Intended for healthcare professionals

Practice Practice Pointer

# Body dysmorphic disorder

BMJ 2015; 350 (Published 18 June 2015) Cite this as: BMJ 2015;350:h2278
1. David Veale, consultant psychiatrist and visiting reader in cognitive behavioural psychotherapies1,
2. Anthony Bewley, consultant dermatologist2
1. 1South London and Maudsley NHS Foundation Trust, and the Institute of Psychiatry, Psychology and Neuroscience, King’s College London, UK
2. 2St Bartholomew’s Hospital, London, UK
1. Correspondence to: D Veale david.veale{at}kcl.ac.uk
• Accepted 20 March 2015

#### The bottom line

• People with body dysmorphic disorder may not reveal the degree of their concern unless asked directly because of shame about their appearance, leading them also to seek inappropriate help

• If body dysmorphic disorder is suspected, ask about degree of preoccupation, distress, and interference with daily life, to distinguish the condition from more common, non-pathological body dissatisfaction and refer for mental health assessment

• Treatment options include cognitive behavioural therapy that is specific for body dysmorphic disorder or a selective serotonin reuptake inhibitor at the highest tolerated dose if symptoms are moderate to severe

People with body dysmorphic disorder (also known as BDD) have a preoccupation with a perceived defect or defects or ugliness in their appearance. The “flaws” are often either a normal physical variation, or appear objectively only slight, yet cause enormous shame or interference in a person’s life.1 The disorder is relatively common, with a prevalence of about 2% in the general population, which makes it more common than schizophrenia or anorexia nervosa.2 3 It occurs equally in both sexes. People with body dysmorphic disorder may present to general practitioners; dermatologists; cosmetic, ear, nose, and throat, and maxillary facial surgeons; orthodontists; gynaecologists; or urologists with a desire to improve their defect. Although the condition is a serious psychiatric disorder, it presents to mental health services less commonly, and usually only when there are additional problems such as depression, being housebound, or a risk of suicide.

The condition is easily trivialised and stigmatised, but doctors should not confuse it with body dissatisfaction, which is common but does not cause major distress or interference with life. Patients with “real disfigurements” may be viewed as more worthy of attention,4 but are often less disabled than a person with body dysmorphic disorder. Patients with the condition consume substantial NHS resources but often remain dissatisfied unless doctors deal with them holistically. “Doctor shopping” and accessing private cosmetic services is common, yet many clinicians are not trained to diagnose and manage such patients and mistakenly focus on the defect. This article explores how a generalist can recognise and diagnose patients with body dysmorphic disorder, understand the risks of dissatisfaction from a cosmetic procedure, and engage people with the disorder in a psychological understanding of their problem and refer them for a mental health assessment.

#### Sources and selection criteria

We referred to published systematic reviews, including the treatment guidelines from the National Institute for Health and Clinical Excellence (NICE, 2005). Controlled trials and narrative or systematic reviews were identified by searches on “body dysmorphic disorder.sh. or body dysmorphi$or dysmorphophobi$ or imagine$ugl$.mp.” in Ovid Medline, Embase and PsychINFO. The overall quality of the evidence for pharmacotherapy and psychological therapy is modest with a limited number of controlled trials.

## How do I recognise patients with body dysmorphic disorder?

People with body dysmorphic disorder may not reveal the degree of their preoccupation and distress unless asked directly because of shame about their appearance. The perceived defects can be multiple, usually around the face, commonly the skin, nose, hair, eyes, lips, or chin. The perceived defects are often serial—for example, once one perceived defect has lessened, another defect will become the focus of the patient’s attention. Any part of the body can be the focus, including the genitalia. Typical problems might be hair thinning, acne, the nose being too large or bent, wrinkles on the skin, features not being in proportion; or features being too masculine (or feminine). When patients describe themselves as ugly or feel that a feature is extremely noticeable or abnormal in a way that is different from your observation, consider the diagnosis of body dysmorphic disorder. It can be distinguished from body dissatisfaction, where worry about a perceived defect is not sufficiently distressing or does not interfere with life to a degree that fulfils the diagnostic criteria for body dysmorphic disorder. Box 1 outlines possible questions to ask and behaviour to observe. Consider asking patients how noticeable or abnormal they believe their defect is on a scale of one to 10. If there is substantial discrepancy between the score of the doctor and that of the patient, then this might start a discussion on an alternative understanding of the problem. Asking a patient to draw a self portrait may also help the doctor understand the perceived defect from the patient’s perspective.

#### Box 1: History and observations to make the diagnosis

Answering yes to all the bulleted questions is likely to mean a diagnosis of body dysmorphic disorder and requires further assessment:

• Do you currently think a lot about the feature(s) you dislike? If yes—On a typical day, how many hour(s) do you spend thinking about your feature(s)? More than an hour a day is the cut off

• Do you check in mirrors or reflective surfaces or touch your feature with your fingers a lot? Do you compare your feature often?

• Does your feature(s) cause you a lot of distress?

• Or, do you try to avoid situations or people because of your feature(s)?

• Or, does your feature(s) interfere with your ability to work or study?

• Or, does your feature(s) interfere in dating or a current relationship?

Observations, which when positive, support a diagnosis:

• • Is your patient wearing any specific attire such as a baseball cap, scarves, or sunglasses, which is out of context and used to camouflage the feature?

• • Is your patient using excessive make-up to camouflage the skin inappropriately?

• • Does your patient have long hair to hide his or her face?

• • Are there scars from skin picking?

• • Does your patient keep his or her head down or have poor eye contact?

The key diagnostic criterion for body dysmorphic disorder is a preoccupation with a perceived defect that is at the forefront of the mind for at least an hour a day, but commonly several hours a day.5 To fulfil the diagnosis, the perceived defect must cause substantial distress or interference with day to day life. At some point during the course of the disorder, the person is likely to have performed repetitive behaviours—for example, checking in mirrors6, checking by touching with his or her fingers, skin picking—or mental acts—for example, ruminating, constantly comparing the feature with the perceived defect with the same feature in other people—in response to the concerns.

People with the disorder are often extremely self conscious and usually avoid social or public situations where they feel scrutinised. Alternatively, they may camouflage themselves inappropriately—for example, wearing a scarf or hat on a warm day. Body dysmorphic disorder is associated with being housebound, high rates of psychiatric hospital admission, suicide ideation, and completed suicide.7 8 Thus, always consider the risk of suicide, especially when patients have lost hope of changing their appearance.

## Common comorbidities and differential diagnosis

Because of the repetitive behaviours and related family history, body dysmorphic disorder is now categorised as part of the obsessive-compulsive and related disorders in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition.5 An eating disorder is the alternative diagnosis when the preoccupation is predominantly focused on being “too fat” or overweight and attempts are made to change appearance by altering the diet. Psychiatric comorbidities such as depression, social phobia, or obsessive-compulsive disorder are common in body dysmorphic disorder. Comorbid social phobia is diagnosed only if there are additional fears of acting in a way that leads to humiliation or embarrassment. Comorbid obsessive-compulsive disorder occurs when the obsessions or compulsions are not restricted to concerns about appearance—for example, checking door locks.

The onset typically occurs during adolescence with, sadly, 10 years or more commonly elapsing before adequate diagnosis and treatment.8 9 It can present in adolescence but usually in a more severe form than in adults. Compared with adults, adolescents who present with body dysmorphic disorder have higher lifetime suicide rates and more delusional beliefs.10 They may also present with school refusal, family discord, and social isolation.

## Cosmetic procedures

People with body dysmorphic disorder commonly seek cosmetic surgery or procedures in the hope that the appearance of their perceived flaw or flaws can improve.8 11 In a group cohort study of dermatology practice, the prevalence was higher in the cosmetic dermatology group (14.0%) compared with the general group (6.7%). Such patients were more likely to be dissatisfied with the results of dermatological treatments.12 Some patients may have had a successful procedure when they were younger (and did not necessarily have body dysmorphic disorder), which reinforces their hope of altering their perceived flaw. In general, the presence of body dysmorphic disorder makes satisfaction with a cosmetic procedure unlikely and unpredictable. This statement is based on expert opinion and on patients seen in psychiatric clinics. There have been only a few small prospective studies in cosmetic settings in which people with body dysmorphic disorder have been identified preoperatively and then followed up.13 At best, a patient may be satisfied with some procedures—when change is unambiguous, for example breast augmentation or labiaplasty.14 But cosmetic procedures are generally unlikely to alter symptoms of body dysmorphic disorder. Dissatisfaction with the cosmetic practitioner is common and repeated surgery is inappropriate—not least because the diagnosis of body dysmorphic disorder may be missed, which might end in litigation.15 In addition, the procedure may make preoccupation with the perceived defect and handicap worse, which would make engagement in treatment more difficult because a further procedure would be needed to correct the current defect. Patients should not be referred for another opinion from a different cosmetic surgeon or dermatologist—it is more important to try to refer your patient for a mental health assessment. Patients can and do recover from body dysmorphic disorder, so a history of body dysmorphic disorder is not a contraindication for a cosmetic procedure, but an indication for caution.

## How can you engage a patient?

It is important to be transparent and indicate what you believe is in the patients’ best interests. Do not argue about the diagnosis—always try to validate patients’ feelings of shame and distress and the degree to which their life is affected. Always leave time for discussion. Box 2 shows one way of approaching the problem. If there is a visible difference, such as mild acne scarring, which can be viewed close up and by raising your aesthetic standards then it is important to indicate you, as a doctor, can see this. Note, however, that some patients are not worried about the evaluation of others but are more concerned with feeling “just so” or symmetrical.

## What happens if patients refuse to accept a diagnosis or appropriate treatment?

Always keep validating patients’ distress or feelings of shame. Help them question whether their current solutions are the problem. Show that you care and that you are trying to act in their best interests. If it is appropriate, continue with a medical treatment. Try to understand their fears of rejection or humiliation, which are probably emotionally conditioned from past experiences. They may not be ready to change at this time, but try to encourage them to return. Emphasise that this is a recognised problem for which there is successful treatment. These treatments may, however, take time and commitment on their part. Recommend further reading and websites on body dysmorphic disorder (box 3). Referrals may include a local or regional psycho-dermatology clinic for skin problems16 or a national specialist service for body dysmorphic disorder. A referral to such units may be more acceptable to patients because they will have more time to feel understood. A clinician should still assess risk and act on any unsafe behaviour by raising concerns with the appropriate protection services.

#### Box 3: Advice and information for patients

##### Books for people with body dysmorphic disorder and their carers
• Phillips KA. The broken mirror: understanding and treating body dysmorphic disorder, 2nd ed. Oxford University Press, 2005

• Veale D, Willson R, Clarke A. Overcoming body image problems including body dysmorphic disorder. Constable and Robinson, 2009

## How is body dysmorphic disorder managed?

National Institute for Health and Clinical Excellence guidelines recommend cognitive behavioural therapy that is specific for body dysmorphic disorder, which follows a protocol over 16-24 sessions.17 Evidence for cognitive behavioural therapy is based on four randomised controlled trials of cognitive behavioural therapy v waiting list and one randomised controlled trial of cognitive behavioural therapy v anxiety management, which showed that cognitive behavioural therapy is more effective in improving severity of body dysmorphic disorder, based on blinded assessments by clinicians.18 The most important part of cognitive behavioural therapy is to maintain engagement and to change the agenda towards decreasing preoccupation, distress, and interference in life. The focus is therefore on building an alternative understanding of the problem and reducing self focused attention and ruminating. Patients are guided through graded exposure or behavioural experiments to test out their fears. Offer those with moderate or severe body dysmorphic disorder a selective serotonin reuptake inhibitor antidepressant at the maximum tolerated dose for at least three months to determine response. Evidence is from two randomised controlled trials.19 20 If one selective serotonin reuptake inhibitor was unhelpful then offer an alternative selective serotonin reuptake inhibitor or clomipramine (a potent serotonin reuptake inhibitor). As in obsessive-compulsive disorder, there may be a high rate of relapse when a selective serotonin reuptake inhibitor is discontinued. There is no evidence for the benefit of antipsychotics to augment a selective serotonin reuptake inhibitor in body dysmorphic disorder.21 When immediate risk is not considered the priority, the doctor needs to continue to engage the patient. This does not mean that the defect is dismissed, but rather that a generalist can consider appropriate treatment of the defect—for example, a topical retinoid or combination agents for acne or mild acne scarring. People with severe or chronic problems should have continuing access to multidisciplinary teams with specialist expertise in body dysmorphic disorder. Inpatient or residential unit services with intensive cognitive behavioural therapy are appropriate for a small number of people in whom one or more trials of therapy and drugs as an outpatient have been ineffective. Patients may be directed towards suitable websites and reading about body dysmorphic disorder (box 3).

Patients were involved in the creation of this article by reviewing the content and suggesting changes to box 1 for the suggested section on discussion with a person with body dysmorphic disorder and what to do when a patient refuses to engage in treatment.

## Notes

Cite this as: BMJ 2015;350:h2278

## Footnotes

• DV acknowledges support from the National Institute for Health Research (NIHR) Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King’s College London.

• Competing interests: We have read and understood BMJ policy on declaration of interests and declare the following interests: DV is a co-author on one of the recommended books for patients.

• Provenance and peer review: Not commissioned; externally peer reviewed.

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