Body Dysmorphic Disorder: Treatment Is Effective
By Fugen Neziroglu, PhD, ABBP, and Katharine Donnelly, MA

Mike, 19, expressed unrelenting concerns about the appearance of his nose. He had undergone cosmetic surgery at the age of 16, and had since been preoccupied by fears that his nose was collapsing. He also believed that defects in his nose were incredibly offensive and visible to all. Anxieties related to his perceived defect interfered with his social life and education, and he began drinking heavily so he could tolerate discomfort in social situations. Eventually he felt compelled to abandon his studies when anxieties related to his perceived facial flaw became unbearable. Once he began intensive outpatient treatment, Mike learned he had body dysmorphic disorder.

As in Mike’s case, most patients suffering from body dysmorphic disorder, or BDD, believe that they have a strong physical defect. Family and friends are usually unable to convince them otherwise. The condition is characterized by an intense preoccupation with an imagined or slight defect in appearance. People with BDD are commonly concerned with aspects that involve the face, such as a too-large nose, a receding hairline, or blemishes.

BDD may affect up to 2 percent of the United States population, appearing equally among men and women. The typical age of onset is between 14 and 20, but it’s not uncommon for the disorder to begin earlier or later.

The current Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), a handbook for mental health professionals, diagnoses BDD according to the following criteria:

• Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person's concern is markedly excessive.
• The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• The preoccupation is not better accounted for by another mental disorder, such as anorexia nervosa.

Related Disorders
Depression and low self-esteem are also common among those with BDD, and research has found that up to 80 percent of individuals with BDD think about or attempt to commit suicide. Research also provides evidence that BDD can be considered a disorder on the obsessive-compulsive spectrum, which includes conditions such as obsessive-compulsive disorder (OCD) and others that are defined by the presence of obsessions and/or compulsions.

Obsessions are intrusive ideas, thoughts, or images that cause much anxiety and distress. Compulsions are repetitive behaviors or mental acts performed to reduce the anxiety produced by obsessions.

In the case of BDD, people experience intrusive negative thoughts related to their appearance, and they perform different behaviors, such as repeatedly looking in a mirror, to cope with their imagined defect.

Causes of BDD
Specific causes of BDD are unknown, but it is commonly viewed as an illness in which certain chemicals, or neurotransmitters, in the brain are influenced. The neurotransmitter serotonin is most likely involved.

Some researchers suggest that BDD is an abnormal response to the physical changes that occur in adolescence. Traumatic incidents, such as being teased about appearance, comments by acquaintances, repeated criticism by family members, and abuse are also thought to be possible triggers of the disorder.

Common Signs and Symptoms
Body dysmorphic disorder is recognized when a distressing preoccupation with physical appearance interferes with daily living. A person suffering with intrusive thoughts about an imagined flaw often develops behaviors such as these:

• Examining the perceived defect in mirrors or shiny surfaces for at least one hour a day.
• Avoiding mirrors or shiny surfaces.
• Camouflaging with hats, scarves, or other clothing, as well as with makeup.
• Altering body posture to hide a profile.
• Constantly questioning family or friends about appearance to seek reassurance.
• Repeatedly consulting cosmetic surgeons, dermatologists, or other medical professionals to find ways to improve appearance.
• Undergoing repeated cosmetic surgery.
• Compulsively picking at perceived blemishes or hairs (which can lead to actual permanent scars).
• Avoiding social situations.
• Going out only when it’s dark outside so the perceived defect is not as visible, or in severe cases, never leaving the house.

How Treatment Helps
Cognitive therapy and exposure and response prevention (ERP) combined with medication are the current treatments of choice.

A study conducted at the Bio-Behavioral Institute in Great Neck, New York, found that four out of five patients showed significant improvement after undergoing a combination of cognitive therapy and ERP. Intensive treatment, with sessions held more than once a week, appears to be the most beneficial.

Cognitive therapy involves challenging and altering faulty thinking patterns, which are believed to lead to negative emotions and behaviors. Patients learn to identify faulty thinking patterns (I must be perfect; The only way to feel better is to look better; If I’m not beautiful, then I must be ugly.), challenge them, and develop more constructive beliefs that lead to positive emotions and behaviors. Clinicians find that cognitive therapy is more effective at the onset of treatment.

Exposure and response prevention (ERP) involves exposing patients to situations they fear and frequently avoid, while preventing them from engaging in the compulsive behaviors that artificially reduce their anxiety. Patients who willingly engage in ERP sessions are exposed to anxiety-provoking situations at their own pace.

Here is an example of ERP treatment for a BDD patient who believes that his nose is too large:

• The therapist makes a list of situations the person avoids or fears, from least to most anxiety provoking. Common situations include attending a party, going on a date, sitting very close to another person on public transportation, having photographs taken, and brightly lit places such as department stores.
• Then the therapist takes the person to these places and encourages him to interact in the situation, while preventing rituals such as mirror checking or hiding his nose. The patient is encouraged to stop all rituals outside of sessions, too, which may mean covering up mirrors in the home and throwing out cosmetic products.
• Between sessions, the patient completes homework assignments that have more exposure exercises. The goal of ERP is for the patient to experience a natural reduction in anxiety in previously feared situations.

Medications may also be prescribed. The class of medications called selective serotonin reuptake inhibitors (SSRIs) has been found to be most effective when accompanied by cognitive therapy and ERP.

Fugen Neziroglu, PhD, ABBP, ABPP, is the Clinical Director of the Bio-Behavior Institute in Great Neck, New York. Katharine Donnelly, MA, is a behavior therapist on the staff.

Resources
Bio-Behavioral Institute; call 516-487-7116 or e-mail biobehavioral@yahoo.com

Body Dysmorphic Disorder and Body Image Program; e-mail Katharine_Phillips@Brown.edu or write The Body Image Program, Butler Hospital, 345 Blackstone Boulevard, Providence, RI 02906