the case with OCD and consistent with prior retrospective data on BDD (Phillips and Hollander 2008). Treatment efficacy was independent of the presence or severity of comorbid depression, OCD, or social anxiety disorder. In a subsequent 12-week randomized, double-blind, parallel-group study (N=67), fluoxetine was significantly more efficacious than placebo for BDD symptoms and psychosocial functioning (Phillips et al. 2002). The response rate to fluoxetine was 53%, versus 18% to placebo. In this study, too, efficacy of fluoxetine was independent of the presence of comorbid major depression or OCD.

Effective SRI treatment decreases BDD-related preoccupation, functional impairment, repetitive behaviors, and distress. Depressive symptoms, anxiety, anger-hostility, and mental health–related quality of life improved in all or most studies that examined these variables (Phillips and Hollander 2008).

87No studies have directly compared the efficacy of different SRIs for BDD. However, a prospective series in a clinical practice (N=90) found similar response rates for each type of SRI (Phillips et al. 2001a).

Efficacy of serotonin reuptake inhibitor monotherapy for delusional body dysmorphic disorder. Although it might be assumed that antipsychotics should be the mainstay of pharmacotherapy for delusional BDD, studies consistently indicate that delusional BDD is as responsive to SRI monotherapy as is nondelusional BDD (Phillips and Hollander 2008). Earlier clinical experience somewhat unexpectedly suggested that this might be the case, which was supported by subsequent findings in open-label trials and the previously noted placebo-controlled fluoxetine study, in which 50% of patients with delusional BDD responded to fluoxetine versus 55% with nondelusional BDD (Phillips and Hollander 2008). In the previously described crossover study, clomipramine monotherapy was even more efficacious for patients with delusional BDD than for those with nondelusional BDD. Thus, an SRI, rather than antipsychotic monotherapy, is recommended for BDD patients with the DSM-5 absent insight/delusional beliefs specifier.

Recommended dosing and trial duration. Available data and clinical experience suggest that BDD often requires SRI dosages in the range typically recommended for OCD, which are higher than those typically used for depression and many other disorders (Phillips 2009); however, dosage-finding studies have not been done in BDD. Some patients benefit from dosages that exceed the pharmaceutical company’s maximum recommended dosage (this approach is not advised for clomipramine or citalopram, however).

The following are the mean daily dosages, as well as typical maximum dosages, used in the author’s clinical practice: fluoxetine, 67±24 mg (120 mg); clomipramine, 203±53 mg (250 mg); fluvoxamine, 308±49 mg (450 mg); sertraline, 202±46 mg (400 mg); paroxetine, 55±13 mg (90 mg); citalopram, 66±36 mg (40 mg currently, per recent FDA recommendations); and escitalopram, 29±12 mg (60 mg) (Phillips 2009). Citalopram is now a much less appealing option for BDD, given FDA dosing limits. Most patients, however, appear to receive relatively low SRI dosages, which is associated with poorer treatment response (Phillips et al. 2006c). It may be advisable to obtain an electrocardiogram if a higher escitalopram dosage is used.

The average time to response has ranged from 4–5 weeks for citalopram and escitalopram to 6–9 weeks for fluoxetine and fluvoxamine (Phillips and Hollander 2008). Even with fairly rapid SRI dose titration, however, many patients do not respond until the tenth or twelfth week of treatment. If SRI response is inadequate after 12–16 weeks of treatment, and the highest dosage tolerated by the patient or recommended by the manufacturer has been 88tried for at least 3–4 of those 12–16 weeks, a medication change should be made (by switching to another SRI or initiating SRI augmentation), because it does not appear that a nonresponder will convert to a responder after 12–16 weeks of treatment during which an adequate dose is reached (although research on this issue is needed) (Phillips 2009).

Based on clinical experience, patients who improve with an SRI should generally remain on it for at least several years, although many patients opt to continue an SRI for far longer. Lifelong treatment should be considered for patients with very severe BDD, those who have relapsed with prior discontinuation of SRIs, and those with multiple suicide attempts due to BDD (Phillips 2009).

Switching to another serotonin reuptake inhibitor versus augmenting. If response to an optimal 12- to 16-week SRI trial is only partial, a longer SRI trial can be considered to determine whether a partial response will further improve. Preliminary data suggest that about 40% of initial SRI responders further improve with continued SRI treatment for 6 more months (Phillips 2009). Alternatively, the SRI can be discontinued and another one tried. A report from a clinical practice found that of those patients who did not respond to an initial adequate SRI trial, 43% responded to at least one subsequent adequate SRI trial (Phillips et al. 2001a).

For partial SRI responders, however, it may be desirable to continue the SRI and augment it with another medication, especially if functioning or suicidality has notably improved with SRI treatment. SRI augmentation strategies may possibly be more effective for patients who have had a partial response, as opposed to no response, to an SRI (Phillips et al. 2001a). Buspirone is a good augmentation option. In a chart-review study, at a mean dosage of 57±15 mg/day, buspirone effectively augmented SRIs in 33% (n=12) of trials, with a large effect size (Phillips et al. 2001a). In the only controlled SRI augmentation study, the typical antipsychotic pimozide was not more efficacious than placebo in augmenting the SRI fluoxetine (response rate of 18% to both pimozide and placebo) (Phillips 2009). A small case series similarly suggested that olanzapine augmentation of SRIs was not efficacious for BDD (Phillips 2009). However, clinical experience suggests that adding an atypical antipsychotic such as ziprasidone or aripiprazole to an SRI is sometimes helpful, especially for associated agitation or severe anxiety.

Chart-review studies and clinical experience suggest that occasional patients improve with SRI augmentation with bupropion, lithium, methylphenidate, or venlafaxine (Phillips 2009). If clomipramine is combined with a selective serotonin reuptake inhibitor (SSRI), clomipramine levels must be closely monitored, given the SSRIs’ potential to substantially raise the level of clomipramine and cause toxicity. Ideally, pulse, blood pressure, and drug and metabolite (desmethylclomipramine) serum levels should be monitored and 89electrocardiograms obtained. Clinicians can consider adding a benzodiazepine to an SRI to treat severe distress, agitation, or anxiety in patients for whom a benzodiazepine is not contraindicated.

Non–Serotonin Reuptake Inhibitor Medication as Monotherapy

If a number of adequate SRI trials have not been adequately helpful, non-SRIs may be considered, although efficacy data are very limited, and they are not currently recommended as first-line treatments for BDD. A small open-label venlafaxine trial (data reported for 11 completers) and an open-label trial of the antiepileptic levetiracetam (n=17, intention-to treat sample) reported efficacy for BDD (Phillips and Hollander 2008). In a retrospective case series, monoamine oxidase inhibitors were efficacious in 30% (n=7) of 23 cases (Phillips and Hollander 2008). The clomipramine/desipramine study noted earlier, case reports, and retrospective case series suggest that tricyclic antidepressants other than clomipramine are usually inefficacious (Phillips and Hollander 2008). Retrospective data suggest that antipsychotics are not effective as monotherapy for either delusional BDD or nondelusional BDD, although prospective studies are needed (Phillips and Hollander 2008), and these medications may have a role as SRI augmenters.

Other Somatic Treatments

Only case series data are available for electroconvulsive therapy, which suggests that it is usually ineffective for BDD (Phillips 2009), although its use may be considered for highly suicidal BDD patients with severe co-occurring depression. No studies or case series have reported on the efficacy of deep brain stimulation or transcranial magnetic stimulation for BDD.

Cognitive-Behavioral Therapy

Treatment Studies

CBT that is tailored to BDD’s unique symptoms is the best-studied psychotherapy for BDD and has been shown to be effective for a majority of patients (Ipser et al. 2009; National Collaborating Centre for Mental Health 2006; Phillips 2009). Efficacy of individual and group CBT was reported in case series (Neziroglu and Yaryura-Tobias 1993; Wilhelm et al. 1999), and in a study of 10 patients who participated in an intensive behavioral therapy program, including a 6-month maintenance program, improvement was maintained at up to 2 years (McKay 1999).

Three published studies of CBT (an additional study used metacognitive therapy) have used a no-treatment wait-list control group. In a study that provided eight weekly 2-hour sessions of BDD-focused CBT in a group format, 90subjects in the CBT group improved more than those in the wait-list control group; BDD-focused CBT was efficacious for 77% (21) of the 27 women (Rosen et al. 1995). In a study of 19 patients, those treated with individual BDD-focused CBT improved significantly more than those on a no-treatment wait list, with 7 of 9 patients no longer meeting diagnostic criteria for BDD (Veale et al. 1996b).

More recently, a study that included a broader range of patients, including those with suicidal ideation and delusional BDD beliefs, randomly assigned 36 adults to 22 sessions of immediate manualized individual CBT for BDD over 24 weeks or to a 12-week wait list. By week 12, 50% (8 of 16) of participants receiving immediate CBT-BDD were responders, compared with 12% (2 of 17) of wait-listed participants (P=0.026). By posttreatment (week 24), 81% (26 of 32) of participants in the combined ITT CBT-BDD sample, and 83% (24 of 29) of treatment completers, met the definition for response. CBT-BDD resulted in significant decreases in BDD severity; gains were maintained at 3- and 6-month follow-up. Depression, insight, and disability also significantly improved, and patient satisfaction was high (Wilhelm et al. 2014).

Despite their promising results, these studies used a wait-list control group and thus did not control for therapist time and attention, leaving open the question of whether nonspecific treatment factors such as these, rather than CBT itself, were responsible for improvement. A recent study (Veale et al. 2014), the first to control for these factors, found that BDD-focused CBT was more efficacious than anxiety management after 12 weeks of treatment. Outcomes improved even further after four additional CBT sessions, and gains were maintained at 1-month follow-up.

Components of CBT for Body Dysmorphic Disorder

CBT needs to be tailored specifically to BDD’s unique symptoms. Because BDD, especially more severe BDD, is typically challenging to treat, and because BDD’s treatment meaningfully differs from that of other disorders, use of a BDD-specific CBT manual is highly recommended. Two evidence-based CBT treatment manuals for adults are now available (Veale and Neziroglu 2010; Wilhelm et al. 2013). Therapists should have basic CBT training and some familiarity with BDD. If one manual is not adequately helpful, the other may be. An evidence-based manualized treatment manual is not currently available for children or adolescents with BDD.

The treatment described here is based on one of these treatment manuals (Wilhelm et al. 2013). First, the therapist must obtain a good understanding of the patient’s BDD and other symptoms, provide psychoeducation about BDD, and build an individualized cognitive-behavioral model of the 91patient’s illness, including hypothesized mechanisms that cause or maintain the patient’s symptoms. This model is used to collaboratively develop a treatment plan and help the patient understand how CBT may be helpful. Treatment goals that involve enhancement of valued life activities should be set. It is often necessary to enhance motivation for treatment, using motivational interviewing strategies. The first three or four sessions should be used to lay this critically important foundation; if they are not, treatment may fail.

Once this foundation is set, treatment then focuses on the following core elements (Wilhelm et al. 2013):

Cognitive restructuring helps patients learn to identify and evaluate their negative appearance-related thoughts and beliefs and to identify cognitive errors (e.g., mind reading, fortune telling, all-or-nothing thinking). Patients learn to develop more accurate and helpful appearance-related beliefs. Core beliefs (e.g., being unlovable, worthless, or inadequate) are addressed with more advanced cognitive techniques.

Response (ritual) prevention helps patients cut down on repetitive compulsive behaviors (e.g., mirror checking, comparing).

Exposure helps patients gradually face avoided situations (usually social situations). Exposure is combined with behavioral experiments in which patients design and carry out experiments to test the accuracy of their beliefs (e.g., going into a grocery store to test the hypothesis that 70% of people will move away from the patient with a look of horror within 5 seconds). Doing cognitive restructuring before and during exposures decreases distorted thinking and makes exposures easier to carry out.

Perceptual retraining, which includes mindfulness skills, addresses patients’ tendency to overfocus on tiny details of their appearance. It helps patients to develop a more holistic view of their appearance by looking at their entire face or body (not just disliked areas) when looking in the mirror, without performing BDD rituals, and to objectively (rather than negatively) describe their body.

Relapse prevention at the end of treatment prepares patients to terminate formal treatment and to continue to implement learned strategies in their daily lives.

Structured daily homework is a required treatment component that enables patients to practice and consolidate skills learned in session.

Additional approaches are recommended for patients with relevant symptoms (Wilhelm et al. 2013):

1. Habit reversal is used to treat BDD-related skin picking, hair plucking (e.g., to remove “excessive” body hair), and body touching.

922. Activity scheduling and scheduling pleasant activities are used for more severely depressed or inactive patients.

3. The problematic behaviors of seeking and receiving cosmetic treatments should be addressed.

4. Body shape and weight concerns, such as muscle dysmorphia, must also be addressed.

5. Motivational interviewing is used at any time during treatment when patients are ambivalent about initiating or continuing treatment.

For patients who are too severely ill or depressed to participate in CBT, medication may improve symptoms to the point where it is feasible for them to do CBT.

Approaches that are not recommended include staring in mirrors (this actually reinforces the ritual of mirror checking), listening to tapes that say the patient is ugly, and creating “flaws” such as painting bright red spots on their face or wearing strange hairdos and going out in public. In all of these circumstances, habituation seems unlikely to occur (perhaps because of patients’ poor insight), and such approaches can make patients worse, even suicidal.

Frequency and Duration

The number of CBT sessions in studies has varied considerably, from 12 weekly sessions (Veale et al. 1996b) to 12 weeks of daily 90-minute sessions (Neziroglu and Yaryura-Tobias 1993). The optimal session frequency and treatment duration are unclear. Most experts would recommend weekly or more frequent sessions for about 6 months, plus daily homework (Wilhelm et al. 2013). More severely ill patients may require more intensive or longer treatment. After formal treatment ends, as-needed booster sessions should be used to reduce the risk of relapse, and patients should continue to practice CBT skills. Patients who have not worked or interacted with people for many years may benefit from skills training following CBT.

Approaches for Treatment-Refractory Body Dysmorphic Disorder

In my clinical experience, most BDD cases that appear treatment refractory are not. Most of these patients have not received adequate pharmacotherapy for BDD. Common problems include inadequately high SRI doses, too brief an SRI trial, and poor medication compliance. In addition, most patients have not been treated with an evidence-based manualized BDD-focused CBT treatment (Veale and Neziroglu 2010; Wilhelm et al. 2013), in part because these manuals have only recently been developed and tested. In some cases, poor homework compliance compromises the treatment outcome. Following 93recommended treatment strategies will likely convert many patients with apparently refractory illness into treatment responders. More severely ill patients should receive both medication and CBT, and more intensive treatment, such as partial hospital or residential treatment, that focuses on treatment of BDD can be considered.

Key Points

Body dysmorphic disorder (BDD) is a common yet underrecognized disorder, with a point prevalence in nationwide epidemiological surveys of 1.7%–2.4%.

BDD is associated with high rates of functional impairment and suicidality; clinicians should closely monitor BDD patients for suicidal ideation and behavior.

Onset of BDD is usually during early adolescence; in two-thirds of cases, the onset is before age 18 years.

BDD has similarities to obsessive-compulsive disorder but also some important differences, such as poorer insight, greater comorbidity with major depressive disorder and possibly also substance use disorders, and higher rates of suicidality—all of which have treatment implications.

Clinicians should diagnose BDD when present and apply BDD-specific treatments; treatments (especially cognitive-behavioral therapy [CBT]) for other disorders are unlikely to be effective.

Individuals with BDD may be difficult to engage and retain in treatment; various strategies, including motivational interviewing, may be needed.

Serotonin reuptake inhibitors (SRIs), the first-line medications for BDD, are often effective for BDD and associated symptoms.

Higher SRI dosages and a longer treatment trial than typically used for depression and most other disorders are often needed.

CBT that is tailored to BDD’s unique symptoms is the first-line psychosocial treatment approach.

Because BDD can be challenging to treat with CBT, use of an evidence-based BDD-specific treatment manual is advised.

References

Albertini RS, Phillips KA: Thirty-three cases of body dysmorphic disorder in children and adolescents. J Am Acad Child Adolesc Psychiatry 38(4):453–459, 1999 10199118

94American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition Revised. Washington, DC, American Psychiatric Association, 1987

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. Washington, DC, American Psychiatric Association, 1994

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. Arlington, VA, American Psychiatric Association, 2013

Bienvenu OJ, Samuels JF, Wuyek LA, et al: Is obsessive-compulsive disorder an anxiety disorder, and what, if any, are spectrum conditions? A family study perspective. Psychol Med 42(1):1–13, 2012 21733222

Bjornsson AS, Didie ER, Grant JE, et al: Age at onset and clinical correlates in body dysmorphic disorder. Compr Psychiatry 54(7):893–903, 2013 23643073

Buchanan BG, Rossell SL, Maller JJ, et al: Brain connectivity in body dysmorphic disorder compared with controls: a diffusion tensor imaging study. Psychol Med 43(12):2513–2521, 2013 23473554

Buhlmann U, Wilhelm S, McNally RJ, et al: Interpretive biases for ambiguous information in body dysmorphic disorder. CNS Spectr 7(6):435–436, 441–443, 2002 15107765

Buhlmann U, Etcoff NL, Wilhelm S: Emotion recognition bias for contempt and anger in body dysmorphic disorder. J Psychiatr Res 40(2):105–111, 2006 15904932

Buhlmann U, Cook LM, Fama JM, et al: Perceived teasing experiences in body dysmorphic disorder. Body Image 4(4):381–385, 2007 18089284

Buhlmann U, Glaesmer H, Mewes R, et al: Updates on the prevalence of body dysmorphic disorder: a population-based survey. Psychiatry Res 178(1):171–175, 2010 20452057

Conroy M, Menard W, Fleming-Ives K, et al: Prevalence and clinical characteristics of body dysmorphic disorder in an adult inpatient setting. Gen Hosp Psychiatry 30(1):67–72, 2008 18164943

Cotterill JA, Cunliffe WJ: Suicide in dermatological patients. Br J Dermatol 137(2):246–250, 1997 9292074

Crerand CE, Phillips KA, Menard W, et al: Nonpsychiatric medical treatment of body dysmorphic disorder. Psychosomatics 46(6):549–555, 2005 16288134

Dunai J, Labuschagne I, Castle DJ, et al: Executive function in body dysmorphic disorder. Psychol Med 40(9):1541–1548, 2010 19951448

Dyl J, Kittler J, Phillips KA, et al: Body dysmorphic disorder and other clinically significant body image concerns in adolescent psychiatric inpatients: prevalence and clinical characteristics. Child Psychiatry Hum Dev 36(4):369–382, 2006 16741679

Eisen JL, Phillips KA, Baer L, et al: The Brown Assessment of Beliefs Scale: reliability and validity. Am J Psychiatry 155(1):102–108, 1998 9433346

Eisen JL, Phillips KA, Coles ME, et al: Insight in obsessive compulsive disorder and body dysmorphic disorder. Compr Psychiatry 45(1):10–15, 2004 14671731

Feusner JD, Moody T, Hembacher E, et al: Abnormalities of visual processing and frontostriatal systems in body dysmorphic disorder. Arch Gen Psychiatry 67(2):197–205, 2010 20124119

Feusner JD, Hembacher E, Moller H, et al: Abnormalities of object visual processing in body dysmorphic disorder. Psychol Med 41(11):2385–2397, 2011 21557897

Feusner JD, Arienzo D, Li W, et al: White matter microstructure in body dysmorphic disorder and its clinical correlates. Psychiatry Res 211(2):132–140, 2013 23375265

95Grant JE, Kim SW, Crow SJ: Prevalence and clinical features of body dysmorphic disorder in adolescent and adult psychiatric inpatients. J Clin Psychiatry 62(7):517–522, 2001 11488361

Grant JE, Kim SW, Eckert ED: Body dysmorphic disorder in patients with anorexia nervosa: prevalence, clinical features, and delusionality of body image. Int J Eat Disord 32(3):291–300, 2002 12210643

Grant JE, Menard W, Pagano ME, et al: Substance use disorders in individuals with body dysmorphic disorder. J Clin Psychiatry 66(3):309–316, quiz 404–405, 2005 15766296

Hart AS, Phillips KA: Symmetry concerns as a symptom of body dysmorphic disorder. J Obsessive Compuls Relat Disord 2(3):292–298, 2013 24058899

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 56(11):1033–1039, 1999 10565503

Hrabosky JI, Cash TF, Veale D, et al: Multidimensional body image comparisons among patients with eating disorders, body dysmorphic disorder, and clinical controls: a multisite study. Body Image 6(3):155–163, 2009 19410528

Ipser JC, Sander C, Stein DJ: Pharmacotherapy and psychotherapy for body dysmorphic disorder. Cochrane Database Syst Rev (1):CD005332, 2009 19160252

Koran LM, Abujaoude E, Large MD, et al: The prevalence of body dysmorphic disorder in the United States adult population. CNS Spectr 13(4):316–322, 2008 18408651

Mayville S, Katz RC, Gipson MT, et al: Assessing the prevalence of body dysmorphic disorder in an ethnically diverse group of adolescents. J Child Fam Stud 8(3):357–362, 1999

McKay D: Two-year follow-up of behavioral treatment and maintenance for body dysmorphic disorder. Behav Modif 23(4):620–629, 1999 10533443

Monzani B, Rijsdijk F, Iervolino AC, et al: Evidence for a genetic overlap between body dysmorphic concerns and obsessive-compulsive symptoms in an adult female community twin sample. Am J Med Genet B Neuropsychiatr Genet 159B(4):376–382, 2012 22434544

National Collaborating Centre for Mental Health: Obsessive-Compulsive Disorder: Core Interventions in the Treatment of Obsessive-Compulsive Disorder and Body Dysmorphic Disorder (NICE Clinical Guidelines, No 31). Leicester, United Kingdom, British Psychological Society, 2006

Neziroglu FA, Yaryura-Tobias JA: Exposure, response prevention, and cognitive therapy in the treatment of body dysmorphic disorder. Behav Ther 24:431–438, 1993

Neziroglu F, Khemlani-Patel S, Yaryura-Tobias JA: Rates of abuse in body dysmorphic disorder and obsessive-compulsive disorder. Body Image 3(2):189–193, 2006 18089222

Phillips KA: Body dysmorphic disorder: the distress of imagined ugliness. Am J Psychiatry 148(9):1138–1149, 1991 1882990

Phillips KA: The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder. New York, Oxford University Press, 2005

Phillips KA: Understanding Body Dysmorphic Disorder: An Essential Guide. New York, Oxford University Press, 2009

Phillips KA, Diaz S: Gender differences in body dysmorphic disorder. J Nerv Ment Dis 185:570–577, 1997

96Phillips KA, Hollander E: Treating body dysmorphic disorder with medication: evidence, misconceptions, and a suggested approach. Body Image 5(1):13–27, 2008 18325859

Phillips KA, Kelly MM: Suicidality in a placebo-controlled fluoxetine study of body dysmorphic disorder. Int Clin Psychopharmacol 24(1):26–28, 2009 19060721

Phillips KA, Menard W: Suicidality in body dysmorphic disorder: a prospective study. Am J Psychiatry 163(7):1280–1282, 2006 16816236

Phillips KA, Hollander E, Rasmussen SA, et al: 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 33(1):17–22, 1997 9133747

Phillips KA, Albertini RS, Siniscalchi JM, et al: Effectiveness of pharmacotherapy for body dysmorphic disorder: a chart-review study. J Clin Psychiatry 62(9):721–727, 2001a 11681769

Phillips KA, Grant J, Siniscalchi J, et al: Surgical and nonpsychiatric medical treatment of patients with body dysmorphic disorder. Psychosomatics 42(6):504–510, 2001b 11815686

Phillips KA, Albertini RS, Rasmussen SA: A randomized placebo-controlled trial of fluoxetine in body dysmorphic disorder. Arch Gen Psychiatry 59(4):381–388, 2002 11926939

Phillips KA, Coles ME, Menard W, et al: Suicidal ideation and suicide attempts in body dysmorphic disorder. J Clin Psychiatry 66(6):717–725, 2005a 15960564

Phillips KA, Menard W, Fay C, et al: Demographic characteristics, phenomenology, comorbidity, and family history in 200 individuals with body dysmorphic disorder. Psychosomatics 46(4):317–325, 2005b 16000674

Phillips KA, Menard W, Fay C, et al: Psychosocial functioning and quality of life in body dysmorphic disorder. Compr Psychiatry 46(4):254–260, 2005c 16175755

Phillips KA, Didie ER, Menard W, et al: Clinical features of body dysmorphic disorder in adolescents and adults. Psychiatry Res 141(3):305–314, 2006a 16499973

Phillips KA, Menard W, Fay C: Gender similarities and differences in 200 individuals with body dysmorphic disorder. Compr Psychiatry 47(2):77–87, 2006b 16490564

Phillips KA, Pagano ME, Menard W: Pharmacotherapy for body dysmorphic disorder: treatment received and illness severity. Ann Clin Psychiatry 18(4):251–257, 2006c 17162625

Phillips KA, Pinto A, Menard W, et al: Obsessive-compulsive disorder versus body dysmorphic disorder: a comparison study of two possibly related disorders. Depress Anxiety 24(6):399–409, 2007 17041935

Phillips KA, Stein DJ, Rauch SL, et al: Should an obsessive-compulsive spectrum grouping of disorders be included in DSM-V? Depress Anxiety 27(6):528–555, 2010a 20533367

Phillips KA, Wilhelm S, Koran LM, et al: Body dysmorphic disorder: some key issues for DSM-V. Depress Anxiety 27(6):573–591, 2010b 20533368

Phillips KA, Pinto A, Hart AS, et al: A comparison of insight in body dysmorphic disorder and obsessive-compulsive disorder. J Psychiatr Res 46(10):1293–1299, 2012 22819678

Phillips KA, Hart A, Menard W, et al: Psychometric evaluation of the Brown Assessment of Beliefs Scale in body dysmorphic disorder. J Nerv Ment Dis 201:640–643, 2013a 23817164

97Phillips KA, Menard W, Quinn E, et al: A 4-year prospective observational follow-up study of course and predictors of course in body dysmorphic disorder. Psychol Med 43(5):1109–1117, 2013b 23171833

Phillips KA, Hart AS, Simpson HB, et al: Delusional versus nondelusional body dysmorphic disorder: recommendations for DSM-5. CNS Spectr 19(1):10–20, 2014 23659348

Rief W, Buhlmann U, Wilhelm S, et al: The prevalence of body dysmorphic disorder: a population-based survey. Psychol Med 36(6):877–885, 2006 16515733

Rosen JC, Ramirez E: A comparison of eating disorders and body dysmorphic disorder on body image and psychological adjustment. J Psychosom Res 44(3–4):441–449, 1998 9587886

Rosen JC, Reiter J, Orosan P: Cognitive-behavioral body image therapy for body dysmorphic disorder. J Consult Clin Psychol 63(2):263–269, 1995 7751487

Sarwer DB: Awareness and identification of body dysmorphic disorder by aesthetic surgeons: results of a survey of American Society for Aesthetic Plastic Surgery members. Aesthet Surg J 22(6):531–535, 2002 19332010

Sarwer DB, Crerand CE: Body dysmorphic disorder and appearance enhancing medical treatments. Body Image 5(1):50–58, 2008 18255365

Tignol J, Biraben-Gotzamanis L, Martin-Guehl C, et al: Body dysmorphic disorder and cosmetic surgery: evolution of 24 subjects with a minimal defect in appearance 5 years after their request for cosmetic surgery. Eur Psychiatry 22(8):520–524, 2007 17900876

Veale D, Neziroglu F: Body Dysmorphic Disorder: A Treatment Manual. Chichester, West Sussex, UK, Wiley-Blackwell, 2010

Veale D, Boocock A, Gournay K, et al: Body dysmorphic disorder. A survey of fifty cases. Br J Psychiatry 169(2):196–201, 1996a 8871796

Veale D, Gournay K, Dryden W, et al: Body dysmorphic disorder: a cognitive behavioural model and pilot randomised controlled trial. Behav Res Ther 34(9):717–729, 1996b 8936754

Veale D, Anson M, Miles S, et al: Efficacy of cognitive behaviour therapy versus anxiety management for body dysmorphic disorder: a randomised controlled trial. Psychother Psychosom 83(6):341–353, 2014

Ware JE Jr: SF-36 Health Survey Manual and Interpretation Guide. Boston, MA, The Health Institute, New England Medical Center, 1993

Wenzel A, Brown GK, Beck AT: Cognitive Therapy for Suicidal Patients: Scientific and Clinical Applications. Washington, DC, American Psychological Association, 2008

Wilhelm S, Otto MW, Lohr B, et al: Cognitive behavior group therapy for body dysmorphic disorder: a case series. Behav Res Ther 37(1):71–75, 1999 9922559

Wilhelm S, Phillips KA, Steketee G: Cognitive-Behavioral Therapy for Body Dysmorphic Disorder: A Treatment Manual. New York, Guilford, 2013

Wilhelm S, Phillips KA, Didie E, et al: Modular cognitive-behavioral therapy for body dysmorphic disorder: a randomized controlled trial. Behav Ther 45(3):314–327, 2014 24680228

Recommended Readings

International OCD Foundation: www.ocfoundation.org

Massachusetts General Hospital OCD and Related Disorders Program—Body Dysmorphic Disorder: www.massgeneral.org/bdd

98Phillips KA: Understanding Body Dysmorphic Disorder: An Essential Guide. New York, Oxford University Press, 2009

Phillips KA, Hollander E: Treating body dysmorphic disorder with medication: evidence, misconceptions, and a suggested approach. Body Image 5(1):13–27, 2008

Rhode Island Hospital Body Dysmorphic Disorder Program: www.rhodeislandhospital.org/bdd

Veale D, Neziroglu F: Body Dysmorphic Disorder: A Treatment Manual. Chichester, West Sussex, UK, Wiley-Blackwell, 2010

Wilhelm S, Phillips KA, Steketee G: Cognitive-Behavioral Therapy for Body Dysmorphic Disorder: A Treatment Manual. New York, Guilford, 2013