Body dysmorphic disorder (BDD) is a preoccupation with an imagined defect in appearance, or excessive concern over a slight physical anomaly. It is characterised by time-consuming behaviours such as mirror gazing, comparing one’s appearance with others, excessive camouflaging to hide the defect, skin picking and seeking reassurance.[1] Symptoms often begin in adolescence.[2] One study suggested that patients with BDD pay more attention to facial appearance in others, compared to controls.[3] Another found that BDD sufferers have a tendency to misinterpret the neutral facial expressions of others in a negative way.[4]

Epidemiology

Population studies suggest a point prevalence rate of 0.72-2.4%.[5] International studies suggest that 6-15% of patients attending cosmetic surgery and dermatology clinics are estimated to have body dysmorphic disorder (BDD).[2] Data concerning sex predominance are sparse. One study of medical students found a higher preponderance in males[6]

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Differences between body dysmorphic disorder and obsessive-compulsive disorder[2][7]

Although there are many similarities between the two conditions – which often co-exist – some differences have been identified. Patients with body dysmorphic disorder (BDD) have significantly poorer insight than those with obsessive-compulsive disorder (OCD) and are more likely to be delusional. They are also significantly more likely to have lifetime suicidal ideation, as well as lifetime major depressive disorder and a lifetime substance use disorder. See also separate Obsessive-compulsive Disorder article.

The General Practitioner’s role[8]

The National Institute for Health and Clinical Excellence (NICE) recommends referral to a specialist multidisciplinary team offering age-appropriate care. This is unlikely to be available in many areas, due to lack of resources but it is worth getting in touch with local mental health trusts to see what is currently available. The GP’s role depends on expertise but it should be remembered that drug management should be part of a package which includes psychological care.

In all patients, however, the GP will need to:
•Identify cases.
•For patients at risk of body dysmorphic disorder (BDD) (depression, social phobia, substance misuse, obsessive-compulsive disorder (OCD),[9] eating disorder, mild disfigurement or blemish seeking dermatology or cosmetic surgery referral), ask the following questions: •Do you worry a lot about the way you look and wish you could think about it less?
•What specific concerns do you have about your appearance?
•On a typical day, how many hours a day is your appearance on your mind? (More than one hour a day is considered excessive).
•What effect does it have on your life?
•Does it make it hard to do your work or be with friends?

•Assess severity – ie how much it is affecting the patient’s ability to function in everyday life.
•Assess risk of self-harm or suicide and presence of comorbidity such as depression.
•Arrange referral to appropriate secondary care provision.
•Ensure continuity of care to avoid multiple assessments, gaps in service and a smooth transition from child to adult services (many patients have lifelong symptoms).
•Promote understanding – make patients/families aware of the involuntary nature of symptoms. Consider patient information leaflets, contact numbers of self-help groups, etc.
•Consider the bigger picture – cultural, social, emotional and mental health needs.
•If the patient is a parent, consider child protection issues.

Management in adults[8]

Patients with mild functional impairment can be managed with low-intensity psychological treatment. This may involve:
•Individual cognitive behavioural therapy (CBT) plus ‘exposure and response prevention’ (ERP)*.
•Individual CBT and ERP by telephone.
•Group CBT.

*ERP is a technique in which patients are repeatedly exposed to the situation causing them anxiety (eg exposure to dirt) and are prevented from performing repetitive actions which lessens that anxiety (eg washing their hands). This method is only used after extensive counselling and discussion with the patient, who knows fully what to expect. After an initial increase in anxiety, the level gradually decreases. This is extremely therapeutic, as the patient feels that they have confronted their worst fears without anything terrible happening.
•Adults with mild symptoms should be offered a selective serotonin reuptake inhibitor (SSRI) if they cannot engage in low-intensity psychological treatment, if such treatment has failed, or if they opt not to have more intensive psychological treatment.
•Adults with moderate symptoms or where low-intensity psychological treatment has failed should be offered high-intensity CBT and ERP (more than 10 hours per patient) or an SSRI.
•Adults with severe symptoms – offer high-intensity psychological therapy plus an SSRI.

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Management in children[8]
•Mild dysfunction – offer guided self help. As for moderate-to-severe if this fails.
•Moderate-to-severe – offer cognitive behavioural therapy and exposure and response prevention (CBT ERP) as for adults but involve family/carers: individual or group depending on the preference of the patient.
•If psychological treatment fails, factors which might require other interventions may be involved, eg co-existence of comorbid conditions, learning disorders, persisting psychosocial risk factors such as family discord, presence of parental mental health problems. In children over the age of 8, adding an SSRI might be appropriate, following multidisciplinary review (but see below concerning safety issues).

Using SSRIs[8][10]

See separate article Selective Serotonin Reuptake Inhibitors and below:
•SSRIs in adults – evidence for use of SSRIs in obsessive-compulsive disorder (OCD) is stronger than for body dysmorphic disorder (BDD). Caution is advised in view of increased risk of suicidal thoughts and self harm in people with depression. It is unclear whether this applies to people with OCD or BDD in absences of other comorbidity; further guidance is awaited.

When prescribing, discuss the following and provide written supporting material: •Craving and tolerance do not occur.
•There is a risk of discontinuation/withdrawal symptoms on stopping the drug, missing doses, or reducing the dose.
•There is a range of potential side-effects, (see individual drugs) including worsening anxiety, suicidal thoughts and self harm, which need to be carefully monitored, especially in the first few weeks of treatment.
•There is commonly a delay in onset of up to 12 weeks, although depressive symptoms improve more quickly.
•In high-risk patients, prescribe limited quantities, keep in contact, especially during first few weeks, and actively monitor for akathisia (restlessness and the urge to move), suicidal ideation, increased anxiety, agitation.
•Monitor all patients around the time of dosage changes.
•NICE recommends fluoxetine as there is more supporting evidence than for other SSRIs.
•If there is no response to a standard dose, check compliance, check interaction with drugs and alcohol, then consider titrating to maximum dose according to the Product Characteristics.
•Continue for at least twelve months; withdraw gradually.

•SSRIs in children and young people (8-18 years) •Caution is advised as there is a risk of self harm or suicide in patients with depression. They are only prescribed by specialists, in conjunction with psychological therapy following assessment by a child and adolescent psychiatrist who should also be involved in dosage changes and discontinuation.
•Fluoxetine is the first-line SSRI for BDD. In the presence of depression, follow NICE guidance for treatment of childhood depression.
•Discuss adverse effects, dosage, monitoring. etc. with the patient/family/carers as per adults (see above).

Treatment failures (applicable to adults, children and young people)[2][8]

The following in conjunction with specialist assessment and multidisciplinary review:
•Try another SSRI.
•Change to clomipramine – but this has greater tendency to produce adverse effects. Do baseline ECG and check blood pressure; start with a small dose, titrate according to response, and monitor regularly.
•Antipsychotics – sometimes used to augment the effect of an SSRI.
•Inpatient treatment – for ‘last resort’ treatment failures.
•Residential/supportive care – for patients with chronic severe dysfunction.
•Patients with BDD do not usually benefit from surgical treatment.[11]