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Therapeutic Approaches to Body Dysmorphic
Disorder
Fugen Neziroglu, PhD
Sony Khemlani-Patel, PhD
Body dysmorphic disorder (BDD) is an obsessive-compulsive spectrum disorder
characterized by an intense preoccupation with an imagined or slight defect in
appearance. BDD has posed a challenge to mental health professionals as a result of its
complex clinical presentation, involving issues such as high overvalued ideation,
comorbidity, suicidality, and severe impairment in daily functioning. This article reviews
the appropriate psychological and psychopharmacological treatment approaches for
BDD, and it offers clinical strategies to address the multiple array of symptoms. [Brief
Treatment and Crisis Intervention 3:307–322 (2003)]
KEY WORDS: body dysmorphic disorder, obsessive-compulsive spectrum disorder,
treatment, behavior therapy, cognitive therapy, psychopharmacological treatment.
Body dysmorphic disorder (BDD) has recently
captured the interest of professionals as a result
of its complex clinical presentation and treatment challenge. BDD is characterized by a preoccupation with an imagined defect in appearance; if a slight defect is present, the person’s
concern is markedly excessive (APA, 2000). Although scholars throughout time have recognized the existence of obsessions with body image, BDD was not highlighted until just over a
century ago. In 1891, Morselli, an Italian psy-
From the Bio-Behavioral Institute (Neziroglu and KhemlaniPatel); from Hofstra University and New York University
(Neziroglu).
Contact author: Fugen Neziroglu, PhD, Bio-Behavioral
Institute, 935 Northern Boulevard, Suite 102, Great Neck,
NY 11021. Phone: (516) 487-7116. Fax: (516) 829-1731.
E-mail: [email protected].
© 2003 Oxford University Press
chiatrist, recognized and described BDD as
“dysmorphophobia,” a fear of being deformed
or becoming deformed, accompanied by much
anxiety (Jerome, 2001). Interestingly, he noted
many of the symptoms described in the current literature, including overvalued ideation
and compulsive behaviors, which are wellrecognized components of the disorder today.
More important, Morselli clearly recognized the
disorder’s classification within the obsessivecompulsive (OC) spectrum by the use of such
terms as “irresistible obsessions and impulsions” (Jerome, 2001). Much of what Morselli
described over a century ago still holds true. He
certainly was correct in his assessment of the
rigid belief system characteristic of BDD.
Morselli’s label was used until 1987, when the
term “body dysmorphic disorder” was introduced into the Diagnostic and Statistical Manual
307
NEZIROGLU AND KHEMLANI-PATEL
of Mental Disorders (DSM) nomenclature. The
scant available literature on dysmorphophobia
vacillated between describing BDD as symptom
of various disorders, as part of a personality disorder, and eventually as a separate syndrome
(Thomas, 1984, 1985), which appeared in the
DSM-III-R in 1987. The major revision in the
DSM-IV allowed for an additional diagnosis of
“delusional disorder, somatic type,” to identify
individuals whose beliefs reached delusional
intensity.
Other early literature mentioned the existence
of BDD as well. Sigmund Freud described a patient he labeled the “Wolf Man,” who was preoccupied with his nose and subsequently neglected his daily life and work as a result of this
symptom. Although Freud did not label him as
having BDD, the patient’s second therapist,
Ruth Brunswick (1928), provided a detailed description of his BDD symptoms. She did not diagnosis him with BDD but stated he had a
type of paranoia, terming it a “hypochondriacal delusion” with “mild ideas of reference.” Furthermore, she noted the “monosymptomatic”
nature of his preoccupation, recognizing that he
was entirely sane when discussing topics other
than his nose.
Phenomenology
Recent research suggests that although BDD is
currently classified as a somatoform disorder in
the DSM-IV-TR (4th ed., text revision, 2001), it
shares many phenomenological and symptom
variables with obsessive-compulsive disorder
(OCD) and its spectrum, and it may be better classified as such (Hollander, Liebowitz,
Winchel, Klumker, & Klein, 1989; McElroy,
Phillips, & Keck, 1994; McKay, Neziroglu, &
Yaryura-Tobias, 1997; Neziroglu & YaryuraTobias, 1993a; Phillips, McElroy, Keck, Pope, &
Hudson, 1993). It meets most of the requirements to qualify as an obsessive-compulsive
308
spectrum disorder, such as the presence of obsessions and compulsions; course; demographics; and similar response to treatment, as well as
similar family history (McElroy et al., 1994).
BDD involves an obsession with either general
physical appearance or with a particular body
part. The most common body parts involve the
head area, such as skin, hair, and nose (McElroy, Phillips, Keck, Hudson, & Pope, 1993; Neziroglu & Yaryura-Tobias, 1993a; Phillips, 1996a,
1996b; Phillips et al., 1993), although any area
can become the focus. Table 1 is a list of the most
common body parts that can be affected. BDD
involving the muscularity of the entire body is
termed “muscle dysmorphia” (Phillips, O’Sullivan, & Pope, 1997; Pope, Gruber, Choi, Olivardia, & Phillips, 1997). BDD is shown to affect
both genders equally (Perugi et al., 1997;
Phillips, 1991; Phillips & Diaz, 1997), and onset
is most frequently in the adolescent years
(McElroy et al., 1993; Phillips et al., 1993; Veale,
Boocock, Gournay, et al., 1996).
TABLE 1. Body Parts Commonly Affected by BDD
Facial features
Skin/complexion
Facial blemishes (vascular markings, redness, acne)
Nose
Ears
Eyes
Forehead
Jaw or chin shape
Face in general
Hair
Body shape
Body size/muscularity
Skin
Hands
Genitals
Asymmetry of a body part
Breasts
Hips
Body hair
Stomach
Feet
Brief Treatment and Crisis Intervention / 3:3 Fall 2003
Approaches to Body Dysmorphic Disorder
Individuals with BDD tend to display many
repetitive behaviors that resemble the compulsions characteristic in OCD. Although mirror
checking is the most common type of compulsion, BDD comprises many other repetitive and
avoidance behaviors, which are listed on Table
2. For those patients who have concerns with
their complexion, they usually exhibit skinpicking compulsions. Recent descriptive studies have found that skin picking in this population is quite predominant (Neziroglu, &
Mancebo, 2001; O’Sullivan, Phillips, Keuthen,
& Wilhelm, 1999; Phillips & Taub, 1995; Wilhelm,
Keuthen, et al., 1999; Yaryura-Tobias, Mancebo, & Neziroglu, 1999). Skin picking may occur because of the patient’s desire to remove
blemishes and have smooth skin, and it may be
triggered by feeling for, or seeing, the blemish.
Interestingly, many of our patients have noted
the presence of somatosensory experiences,
such as tingling or tightening sensations, which
trigger an episode of picking. To achieve their
goal, they may dig into their skins with their fingernails, tweezers, and, at times, even with
knives. We have seen individuals who have
ruined their complexion, ultimately requiring
plastic surgery to correct the tissue damage. The
overt damage due to skin picking usually leads
to further avoidance of social situations.
Many individuals with BDD avoid social or
performance situations (McElroy et al., 1993). Impairment is quite severe in BDD, with patients remaining housebound and isolated for years. Similar to panic disorder, patients’ boundaries get
smaller and smaller, not because they are afraid of
the physical symptoms of anxiety, but because
they subjectively feel too ugly to be out in public.
It is our belief that BDD patients have low selfesteem and that they are disgusted by their appearance. Most interesting, however, is the observation that most patients feel ugly in relation
to their idealized self-image, rather than according to standards of the general population. In
fact, they may perceive themselves as having av-
TABLE 2. Behaviors Commonly Seen in BDD
Mirror checking/mirror avoidance
Camouflaging using articles of clothing
Avoidance of certain clothing
Excessive grooming
Excessive use of cosmetic/beauty products
Seeking cosmetic/dermatological consults
Seeking cosmetic/dermatological procedures
Seeking reassurance from others about appearance
Altering body posture to camouflage body part
Avoidance of social situations
Avoidance of crowded places
Skin picking
Comparing body part of concern to others
Being late for work and/or social events
erage attractiveness but would like to be on the
higher end of the attractiveness continuum.
Their compulsive behaviors, as listed in Table
2, may be initially sufficient to allow them to
have some mobility, but with certain accommodations in their behavior. For example, they may
initially be able to go out during the day but
would eventually feel more comfortable engaging in activities only at night, believing their
“defect” to be less visible in the dark. It is not
uncommon for BDD patients to slowly decrease
the type or manner of activities they engage in,
such as choosing to sit in the back of a classroom, go to less and less crowded places, get less
and less close up to people, spend time with only
family members, avoid dating, and so on. The
avoidance of these various situations occurs because of their belief that they are unattractive in
relation to their idealized self-image and because they believe others will notice their defects. If untreated, most BDD patients will become homebound; some may even be confined
to various rooms in their own homes, having
very limited outside contact. They may not allow others into their homes, which is similar to
OCD patients, except their refusal is based on
not letting others’ see their appearance.
It is common for individuals with BDD to seek
Brief Treatment and Crisis Intervention / 3:3 Fall 2003
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NEZIROGLU AND KHEMLANI-PATEL
cosmetic and/or dermatological procedures to correct the perceived defect (Phillips et al., 1993). In
fact, most patients do not seek help from mental
health professionals unless requested by family
members, because they are depressed or because
all else has failed. However, we are hopeful that as
the disorder is more recognized by the general
public, more cognitive, behavioral, and pharmacological treatments will be sought.
Variables Affecting Treatment
Outcome
BDD poses a challenge to mental health professionals for various reasons. BDD individuals
tend to exhibit a low motivation to seek psychiatric and psychological treatment (Neziroglu,
Anderson, & Yaryura-Tobias, 1999; Phillips,
1996a, 1996b). Overvalued ideation, which can
be defined as a “fixed belief with doubting overtones that is unresponsive to challenges” (Neziroglu & Yaryura-Tobias, 1997) with an underlying affective component (Yaryura-Tobias &
Neziroglu, 1997b), also tends to be high in BDD
individuals. Veale and Lambrou (2002) also
reported that BDD patients may have greater
aesthetic perceptual skills and aesthetic standards than healthy individuals, which, in addition to overvalued ideas, may contribute to low
motivation to engage in psychological treatment.
Although research does indicate that the delusional and nondelusional forms of BDD do not
differ on many variables and that they do respond similarly to treatment (Phillips, McElroy,
Keck, Hudson, & Pope, 1994), it is our clinical experience that delusional patients are more challenging to treat. The psychological treatment
strategies have to be frequently modified since
BDD patients tend to be resistant to traditional
behavioral therapy techniques and thus require a combined psychological and pharmacological treatment strategy. Before exposure and
response prevention is attempted, treatment
310
should initially consist of cognitive therapy with
the appropriate medication to decrease the degree of belief. The cognitive therapy should first
address compliance and motivation to engage in
treatment, rather than challenge maladaptive beliefs related to appearance. Increased flexibility
in allowing the patient to engage in avoidance
and compulsive behaviors is often necessary.
The time frame for treatment is also longer due to
the decreased compliance rate. It is our experience that delusional BDD patients are less likely
to follow through or agree with the necessity of
homework exercises. Furthermore, these patients are not in agreement with the standard
goals of treatment, because they attribute their
suffering to their appearance rather than to a
psychiatric illness. Delusional BDD patients may
also require more case-management strategies,
such as frequent collaboration with cosmetic
surgeons and/or dermatologists.
BDD patients are also a challenge to treat due to
a high degree of comorbid conditions, including
mood disorders (Neziroglu, McKay, Todaro, &
Yaryura-Tobias, 1996; Phillips, 1991; Phillips et
al., 1993), anxiety disorders (Brawman-Mintzer
et al., 1995; Phillips et al., 1993; Wilhelm, Otto,
Zucker, & Pollack, 1997) and personality disorders (Cohen et al., 2000; Neziroglu et al., 1996;
Phillips & McElroy, 2000), thus making it difficult for clinicians to focus solely on BDD symptoms. A high incidence of suicidal ideation and
attempts, from 40% (Phillips et al., 1993) to 45%
(Perugi et al., 1997), as well as a high incidence
of hospitalizations (58%; Khemlani-Patel, 2001)
complicates the clinical picture. Our opinion is
that most BDD patients not only have secondary
depression due to their symptoms but also have
a comorbid major depressive illness. We also believe that, unlike OCD patients who demonstrate
anxiety, the BDD patient’s affective component
is more often depression and disgust. Preliminary research also indicates that many BDD
individuals have suffered significant physical,
emotional, and sexual trauma as children and
Brief Treatment and Crisis Intervention / 3:3 Fall 2003
Approaches to Body Dysmorphic Disorder
adolescents (Neziroglu, Khemlani-Patel, Hsia, &
Yaryura-Tobias, 2001; Neziroglu, KhemlaniPatel, & Yaryura-Tobias, 2002). Due to the debilitating aspects of this disorder, employment
status is quite low (McElroy et al., 1993; Phillips
et al., 1994), and most patients are unmarried
(McElroy et al., 1993; Phillips et al., 1993), providing further evidence for the severe impact
on daily functioning.
All of the above factors complicate the clinical
picture and lead to less than satisfactory treatment outcomes. Clinicians treating BDD need to
be cognizant of these variables in order to design an effective treatment strategy. Therapists
should conduct a proper assessment of the
severity of depression and suicidality before
treatment to determine if these symptoms will
affect the BDD treatment. Patients who are preoccupied with suicide or have a comorbid depressive disorder can have great difficulty engaging in the BDD treatment. In these cases, comorbid symptoms should be addressed first.
Diagnosis and Assessment
Most patients will not report their concern with
their appearance unless the clinician specifically
assesses for BDD symptoms. They often seek
help for OCD, another comorbid condition,
and/or depression. Therefore, clinicians treating the OC spectrum disorders often have to
probe in order to derive a proper diagnosis. In
addition to the most common symptoms displayed in BDD, such as those listed in Table 2,
other symptoms warrant closer assessment. As
mentioned previously, since BDD has a high degree of comorbid diagnoses, patients who present with treatment-resistant depression, social
anxiety, obsessive thoughts, severe impairment
in social and occupational functioning, and skin
picking should all be questioned about any current preoccupation with physical appearance.
Furthermore, patients who already present with
an obsessive-compulsive spectrum disorder
should be screened for BDD since a high degree of comorbidity exists between these disorders and BDD (Brawman-Mintzer et al., 1995;
Phillips et al., 1993; Wilhelm et al., 1997).
Many assessment instruments can aid the clinician in accurately diagnosing BDD, including the
Yale Brown Obsessive-Compulsive Scale for BDD
(YBOCS-BDD; Phillips, Hollander, et al., 1997) and
the Body Dysmorphic Disorder Exam (BDDE;
Rosen & Reiter, 1996). Other instruments that may
be useful include the Overvalued Ideas Scale
(OVIS; Neziroglu, McKay, Yaryura-Tobias,
Stevens, & Todaro, 1999; Neziroglu, Stevens, &
Yaryura-Tobias, 1999; Neziroglu, Stevens, McKay,
& Yaryura-Tobias, 2001) as well as depression and
anxiety measures, such as the Beck Depression
Inventory-II (Beck, Steer, & Brown, 1996) and
the Beck Anxiety Inventory (Beck, Epstein,
Brown, & Steer, 1988). Since patients experience
significant impairment in daily functioning and
a low quality of life, an instrument such as the
Quality of Life Inventory (Frisch, 1994) can better assess BDD’s impact on the individual’s functioning. Since BDD is often accompanied by a
reluctance to engage and comply with treatment recommendations, a measure of readiness
and/or motivation to change should also be an
integral component of an initial evaluation. The
University of Rhode Island Change Assessment
(URICA; McConnaughy, Prochaska, & Velicer,
1983) may be an appropriate assessment tool for
this purpose.
Psychological Treatment
Although the scientific treatment literature is
still scarce for BDD, cognitive and behavioral
treatment seems to be the treatment of choice.
The literature consists largely of case reports
and case series, with treatment frequency, duration, and type varying slightly from one case
to another. See Table 3 for a summary of the
Brief Treatment and Crisis Intervention / 3:3 Fall 2003
311
312
Brief Treatment and Crisis Intervention / 3:3 Fall 2003
Case report; 17-year-old female
Case report; N = 8; 3 out of 8
displayed BDD symptoms
Randomized wait list control;
N = 31; all female, no formal
diagnosis
Case report; N = 5
Randomized group therapy;
N = 23; no formal diagnosis;
eating disorders excluded
Case report; 20-year-old male
therapy
Case report; 37-year-old male
Case report; N = 5;
all comorbid OCD
Solyom, DiNicola, Phil,
Sookman, & Luchins (1985)
Butters & Cash (1987)
Marks & Mishan (1988)
Rosen, Saltzberg, &
Srebnik
(1989)
Watts (1990)
Vitiello & DeLeon (1990)
Neziroglu &
Yaryura-Tobias (1993b)
Case report; 27-year-old male
Munjack (1978)
Braddock (1982)
Participants and Design
Authors
TABLE 3. Summary of Psychological Treatment Literature
Varied for each participant
6 sessions
Varied for each participant;
up to 70 sessions
4 months’ hospitalization
11 sessions
Treatment Duration
ERP and cognitive therapy
Behavioral and
psychoanalysis; Medication
ERP and interpretative
Varied for each patient
Many years
36 sessions
6 weeks; small group format; 6 sessions
correction of body size
estimation; modification of
distorted thinking, and
exposure to avoided situations
ERP, medication
Systematic desensitization;
in vivo desensitization;
cognitive therapy
Flooding, thought stopping,
aversion relief, medication
Hospitalization, social skills,
and assertiveness training,
refraining from appearance
discussions, medication
Systematic desensitization
Treatment
Improvement on BDD
symptom measure and
overvalued ideation
Unsuccessful according
to authors’ report
Successful according to
author’s report
Statistically significant
improvement on size
overestimation, body
dissatisfaction, and
behavioral avoidance
Successful according to
authors’ report
Statistically significant
differences on affective
body image, maladaptive
body image cognitions,
enhanced social selfesteem, self-report
physical fitness, and
sexuality
One patient
demonstrated
improvement
Socialization and
assertiveness
improved but not
belief in defect
Successful according
to author report
Outcome
Brief Treatment and Crisis Intervention / 3:3 Fall 2003
313
Participants and Design
Case report; N = 2; 19-year-old
female concerned with body odor,
and 24-year-old female concerned
appearance
Case report; 30 participants
Case report; 24-year-old male
Case report; 24-year-old male
Random assignment to treatment
with a no treatment control group;
N = 54; all female
Authors
Newell & Shrub (1994)
Gomez-Perez, Marks, &
Gutierrez-Fisac (1994)
Schmidt & Harrington
(1995)
Cromarty & Marks (1995)
Rosen, Reiter, &
Orosan (1995)
Group therapy format
consisting of cognitive
therapy and ERP
ERP, cognitive therapy
and rational role play
2-week baseline, 60-minute
sessions involving cognitive
therapy and collaborative
behavioral experiments
ERP; hospitalization
Role play exercise to modify
beliefs followed by patientinitiated exposure
Treatment
8 sessions, each 2 hours
in duration
7 sessions in vivo ERP; 6
months later, 2 sessions
of ERP followed by 2
sessions of rational
role play
9 sessions
Not reported
Total therapist time 25 hours
for patient 1, and 8 hours for
patient 2
Treatment Duration
Statistically significant
between and within
group differences on
interview and self-report
measures of BDD
symptoms, dissatisfaction
with body shape and
looks, overall
psychological distress
and self-esteem
Improvement on selfreport measure of main
problem, dysmorphic
belief, work and leisure,
total phobia and anxiety/
depression
Improvement on BDD
beliefs, self-report
measures of depression
and anxiety, worry
and distress, and
overall distress level
Statistically significant
improvement on avoidance, work, and social
adjustment, as well as in
BDD beliefs; gains
maintained on follow-up
Improvement on
symptoms and
avoidance according
to authors’ reports;
maintained on follow-up
Outcome
314
Brief Treatment and Crisis Intervention / 3:3 Fall 2003
Participants and Design
Single subject multiple baseline;
N=4
Randomized wait-list control;
N = 19
N = 17; all comorbid personality
disorder
Random assignment; N = 10
Case report; N = 7
Authors
Campisi (1995)
Veale, Gournay, et al. (1996)
Neziroglu, McKay, Todaro,
& Yaryura-Tobias (1996)
McKay, Todaro, et al. (1997)
Brown, McGoldrick,
& Buchanan (1997)
TABLE 3 continued. Summary of Psychological Treatment Literature
Eye movement
desensitization
reprocessing (EMDR)
ERP followed by
maintenance program
consisting of
psychoeducation about
relapse, biweekly
administration of measures
Cognitive therapy and
exposure and response
prevention
Cognitive and behavioral
therapy
ERP
Treatment
Varied for each participant
6 weeks of ERP 5 times a
week for 90 minutes,
followed by 6 months
of maintenance
4 weeks of daily sessions
90 minutes in duration
12 weeks
7 weeks; sessions 90 minutes
3 times a week
Treatment Duration
Improvement according
to author report in 6 out
of 7 participants
Statistically significant
improvement on
interview and self-report
measures of BDD
symptoms, depression,
anxiety, and a
behavioral measure of
avoidance during initial
treatment; improvement
maintained on anxiety
and depression after
maintenance phase
12 out of 17 displayed
50% improvement on
interview based
symptom measure
Statistically significant
improvement on
interview and self-report
measures of BDD
symptoms, depression
and anxiety
Statistically significant
improvement on
interview based BDD
symptoms in 3 out of 4
participants
Outcome
Brief Treatment and Crisis Intervention / 3:3 Fall 2003
315
Single subject, multiple baseline;
N=4
Between group; N = 10
Geremia & Neziroglu (2001)
Khemlani-Patel (2001)
N = 10
McKay (1999)
Case report; 16-year-old female
Case series; N = 13;
attrition rate = 4
Wilhelm, Otto, Lohr,
& Deckersbach (1999)
Sobanski & Schmidt (2000)
Participants and Design
Authors
Cognitive and ERP versus
ERP Alone
Cognitive therapy;
medication stabilization
ERP; medication
Follow-up after
cognitive behavioral
treatment and maintenance
Group therapy consisting of
psychoeducation, cognitive
therapy, ERP and scheduling
of pleasant events
Treatment
2-week baseline, 8-week
treatment, follow-up 6
weeks posttreatment
3 or 5 weeks baseline; 7
weeksof treatment with
sessions twice a week for
75 minutes; follow-up 3
weeks posttreatment
10 weeks
Follow-up at 12, 18, and 24
months posttreatment
12 weeks of 90-minute
sessions
Treatment Duration
Statistically significant
improvement on
symptom and affective
measures; no group
differences
Statistically significant
reduction in BDD
symptoms and
overvalued ideation in 2
out of 4 participants;
statistically
significant improvement
on dissatisfaction with
body parts and on selfreport depression and
anxiety in 3 out of 4
participants
Successful according to
authors’ report; gains
maintained at 6-month
follow-up
Participants in the
maintenance program
successful in preventing
symptom relapse, lower
self-report anxiety and
depression
Statistically significant
improvement on
interview based BBD
symptoms and selfreport measure of
depression
Outcome
NEZIROGLU AND KHEMLANI-PATEL
current treatment literature. Medication trials
within psychological treatment studies have
also rarely been controlled. Many of the studies have successfully relied on a combination
of cognitive and behavioral techniques. Overall, results of the studies indicate that in vivo
(or imaginal) exposure and response prevention (ERP; Braddock, 1982; Campisi, 1995;
Marks & Mishan, 1988; McKay, Todaro, et al.,
1997; Munjack, 1978), cognitive therapy
(Geremia & Neziroglu, 2001), as well as a combination of the two are effective (KhemlaniPatel, 2001; Neziroglu & Yaryura-Tobias,
1993b; Schmidt & Harrington, 1995; Veale,
Gournay, Dryden, et al., 1996). Studies reporting results with group treatment are also promising (Rosen, Reiter, & Orosan, 1995; Wilhelm,
Otto, Lohr, & Deckersbach, 1999). In general, as
in OCD, an intensive treatment approach is more
effective than weekly sessions, and family involvement can lead to quicker treatment gains.
The treatment for BDD is based on approaches for OCD. ERP involves gradually exposing patients’ defects in anxiety-provoking
situations while preventing them from behaving in ways that artificially reduce the anxiety.
For example, a patient who avoids having his
hairline be seen in various public situations by
wearing a cap may be asked to expose his hair
in more and more anxiety-provoking situations without covering his hair. He may be first
asked to go to noncrowded places and stay far
away from others; then he may be gradually exposed to increasingly crowded public places
while slowly decreasing the amount of
camouflaging.
Much debate has been centered on the effectiveness of cognitive therapy as a sole treatment
strategy for obsessive-compulsive spectrum disorders. Recent research for BDD indicates that it
may be quite effective (Geremia & Neziroglu,
2001). Cognitive therapy using strategies either
developed by Beck or Ellis seems to be effective
for BDD. They involve the identification and
disputation of either cognitive distortions or ir316
rational beliefs, respectively, so that the patient
can achieve a more rational thinking style.
Pharmacological Treatment
Pharmacological studies have demonstrated consistent results with the use of the newer generation of antidepressants called the “selective serotonin reuptake inhibitors” (SSRIs), which have
been successful in various diagnoses including
OCD and major depression. SSRIs are known as
“broad spectrum” drugs, effective in a variety of
psychiatric disorders, including BDD (Phillips,
1996c). Other studies, however, have found a positive treatment response with clomipramine,
which is a serotonin reuptake blocker but not selective for serotonin alone (Hollander et al., 1999).
Case reports and open-label studies have demonstrated success with fluoxetine (Brady, Austin, & Lydiard, 1990) and fluvoxamine (Kaplan &
Lictenberg, 1995; Phillips, Dwight, & McElroy,
1998; Phillips, McElroy, Dwight, Eisen, & Rasmussen, 2001). Augmentation strategies are often
necessary for BDD, with the use of buspirone
(Phillips, 1996d; Phillips, Albertini, Siniscalchi,
Khan, & Robinson, 2001) and neuroleptics (Phillips, Albertini, Siniscalchi, Khan, & Robinson,
2001; Yaryura-Tobias & Neziroglu, 1997a,
1997b), as noted in the literature. Response to
SRIs seems to be positive even in cases of delusional BDD (Phillips, McElroy, Dwight, et al.,
2001; Phillips et al., 1994). Recently, more controlled studies with BDD also corroborate earlier
research, with positive responses to fluoxetine
(Phillips, Albertini, & Rasmussen, 2002). Although data is limited, the current consensus indicates that higher SRI doses, augmentation
strategies, and longer treatment trials are the
most efficacious strategies (Phillips, 2002).
Case Example
The patient participated in a research study involving 8 weeks of an intensive treatment pro-
Brief Treatment and Crisis Intervention / 3:3 Fall 2003
Approaches to Body Dysmorphic Disorder
gram, consisting of 4 weeks of cognitive therapy
followed by 4 weeks of behavioral therapy. A 2week baseline data-gathering phase preceded
treatment. Treatment was conducted on an individual basis, three times a week for 90-minute
sessions.
The patient, Carol, was a 25-year-old divorced
female employed full-time. BDD symptoms began at age 14 with concerns about her hair and
facial blemishes. When Carol entered treatment,
her primary concern was facial acne, despite
having a clear complexion. She engaged in many
behaviors that could be initially misconstrued
for common compulsions seen in individuals
who present with OCD contamination issues.
Upon further probing, however, the behaviors
were all related to appearance concerns. She
washed her hands and face frequently, and she
avoided touching objects in public places, such
as doorknobs and elevator buttons, all of which
she believed would make her face dirty and lead
to acne. In addition, she engaged in excessive
use of antibacterial products to keep her hands
clean, as well as cosmetic products to prevent
acne. Carol also engaged in compulsive mirror
checking, having to take frequent breaks from
work to check her appearance in daylight, with
the use of a compact mirror. She engaged in skin
picking when she noticed a facial blemish, using
not only her fingernails but tweezers and the
aid of a magnifying mirror. If she believed her
hands to be dirty, she avoided touching her face
until she had an opportunity to clean them. She
frequently avoided social situations, especially
ones related to the outdoors, believing her defects to be more visible in bright daylight. Carol
was hospitalized at age 27 for three days for severe depression secondary to BDD. Her comorbid diagnosis of OCD began at age 9.
Carol was on a stabilized dose of clomipramine
25 mg and fluvoxamine 300 mg for 12 weeks
prior to our treatment and for the duration of
the study. She had been in psychological treatment for many years but never received cognitive and behavioral treatment.
Assessment Methods
All of the self-report measures mentioned above
were utilized by the therapists to aid in an appropriate treatment program and to monitor
treatment response. All of the measures were
given during baseline, in the final week of cognitive therapy and posttreatment.
Intervention Techniques
Carol participated in 2 weeks of baseline data
gathering, in which she was also educated
about the premise of both cognitive and behavioral treatment. She was taught how to keep
daily records of dysfunctional thoughts related
to her appearance. The maladaptive thoughts
were challenged in individual sessions, and alternate, more adaptive thoughts were constructed. After 4 weeks of cognitive therapy,
equaling 12 sessions, Carol was able to independently challenge her own maladaptive
thoughts.
Following the cognitive therapy, a hierarchy
of feared or avoided situations was constructed,
and she was slowly exposed to these situations
in session. See Table 4 for her hierarchy. Her
hierarchy consisted mainly of situations she believed would result in facial acne, as well as situations in which she believed her facial blemishes would be more noticeable to others. After
each session, the patient was encouraged to
complete homework assignments similar to exposure exercises conducted in session.
Treatment Outcome
Carol responded well to treatment. She was compliant with homework assignments, and she attended sessions regularly. She demonstrated
significant improvement on BDD symptom
measures, anxiety, and overvalued ideation. Interestingly, overall quality of life was still low at
posttreatment, despite demonstrating treatment
success and symptom improvement. This phe-
Brief Treatment and Crisis Intervention / 3:3 Fall 2003
317
NEZIROGLU AND KHEMLANI-PATEL
TABLE 4. Hierarchy for Case Example
10
20
30
40
50
60
70
80
90
100
Touch face after taking a shower
Touch face after touching newspaper/magazine
Touch face after touching money
Sleep on side with face touching pillow
Sit next to someone in clinic waiting room
Use “greasy” moisturizing hand lotion on face
Physical exercise to the point of sweating
Reuse bath towel
Touch face after touching public elevator button
Eat “greasy” foods, such as french fries or pizza
Lay down on carpeted floor with cheek touching floor
Go to the beach
Go on sailboat with friends
Leave make-up on overnight
Touch face after touching doorknob in public bathroom
TABLE 5. Pre-, Mid-, and Posttreatment Scores on Assessment Measures for Case Example
BDD-YBOCS
Obsessions
Compulsions
Total Score
BDDEa
OVISb
BAI
BDI-II
QOLI
Pretreatment
Midtreatment
Posttreatment
18
17
35 (extreme)
113
6.7
28 (moderate-severe)
5 (minimal)
36 (very low)
8
9
17 (moderate)
48
2.3
7 (normal)
5 (minimal)
42 (low)
6
4
10(mild)
18
1.3
0
0
42 (low)
Note. BDD-YBOCS = Body Dysmorphic Disorder Yale-Brown Obsessive-Compulsive Scale; BDDE = Body Dysmorphic Disorder Evaluation;
OVIS = Overvalued Ideation Scale; BAI = Beck Anxiety Inventory; BDI-II = Beck Depression Inventory–Version 2; QOLI = Quality of Life Inventory
Scores above 66 on the BDDE suggest a diagnosis of BDD.
a
OVIS scores range from 1 to 10, with higher scores indicating higher overvalued ideation.
b
nomenon is consistent with research indicating
that BDD patients have a significantly low overall
quality of life (Phillips, 2000). See Table 5 for preand posttreatment scores on treatment measures.
Summary and Conclusion
Given the complexity of it’s presentation, BDD
poses a treatment challenge for mental health
professionals. Based on promising research and
standardized treatment for OCD, the current
318
treatment for BDD is advancing at a rapid pace.
Mental health professionals are encouraged
to keep a positive outlook in treating individuals, while being cognizant of the many aforementioned factors that can impede treatment
outcome. Often these variables need to be addressed first in order to achieve a positive treatment outcome. In general, the authors recommend a multimodal treatment approach consisting of pharmacological and psychological
treatment. Engaging family members in therapy,
as well as collaboration with other mental health
Brief Treatment and Crisis Intervention / 3:3 Fall 2003
Approaches to Body Dysmorphic Disorder
and medical professionals involved with the patient’s treatment, is also highly recommended.
Furthermore, intensive psychological treatment
seems to be more effective than weekly sessions.
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