Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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 309 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. References American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author. Beck, A. T., Epstein, N., Brown, G., & Steer, R. A. (1988). The Beck Anxiety Inventory. San Antonio: Harcourt, Brace, Jovanovich. Beck, A. T., Steer, R. A., & Brown, G. (1996). The Beck Depression Inventory (2nd ed.). San Antonio: Harcourt, Brace, & Company. Braddock, L. E. (1982). Dysmorphophobia in adolescence: A case report. British Journal of Psychiatry, 140, 199–201. Brady, K. T., Austin, L., & Lydiard, R. B. (1990). Body dysmorphic disorder: The relationship to obsessive-compulsive disorder. Journal of Nervous and Mental Disease, 178, 538–540. Brawman-Mintzer, O., Lydiard, B., Phillips, K. A., Morton, A., Czepowicz, V., Emmanuel, N., et al. (1995). Body dysmorphic disorder in patients with anxiety disorders and major depression: A comorbidity study. American Journal of Psychiatry, 152, 1665–1667. Brown, K. W., McGoldrick, T., & Buchanan, R. (1997). Body dysmorphic disorder: Seven cases treated with eye movement desensitization and reprocessing. Behavioural and Cognitive Psychotherapy, 25, 203–207. Brunswick, R. (1928). A supplement to Freud’s “History of an infantile neurosis.” International Journal of Psychoanalysis, 9, 439–476. Butters, J. W., & Cash, T. F. (1987). Cognitivebehavioral treatment of women’s body image dissatisfaction. Journal of Consulting and Clinical Psychology, 55, 889–897. Campisi, T. A. (1995). Exposure and response prevention in the treatment of body dysmorphic disorder. Unpublished doctoral dissertation, Hofstra University, Hempstead, NY. Cohen, L. J., Kingston, P., Bell, A., Kown, J., Aronowitz, B., & Hollander, E. (2000). Comorbid personality impairment in body dysmorphic disorder. Comprehensive Psychiatry, 41, 4–12. Cromarty, P., & Marks, I. (1995). Does rational role play enhance the outcome of exposure therapy in dysmorphophobia? British Journal of Psychiatry, 167, 399–402. Frisch, M. B. (1994). The Quality of Life Inventory. Minneapolis, MN: National Computer Systems. Geremia, G. M., & Neziroglu, F. (2001). Cognitive therapy in the treatment of body dysmorphic disorder. Clinical Psychology and Psychotherapy, 8, 243–251. Gomez-Perez, J. C., Marks, I. M., & Gutierrez-Fisac, J. L. (1994). Dysmorphophobia: Clinical features and outcome with behavior therapy. European Psychiatry, 9, 229–235. Hollander, E., Allen, A., Kown, J., Aronowitz, B., Schmeidler, J., Wong, C., et al. (1999). Clomipramine vs. desipramine crossover trial in body dysmorphic disorder. Archives of General Psychiatry, 56, 1033–1039. Hollander, E, Liebowitz, M. R., Winchel, R., Klumker, A., & Klein, D. F. (1989). Treatment of body dysmorphic disorder with serotonin reuptake blockers. American Journal of Psychiaty, 146, 768–770. Jerome, L. (2001). Dysmorphophobia and taphephobia: Two hitherto undescribed forms of insanity with fixed ideas. History of Psychiatry, 12, 103–114. Kaplan, Z., & Lictenberg, P. (1995). Delusional disorder, somatic subtype, treated with fluvoxamine. European Journal of Psychiatry, 9, 238–241. Khemlani-Patel, S. (2001). Cognitive and behavioral therapy for body dysmorphic disorder: A comparative investigation. Unpublished doctoral dissertation, Hofstra University, Hempstead, New York. Marks, I., & Mishan, J. (1988). Dysmorphic avoidance with disturbed bodily perception. A pilot study of exposure therapy. British Journal of Psychiatry, 152, 674–678. McConnaughy, E. A., Prochaska, J. O., & Velicer, W. F. (1983). Stages of change in psychotherapy: Measurement of sample profiles. Psychotherapy: Theory, Research, and Practice, 20, 368–375. Brief Treatment and Crisis Intervention / 3:3 Fall 2003 319 NEZIROGLU AND KHEMLANI-PATEL McElroy, S. L., Phillips, K. A., & Keck, P. E. (1994). Obsessive-compulsive spectrum disorders. Journal of Clinical Psychiatry, 55, 33–51. McElroy, S. L., Phillips, K. A., Keck, P. E., Hudson, J. I., & Pope, H. G. (1993). Body dysmorphic disorder: Does it have a psychotic subtype? Journal of Clinical Psychiatry, 54, 389–395. McKay, D. (1999). Two year follow-up of behavioral treatment and maintenance for body dysmorphic disorder. Behavior Modification, 123, 621–630. McKay, D., Neziroglu, F., & Yaryura-Tobias, J. A. (1997). Comparison of clinical characteristics in obsessive-compulsive disorder and body dysmorphic disorder. Journal of Anxiety Disorders, 11, 447–454. McKay, D., Todaro, J., Neziroglu, F., Campisi, T., Moritz, K., & Yaryura-Tobias, J. A. (1997). Body dysmorphic disorder: A preliminary evaluation of treatment and maintenance using exposure and response prevention. Behavior Research and Therapy, 35, 67–70. Munjack, D. J. (1978). The behavioral treatment of dysmorphophobia. Journal of Behavior Therapy and Experimental Psychiatry, 9, 53–56. Newell, R., & Shrubb, S. (1994). Attitude change and behaviour therapy in body dysmorphic disorder: Two case reports. Behavioural and Cognitive Psychotherapy, 22, 163–169. Neziroglu, F., Anderson, M. C., & Yaryura-Tobias, J. A. (1999). An in-depth review of obsessivecompulsive disorder, body dysmorphic disorder, hypochondriasis, and trichotillomania: Therapeutic issues and current research. Crisis Intervention, 5, 59–94. Neziroglu, F., Khemlani-Patel, S., Hsia, C., & Yaryura-Tobias, J. A. (2001, July). Incidence of abuse in body dysmorphic disorder. Paper presented at the World Congress of Behavioral and Cognitive Therapies, Vancouver, BC, Canada. Neziroglu, F., Khemlani-Patel, S., & Yaryura-Tobias, J. A. (2002). Incidence of abuse in body dysmorphic disorder and obsessive-compulsive disorder. Unpublished manuscript. Neziroglu, F., & Mancebo, M. (2001). Skin picking as a form of self-injurious behavior. Psychiatric Annals, 31, 549–555. 320 Neziroglu, F., McKay, D., Todaro, J., & YaryuraTobias, J. A. (1996). Effect of cognitive behavior therapy on persons with body dysmorphic disorder and comorbid axis II diagnoses. Behavior Therapy, 27, 67–77. Neziroglu, F., McKay, D., Yaryura-Tobias, J. A., Stevens, K., & Todaro, J. (1999). The overvalued ideas scale: Development, reliability and validity in obsessive-compulsive disorder. Behaviour Research and Therapy, 37, 881–902. Neziroglu, F., Stevens, K. P., McKay, D., & YaryuraTobias, J. A. (2001). Predictive validity of the overvalued ideas scale: Outcome in obsessivecompulsive and body dysmorphic disorders. Behaviour Research and Therapy, 39, 745–756. Neziroglu, F., Stevens, K., Yaryura-Tobias, J. A. (1999). Overvalued ideas and their impact on treatment outcome. Revista Brasileira de Psiquiatria, 21, 209–216. Neziroglu, F., & Yaryura-Tobias, J. A. (1997). A review of cognitive behavioral and pharmacological treatment of body dysmorphic disorder. Behavior Modification, 21, 324–330. Neziroglu, F, & Yaryura-Tobias, J. A. (1993a). Body dysmorphic disorder: Phenomenology and case descriptions. Behavioural Psychotherapy, 21, 27–36. Neziroglu, F, & Yaryura-Tobias, J. A. (1993b). Exposure, response prevention, and cognitive therapy in the treatment of body dysmorphic disorder. Behavior Therapy, 24, 431–438. O’Sullivan, R. L., Phillips, K. A., Keuthen, N.J., & Wilhelm, S. (1999). Near fatal skin picking from delusional body dysmorphic disorder response to fluvoxamine. Psychosomatics, 40, 79–81. Perugi, G., Akiskal, H. S., Giannotti, D., Frare, F., DiVaio, S., & Cassano, G. B. (1997). Gender related differences in body dysmorphic disorder (Dysmorphophobia). Journal of Nervous and Mental Disease, 185, 578–582. Phillips, K. A. (2002). Pharmacological treatment of body dysmorphic disorder: Review of the evidence and a recommended treatment approach. CNS Spectrums, 7, 453–463. Phillips, K. A. (2000). Quality of life for patients with body dysmorphic disorder. Journal of Nervous and Mental Disease, 188, 170–175. Brief Treatment and Crisis Intervention / 3:3 Fall 2003 Approaches to Body Dysmorphic Disorder Phillips, K. A. (1996a). The broken mirror. New York: Oxford University Press. Phillips, K. A. (1996b). Body dysmorphic disorder: Diagnosis and treatment of imagined ugliness. Journal of Clinical Psychiatry, 57(Suppl. 8), 61–64. Phillips, K. A. (1996c). Pharmacological treatment of body dysmorphic disorder. Psychoparmacology Bulletin, 32, 597–605. Phillips, K. A. (1996d). An open study of buspirone augmentation of serotonin reuptake inhibitors in body dysmorphic disorder. Psychopharmacology Bulletin, 32, 175–180. Phillips, K. A. (1991). Body dysmorphic disorder: The distress of imagined ugliness. American Journal of Psychiatry, 148, 1138–1149. Phillips, K. A., Albertini, R. S., & Rasmussen, S. A. (2002). A randomized placebo controlled trial of fluoxetine in body dysmorphic disorder. Archives of General Psychiatry, 59, 381–388. Phillips, K. A., Albertini, R. S., Siniscalchi, J. M., Khan, A., & Robinson, M. (2001). Effectiveness of pharmacotherapy for body dysmorphic disorder: A chart review study. Journal of Clinical Psychiatry, 62, 721–727. Phillips, K. A., & Diaz, S. F. (1997). Gender differences in body dysmorphic disorder. The Journal of Nervous and Mental Disease, 185, 570–577. Phillips, K. A., Dwight, M. M., & McElroy, S. L. (1998). Efficacy and safety of fluvoxamine in body dysmorphic disorder. Journal of Clinical Psychiatry, 59, 165–171. Phillips, K. A., Hollander, E., Rasmussen, S. A., Aronowitz, B. R., DeCaria, C., & Goodman, W. K. (1997). A severity rating scale for body dysmorphic disorder: Development, reliability, and validity of a modified version of the Yale Brown Obsessive-Compulsive Scale. Psychopharmacology Bulletin, 33, 17–22. Phillips, K. A., & McElroy, S. (2000). Personality disorders and traits in patients with body dysmorphic disorder. Comprehensive Psychiatry, 41, 229–236. Phillips, K. A., McElroy, S. L., Dwight, M. M., Eisen, J. L., & Rasmussen, S. A. (2001). Delusionality and response to open label fluvoxamine in body dysmorphic disorder. Journal of Clinical Psychiatry, 62, 87–91. Phillips, K. A., McElroy, S. L., Keck, P. E., Hudson, J. I., & Pope, H. G. (1994). A comparison of delusional and non-delusional body dysmorphic disorder in 100 cases. Psychopharmacology Bulletin, 30, 179–186. Phillips, K. A., McElroy, S. L., Keck, P. E., Pope, H. G., & Hudson, J. I. (1993). Body dysmorphic disorder: 30 cases of imagined ugliness. American Journal of Psychiatry, 150, 302–308. Phillips, K. A., O’Sullivan, R. L., & Pope, H. G. (1997). Muscle dysmorphia. Journal of Clinical Psychiatry, 58, 361. Phillips, K. A., & Taub, S. L. (1995). Skin picking as a symptom of body dysmorphic disorder. Psychopharmacology Bulletin, 31, 279–288. Pope, H. G., Gruber, A. J., Choi, P., Olivardia, R., & Phillips, K. A. (1997). Muscle dysmorphia: An underrecognized form of body dysmorphic disorder. Psychosomatics, 38, 548–557. Rosen, J. C., & Reiter, J. (1996). Development of the body dysmorphic disorder exam. Behaviour Research and Therapy, 34, 755–766. Rosen, J. C., Reiter, J., & Orosan, P. (1995). Cognitive-behavioral body image therapy for body dysmorphic disorder. Journal of Consulting and Clinical Psychology, 63, 263–269. Rosen, J. C., Saltzberg, E., & Srebnik, D. (1989). Cognitive behavior therapy for negative body image. Behavior Therapy, 20, 393–404. Schmidt, N. B., & Harrington, P. (1995). Cognitivebehavioral treatment of body dysmorphic disorder: A case report. Journal of Behavior Therapy and Experimental Psychiatry, 26, 161–167. Sobanski, E., & Schmidt, M. H. (2000). Everybody looks at my pubic bone: A case report of an adolescent patient with body dysmorphic disorder. Acta Psychiatrica Scandinavica, 101, 80–82. Solyom, L., DiNicola, V. F., Phil, M., Sookman, D., & Luchins, D. (1985). Is there an obsessive psicosis? Aetiological and prognostic factors in an atypical form of obsessive-compulsive neurosis. Canadian Journal of Psychiatry, 30, 372–380. Thomas, C. S. (1984). Dysmorphophobia: A question of definition. British Journal of Psychiatry, 144, 513–516. Thomas, C. S. (1985). Disorders with overvalued ideas. British Journal of Psychiatry, 146, 215. Brief Treatment and Crisis Intervention / 3:3 Fall 2003 321 NEZIROGLU AND KHEMLANI-PATEL Veale, D. M., Boocock, A., Gournay, K., Dryden, W., Shah, F., Willson, R., et al. (1996). Body dysmorphic disorder: A survey of fifty cases. British Journal of Psychiatry, 169, 196–201. Veale, D. M., Gournay, K., Dryden, W., Boocock, A., Shah, F., Willson, R., et al. (1996). Body dysmorphic disorder: A cognitive behavioural model and pilot randomized controlled trial. Behavior Research and Therapy,34, 717–729. Veale, D. M., & Lambrou, C. (2002). The importance of aesthetics in body dysmorphic disorder. CNS Spectrums, 7, 429–431. Vitiello, B., & DeLeon, J. (1990). Dysmorphophobia misdiagnosed as obsessive-compulsive disorder. Psychosomatics, 31, 220–222. Watts, F. N. (1990). Aversion to body hair: A case study in the integration of behavioural and interpretative methods. British Journal of Medical Psychology, 63, 335–340. Wilhelm, S., Keuthen, N.J., Deckersbach, T., Engelhard, I. M., Forker, A. E., Baer, L., et al. (1999). Self-injurious skin picking: Clinical characteris- 322 tics and comorbidity. Journal of Clinical Psychiatry, 60, 454–459. Wilhelm, S., Otto, M. L., Lohr, B., & Deckersbach, T. (1999). Cognitive behavioral group therapy for body dysmorphic disorder: A case series. Behaviour Research and Therapy, 37, 71–75. Wilhelm, S., Otto, M. W., Zucker, B. G., & Pollack, M. H. (1997). Prevalence of body dysmorphic disorder in patients with anxiety disorders. Journal of Anxiety Disorders, 11, 499–502. Yaryura-Tobias, J. A., Mancebo, M. C., & Neziroglu, F. (1999). Clinical and theoretical issues in selfinjurious behavior. Revista Brasileira de Psiquiatria, 21, 178–183. Yaryura-Tobias, J. A., & Neziroglu, F. (1997a). Biobehavioral treatment of obsessive-compulsive spectrum disorders. New York: W. W. Norton & Company. Yaryura-Tobias, J. A., & Neziroglu, F. (1997b). Obsessive-compulsive disorders spectrum: pathogenesis, diagnosis, and treatment. Washington, DC: American Psychiatric Press. Brief Treatment and Crisis Intervention / 3:3 Fall 2003