Advances in psychiatric treatment (2011), vol. 17, 142–149  doi: 10.1192/apt.bp.109.

007716

ARTICLE Body dysmorphic disorder

Jennifer Ross & Simon Gowers

Jennifer Ross is an assistant with the disorder and Freud’s description of ‘the
psychologist and Simon Gowers is Summary
Wolf Man’ can be seen as a probable case of body
a Professor of Adolescent Psychiatry Body dysmorphic disorder is a distressing and
in the Section of Adolescent dysmorphic disorder (Brunswick 1928).
often disabling condition characterised by a
Psychiatry, University of Liverpool, Eventually, dysmorphophobia was renamed
UK. Correspondence  Professor
preoccupation with imagined or slight physical
body dysmorphic disorder, to distinguish it from
Simon Gowers, FRCPsych, University defects in appearance. It has been recognised as
a mental disorder for many years (and named body primary phobic conditions, and listed as an
of Liverpool, Section of Adolescent
Psychiatry, Academic Unit, 79 dysmorphic disorder since 1980), but epidemiological atypical somatoform disorder in the American
Liverpool Road, Chester CH2 1AW, studies and clinical trials have been few. To a Psychiatric Association’s DSM-III in 1980. No
UK. Email: simon.gowers@cwp. large extent, the disorder has been ignored by diagnostic criteria were included until the 1987
nhs.uk
the mental health community, who often fail revision (DSM-III-R), in which it was classified
to elicit the diagnosis. This article reviews the as a separate disorder, with delusional and non-
diagnostic criteria for the disorder, its validity delusional subtypes.
and its relationship to other disorders such as With the publication of DSM-IV (American
obsessive–compulsive disorder, anorexia nervosa, Psychiatric Association 1994), the criteria for body
social phobia and somatisation disorders. The
dysmorphic disorder were altered so that beliefs
course of the illness, its aetiology and treatment
approaches are discussed. As research is growing of a delusional nature were removed and coded
alongside an increase in patient presentations, body separately on Axis I as delusional disorder, somatic
dysmorphic disorder requires a coherent response type. Body dysmorphic disorder is included in
from healthcare services. the ICD-10 under ‘hypochondriacal disorder’
(F45.2), alongside hypochondriasis (World Health
Declaration of interest
Organization 2007), which seems a less satisfactory
None.
classification. Furthermore, ICD-10 suggests a
diagnosis of ‘Other persistent delusional disorder’
(F22.8) as an alternative in those whose beliefs are
Body dysmorphic disorder centres on an excessive
delusional, rather than this being an additional
concern and preoccupation with an imagined or
disorder as in DSM-IV. A DSM-5 working group
minor defect in one’s physical features. It is often
is currently considering whether body dysmorphic
disabling, but is underrecognised and often mis­
disorder should be included within the category of
understood by the general public and clinicians.
obsessive–compulsive spectrum disorders (Phillips
Individuals with the disorder display a wide variety
2009). The key points of the DSM-IV and ICD-10
of symptoms, generally involving obsessive thoughts
criteria are compared in Box 1.
and compulsive behaviours relating to physical
appearance. Facial features are most commonly the
object of dissatisfaction. Body dysmorphic dis­order
is generally viewed as an obsessive–compulsive Box 1 Diagnostic criteria for body
spectrum disorder, although some see it as an dysmorphic disorder
anxiety disorder, and it is classified in DSM-IV
Both DSM-IV (American Psychiatric Association 1994)
as a somatoform disorder (American Psychiatric and ICD-10 (World Health Organization 2007) refer
Association 1994). It is sometimes confused with to preoccupation with appearance – in DSM (300.7)
social anxiety disorder (with which it is commonly this is described as preoccupation with an imagined
comorbid) as individuals with body dysmorphic defect, whereas ICD (which includes body dysmorphic
disorder tend to be shy and socially avoidant. disorder within F45.2 hypochondriacal disorder) refers to
persistent preoccupation with physical appearance.
History of the concept Both systems now exclude delusional forms of
Although body dysmorphic disorder has only dysmorphophobia.
recently been included in diagnostic systems, DSM requires impairment of social or occupational
recognisable descriptions date to the 19th century.  functioning for the diagnosis, whereas ICD draws
The characteristic features of ‘dysmorphophobia’ attention to the frequent occurrence of psychiatric
were first described in 1886 by Morselli. comorbidity (especially depression and anxiety).
Subsequently, Kraepelin also described patients

142
 Body dysmorphic disorder

Reliability and validity of the diagnosis been questioned. Phillips et al (1994) compared
Concern about appearance is very common and the 48 patients with non-delusional body dysmorphic
boundary between mild body dysmorphic disorder disorder with 52 patients with delusional body
and normal concern is often unclear. However, as dysmorphic disorder and found that they did not
with mood and anxiety disorders, the threshold significantly differ in terms of sociodemographics,
for ‘caseness’ rests on the extent of impairment phenomenology, course of illness, associated
and preoccupation (often proposed as an hour a features, comorbidity or treatment response.
day at the forefront of one’s mind). The perceived Patients with delusions had higher total scores on
defect(s) or flaw(s) in physical appearance should the modified Yale–Brown Obsessive Compulsive
not be observable or should appear slight to Scale questionnaire, suggesting that the delusional
others. Cultural variables may play a significant variant of body dysmorphic disorder may be a
part in the subjectivity behind determining which more severe form of the disorder.
physical appearances are considered to be within
the normal range, but any preoccupation should be Epidemiology
considered abnormal. The incidence of body dysmorphic disorder is
Symptoms of body dysmorphic disorder overlap uncertain as population-based studies are lacking.
with those of other psychiatric disorders, such as Most individuals are first aware of symptoms
major depressive disorder, obsessive–compulsive during adolescence or early adulthood but in some,
disorder (OCD), social phobia and eating disorders. symptoms begin to appear in middle childhood
In one study comparing body dysmorphic disorder and in others, quite late in life, often after a
with social phobia, 39.3% of 178 individuals with traumatic event. Reported rates vary depending
current body dysmorphic disorder had comorbid on the gender ratio, the diagnostic threshold and
lifetime social phobia (34.3% had current social instrument used to measure body dysmorphic
phobia) (Coles 2006). Social phobia onset disorder, the culture and the survey method used.
was typically before that of body dysmorphic For example, a German population study (Rief
disorder and unrelated to appearance concerns. 2006) involving 2552 individuals aged 14 and
Individuals with body dysmorphic disorder, with above gave a prevalence of 1.7% (95% CI 1.2–2.1).
and without lifetime social phobia, were similar Unlike eating disorders, which are much more
in many characteristics such as age at body prevalent in women, body dysmorphic disorder
dysmorphic disorder onset, gender distribution, appears to be as common in men as in women (at
body dysmorphic disorder severity and overall least in Western societies), although fewer men
functional disability (Coles 2006). seek help for the disorder than women (Phillips
Although body dysmorphic disorder is categorised 2005a). Surveys of body dysmorphic dis­order in
as a somatoform disorder in DSM-IV, many now cosmetic surgery settings and dermatology clinics
view it as more closely related to OCD, due to suggest that the disorder is relatively common in
its obsessive–compulsive symptoms and positive these populations, with a prevalence of between
response to similar therapy and drug treatments. 3 and 10%. In psychiatric settings the diagnosis
It appears to differ in several important respects (although relatively easy to make) is often missed,
however. Only 30% of people with OCD have an as clinicians do not routinely ask about it. Thus in
additional diagnosis of depression, compared with a study of consecutive adult psychiatric in-patients
80–90% of people with body dysmorphic disorder (Grant 2001), 16 of 122 individuals (13.1%) were
(Phillips 2007). Although in this series there diagnosed as having body dysmorphic disorder,
was considerable overlap between the disorders, although none had been diagnosed as such by their
differences also emerged over the degree of insight, treating psychiatrist. All 16 patients reported that
suicidal ideology and depressive comorbidity (all they would not raise the issue with their doctor
higher in body dysmorphic disorder). In contrast to unless specifically asked because of feelings of
OCD, individuals with body dysmorphic disorder shame.
do not normally find relief of anxiety by performing Conroy et al (2008) found a similar rate of 16%
rituals such as mirror checking or grooming rituals among psychiatric in-patients. A high proportion
– instead these may increase feelings of despair. of patients reported that body dysmorphic disorder
Unlike other anxiety disorders, body dysmorphic symptoms contributed to their suicidality, but only
disorder is much more likely to be accompanied 1 out of the 16 (6.3%) had reported symptoms to
by feelings of shame, guilt, disgust, self-hatred the in-patient psychiatrist; the other 15 were too
and depression. embarrassed to do so.
The distinction between delusional and non- Both of these studies underline the importance
delusional forms of body dysmorphic disorder has of routinely asking a screening question for body

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Ross & Gowers

dysmorphic disorder in psychiatric service users, concerns. However, the disorder covers a large
particularly in-patients and those presenting spectrum of functionality, with some individuals
with depression, social phobia, OCD, alcohol or merely being preoccupied with obsessive thoughts
substance misuse or suicidal ideation. about appearance and others being completely
Because patients do not readily volunteer their housebound or subject to suicidal ideas.
symptoms, the National Institute for Health and Body dysmorphic disorder may lead to avoidant
Clinical Excellence (NICE) guidelines for body behaviours, culminating in extreme social isolation.
dysmorphic disorder (National Collaborating In some cases, multiple surgery and attempts at
Centre for Mental Health 2005) suggest that a body modification (including self-mutilation) are
simple open question should be used in a psychiatric employed, although these generally fail to improve
assessment interview. An example is: ‘Some people the person’s view of their ‘defect’. Depression is very
worry a lot about their appearance. Do you worry a common and occasionally leads to suicide. Body
lot about the way you look and wish that you could dysmorphic disorder sometimes occurs in episodic
think about it less?’ When answered positively, ‘attacks’, which are followed by a spell of normal
this should be followed up with further questions functioning. In such episodes, the person will be
to clarify the extent and nature of bodily concerns consumed with self-doubt, comparing themselves
and, for example, to distinguish body dysmorphic to others and feeling extremely anxious.
disorder from a possible eating disorder. Many of the symptoms (Box 2) and behaviours
(Box 3) associated with body dysmorphic disorder
Clinical features are determined by the nature of the individual’s
perceived defect (Box 4), for example, the (over) use
‘I didn’t go to college yesterday. I got up early and
started to get ready to go today but I couldn’t. I put of cosmetics is common in those with a perceived
my makeup on but nothing would go right. I look at skin defect. Although the most frequent obsessions
my reflection and I feel physically sick. I have huge concern facial appearance, many women are
bags under my eyes and my eyelids are red. My face
plagued with body proportion concerns, while
is all swollen and the skin is terrible. I just collapsed
in tears. My mum was angry with me because I men tend to be preoccupied with the need to be
didn’t go, and I just felt worthless. She said there was larger and more muscular. Phillips & Diaz (1997)
nothing wrong with me and I was ruining my life. I assessed gender differences in 188 individuals with
don’t want to be like this. Yesterday I cut myself all body dysmorphic disorder (93 women and 95 men).
over my arms and my hands, and today it’s starting
to hurt a bit as the wounds start to heal. I’ve been
Men and women did not significantly differ in
crying a lot. I thought maybe things were getting terms of most variables examined, including rates
better but I was just kidding myself. Nothing can get of major depression, although women were more
better yet. I’m just trapped.’ (Anonymous 2002) likely to be preoccupied with their hips and their
This personal account illustrates how distressing weight, pick their skin and camouflage their skin
the disorder can be. To some extent, the preoccu­ with makeup, and have comorbid bulimia nervosa.
pations of body dysmorphic disorder can lie at Men were more likely to be preoccupied with body
one end of a continuum of ordinary appearance build, genitals and hair thinning, be unmarried
and misuse alcohol. Men were as likely as women
to have sought cosmetic surgery.
Box 2 Common symptoms
Compulsive behaviours
• Preoccupation with mock their perceived • Decreased academic
perceived appearance of defect performance (problems Mirror-checking
defect • Feelings of shame maintaining grades, Mirror-checking is one of the most common
• Depressive symptoms problems with school/ compulsive behaviours in body dysmorphic
• Social and family
college attendance)
• Delusional thoughts withdrawal, social phobia, disorder, although often with much ambivalence.
and beliefs related to loneliness and self- • Problems initiating Individuals often check their appearance in other
appearance imposed social isolation and maintaining reflective surfaces such as shop windows. Others,
relationships (both
• Suicidal ideation • Overdependence on meanwhile, avoid mirrors altogether, covering
intimate relationships and
Anxiety, panic attacks others such as a partner, them, taking them down or turning off lights when
•
friendships)
friend or parents they approach one. Because a body dysmorphic
• Chronic low self-esteem • Alcohol and/or drug
• Inability to work or an disorder attack often occurs during a stressful time,
• Self-consciousness in misuse (often an attempt
inability to focus at work compulsive behaviour such as mirror-checking will
social situations; thinking to self-medicate)
owing to preoccupation increase as well. Therefore, many people find that
that others notice and
with appearance they associate their self-hatred and hopelessness
with mirrors and their reflection.

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 Body dysmorphic disorder

Cameras and photography

Box 3 Compulsive behaviours
Many concerns focus on photographs. A person
with body dysmorphic disorder may avoid intimate • Mirror-checking, glancing in reflective favourite celebrities or models that the
family gatherings just to prevent themselves from doors, windows and other reflective person with body dysmorphic disorder
being photographed. Having their face caught surfaces wishes to resemble
on film creates much distress, as the person • Alternatively, avoidance of one’s own • Use of distraction techniques: an attempt
may become concerned about who will see it reflection or photographs of oneself; often to divert attention away from the person’s
and what they will think. A photograph almost the removal of mirrors from the home perceived defect (e.g. wearing extravagant
always convinces someone with body dysmorphic • Attempting to camouflage imagined defect clothing or excessive jewellery)
disorder that their negative self-image is justified. (e.g. using cosmetic camouflage, wearing • Compulsive information-seeking: reading
Most people with the disorder do not want to take baggy clothing, maintaining specific body books, newspaper articles and websites
a chance of being photographed, as looking at an posture or wearing hats) which relate to the person’s perceived
image they consider to be unfavourable can bring • Excessive grooming behaviours (e.g. skin- defect (e.g. hair loss or dieting and
picking, combing hair, plucking eyebrows, exercise)
about an attack.
shaving) • Preoccupation with plastic surgery or
Social and occupational functioning • Compulsive skin-touching, especially to dermatology procedures

Many individuals with body dysmorphic disorder measure or feel the perceived defect • Attempt to perform cosmetic surgery
Becoming hostile towards people for no on themselves, including liposuction or
are very uncomfortable in social situations as •

known reason, especially those of the removal of unwanted blemishes

they have difficulty relating to other people. Their
natural body language is often restricted, because opposite gender • Avoidant behaviour: avoiding leaving the
Seeking reassurance from loved ones home, or only leaving the home at certain
they feel stressed that people around them might •
times, for example, at night
observe them and judge them unfavourably. • Excessive dieting and exercise
Because of this fear, some people will not leave (Phillips 2005a)
• Comparing appearance/body parts with
the house during the day time and avoid social that of others, or obsessive viewing of
situations. Some are able to hold down a job and
keep a social life, but most are constantly worrying
about what others think of them. They harbour
feelings of inferiority and it causes much distress, Quality of life
often unseen by outsiders. A range of standardised quality-of-life measures
have suggested that individuals with body
Academic functioning dysmorphic disorder, regardless of whether or not
Because the onset of body dysmorphic disorder they are involved in treatment, have remarkably
typically occurs in adolescence, an individual’s poor functioning and quality of life (Phillips
academic functioning may be significantly 2005b).
affected. Depending on the severity of symptoms,
an individual may experience great difficulty
maintaining grades and attendance or, in severe Box 4 Common locations of perceived defects
cases, may drop out of school and therefore not • Skin (73%) • Face size/shape (12%) • Forehead (6%)
reach their academic potential. The vast majority
• Hair (56%) • Lips (12%) • Feet (6%)
of people with body dysmorphic disorder (90%)
say that their disorder has an impact on their • Nose (37%) • Buttocks (12%) • Hands (6%)
academic/occupational functioning, and 99% say • Weight (22%) • Chin (11%) • Jaw (6%)
that their disorder has an impact on their social • Abdomen (22%) • Eyebrows (11%) • Mouth (6%)
functioning (Phillips 2005a). • Breasts/chest/nipples • Hips (11%) • Back (6%)
(21%) • Ears (9%) • Fingers (5%)
Relationships • Eyes (20%) • Arms/wrists (9%) • Neck (5%)
Despite a strong desire for relationships with other • Thighs (20%) • Waist (9%) • Shoulders (3%)
people, many individuals with body dysmorphic
• Teeth (20%) Genitals (8%) Knees (3%)
disorder will instead choose to be lonely rather • •

than risk being rejected or humiliated about their

• Legs (overall) (18%) • Cheeks/cheekbones (8%) • Toes (3%)
appearance by getting involved with others. Many • Body build/bone structure • Calves (8%) • Ankles (2%)
people with the disorder also have coexisting (16%)
• Height (7%) • Facial muscles (1%)
social phobia and/or avoidant personality disorder, • Facial features (general)
• Head size/shape (6%) (Phillips 2005a)
making the individual’s ability to establish (14%)
relationships problematic.

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Ross & Gowers

Comorbidity Suicidality
Comorbidity with other psychiatric disorders Studies have consistently found suicidal ideation
is common. About 80% of people with body and suicide attempts to be common in people
dysmorphic disorder will experience major with body dysmorphic disorder. Suicidality may
depressive disorder at some point in their life, increase when cosmetic surgery is denied. Veale et
significantly more than the 10–20% expected in al (1996) found that 25–30% of patients with body
the general population (Phillips 2005a). About dysmorphic disorder in a psychiatric clinic have
37% also have social phobia and about 32% had a history of attempted suicide.
fulfil criteria for OCD. Eating disorders such as A total of 200 individuals with DSM-IV body
anorexia nervosa and bulimia nervosa are also dysmorphic disorder recruited from diverse sources
sometimes found in women with body dysmorphic were assessed with standard measures (Phillips
disorder, as are generalised anxiety disorder and 2005b). Patients had high rates of lifetime suicidal
trichotillomania. As comorbidity is the rule, it is ideation (78.0%) and suicide attempts (27.5%).
more important clinically to differentiate when Body dysmorphic disorder was judged to be the
body dysmorphic disorder is the main problem primary reason for suicidal ideation in 70.5% of
and which comorbid features would disappear if those with a history of ideation and nearly half of
the disorder was effectively treated, and which are those with a past suicide attempt.
true coexisting disorders. In another study of 185 participants with body
dysmorphic disorder, suicidal ideation was reported
Obsessive–compulsive disorder by 57.8% per year, and 2.6% per year attempted
Phillips et al (2007) compared the characteristics suicide. Two individuals (0.3% per year) completed
of patients with OCD (n = 210), body dysmorphic suicide (Phillips 2006).
disorder (n = 45) and comorbid body dysmorphic
disorder/OCD (n = 40). Those with obsessive– Aetiology
compulsive disorder and body dysmorphic Body dysmorphic disorder usually develops in
disorder did not significantly differ in terms of adolescence, a time when people are generally most
demographic features, age at onset or illness sensitive about their appearance. As with other
duration. However, patients with body dysmorphic anxiety and somatic disorders, a multifactorial
disorder had significantly poorer insight than those aetiology is presumed. Most likely, the cause
with OCD and were more likely to have delusions. comprises a complex combination of biological,
Individuals with body dysmorphic disorder were psychological and environmental factors.
also significantly more likely than those with
OCD to have lifetime suicidal ideation, as well as Biological factors
lifetime major depressive disorder and a substance
Genetic predisposition is suggested by family
use disorder.
studies. Approximately 20% of people with body
dysmorphic disorder have at least one first-degree
Eating disorders
relative who also has the disorder. It is not clear,
A number of studies have shown comorbidity with however, whether this reflects genetic or shared
eating disorders. Rabe-Jablonska & Tomasz (2000) environmental factors. No twin studies or genetic
examined 36 adolescents with anorexia nervosa studies have been conducted specifically for body
and 40 healthy controls. They found symptoms of dysmorphic disorder. A family history of OCD
body dysmorphic disorder in 25% of those with has also been found to exist in those with body
anorexia nervosa and these were generally present dysmorphic disorder suggesting a possible shared
for at least 6 months before the eating disorder genetic vulnerability.
emerged. Phillips & Diaz (1997) have shown an Abnormalities in serotonergic pathways have
association between body dysmorphic disorder been postulated, given serotonin’s purported role
and bulimia. in regulating anxiety, as well as in such processes
as sleep and memory function. It is hypothesised
Personality disorders that people with body dysmorphic disorder may
At least 50% of individuals with body dysmorphic have blocked or damaged receptor sites that
disorder have comorbid personality disorder. The prevent serotonin from having its full effect
most common are Cluster C personality types, (Phillips 2005a), although this is unconfirmed
with avoidant, paranoid, obsessive–compulsive and not specific to body dysmorphic disorder.
and dependent personality disorders the most Nevertheless, many patients with body dysmorphic
prevalent. disorder respond positively to selective serotonin

146 Advances in psychiatric treatment (2011), vol. 17, 142–149  doi: 10.1192/apt.bp.109.007716
 Body dysmorphic disorder

reuptake inhibitors (SSRIs), lending support to the Psychological interventions

theory. Dysregulation of other neurotransmitters
Cognitive–behavioural therapy
such as dopamine and gamma aminobutyric acid
have also been proposed as contributory factors in Cognitive–behavioural therapy (CBT) is considered
the development of the disorder (Phillips 2005a). the treatment of choice. Pathological processes
such as ruminating and comparing are focused
Psychological and environmental factors on using exposure and behavioural experiments
(Veale 2010). There have been a small number of
A range of environmental variables have been
randomised controlled trials (RCTs) demonstrating
postulated as aetiological factors within a variety
the effectiveness of CBT.
of theoretical frameworks such as social learning
Rosen et al (1995) randomly assigned 54 indivi­
theory, operant conditioning and cognitive–
duals with body dysmorphic disorder to CBT or no
behavioural models (Neziroglu 2008). Parenting
treatment. Patients were treated in small groups for
attitudes may contribute to body dysmorphic
eight 2-hour sessions. Therapy involved modification
disorder, for example where parents place excessive
of intrusive thoughts of body dissatisfaction and
emphasis on aesthetic appearance. Bullying
overvalued beliefs about physical appearance,
regarding appearance may play a contributory
exposure to avoided body image situations, and
role – about 60% of people with body dysmorphic
elimination of body checking. Symptoms of body
disorder report frequent or chronic childhood
dysmorphic disorder were significantly decreased
teasing (Phillips 2005a).
in the CBT group, and the disorder was absent in
Personality traits which have been proposed
82% of participants at the end of treatment and
as vulnerability factors include perfectionism,
77% at follow-up. Overall psychological symptoms
introversion, narcissism, schizoid personality and
and self-esteem also improved.
avoidant personality.
Veale et al (1996) conducted a small RCT in
Life events such as physical or sexual trauma,
which 19 patients were randomly allocated to either
rejection with subsequent insecurity, as well as
CBT or a waiting list control group over 12 weeks.
social and academic stresses during adolescence
There were no significant pre–post differences
have been postulated to precipitate the condition.
on any of the measures in the waiting list group.
Media influences, meanwhile, emphasising the
There were significant changes in the CBT group
necessity of aesthetic beauty, may contribute to
on specific measures of body dysmorphic disorder
body dysmorphic disorder in a similar way as is
and depressed mood.
proposed for eating disorders (Neziroglu 2008).
Exposure and response prevention
Course
Exposure and response prevention involves facing
The course of the disorder is often chronic, with
anxiety-provoking situations while resisting the
a poor prognosis for complete recovery. Even with
typical (reinforcing) response to them. It is often
specialised treatment, the recovery process is often
given in conjunction with CBT. The individual
long, and remission and relapse are common.
draws up a hierarchical list of feared and avoided
situations and then selects an item to address.
Treatment
Patients may be asked to consider an alternative
Attitude to treatment and motivation explanation for their body image problem and to
Although effective treatments are available test this out to determine whether their method
either specifically for body dysmorphic disorder of coping (avoidance, checking, comparing,
or comorbid symptoms, there are a number of ruminating, being excessively self-focused)
obstacles to their effective delivery. Many people maintains their preoccupation and distress.
with body dysmorphic disorder have depression, Gradually, patients are encouraged to increase
making them unmotivated to work towards exposure to public and social situations while
recovery. Others are highly sceptical of the idea dropping their safety behaviours.
that they have a psychological disorder at all and
seek cosmetic procedures as an alternative to Pharmacological treatment
psycho­logical treatment. Many are housebound A range of antidepressants have been used in body
and have extreme social phobia or are too anxious, dysmorphic disorder (most commonly SSRIs), but
embarrassed or ashamed to seek treatment and talk RCTs have been few.
to a therapist. Finally, body dysmorphic disorder Higher doses of SSRIs and longer durations of
is often misunderstood by therapists and finding treatment than those used for other psychiatric
effective treatment can therefore be challenging. disorders including depression are often needed,

Advances in psychiatric treatment (2011), vol. 17, 142–149  doi: 10.1192/apt.bp.109.007716 147
Ross & Gowers

as with the treatment of OCD, and there is a Centre for Mental Health 2005) suggest a stepped-
MCQ answers
possibility of relapse on discontinuation of SSRIs. care approach to treatment. For mild cases, or as a
1 c 2 c 3 d 4 a 5 e
In a placebo-controlled parallel group study first step, guided self-help is recommended, using a
of fluoxetine (Phillips 2002), 67 patients were book such as that by Veale and colleagues (2009).
randomised to either fluoxetine or placebo: 18 A meta-analysis of studies of psychological and
(53%) responded to fluoxetine compared with pharmacological interventions (Williams 2006)
6 (18%) to placebo. Body dysmorphic disorder supported the effectiveness of both psychological
symptoms of patients with delusions were as likely therapies (mainly CBT) and pharmacological
as those of patients without delusions to respond treatment (mainly SSRIs). The NICE guidelines
to fluoxetine. Treatment response was independent concluded therefore that individuals with a disorder
of the duration and severity of the disorder and the of moderate severity should be offered an SSRI or
presence of major depression, OCD or personality CBT, with a combination of the two reserved for
disorder. Fluoxetine was generally well tolerated. severe cases. The guidelines do not recommend
A double-blind, crossover study of clomipramine the use of antipsychotics, as even patients with
v. desipramine involving 29 people with body comorbid delusional disorder may respond to an
dysmorphic disorder found clomipramine to be SSRI. Those failing to make progress should be
superior as measured by assessment of participants’ referred to a multidisciplinary specialist service for
obsessive preoccupation, repetitive behaviours and OCD/body dysmorphic disorder.
global ratings of symptom severity (Hollander
1999). This treatment efficacy was independent Conclusions
of the presence or severity of comorbid OCD, Body dysmorphic disorder remains poorly under­
depression or social phobia. Clomipramine was stood and rarely identified within generic mental
also found to be effective in this study among health services. Guidance from NICE and revised
patients with delusional beliefs. classification systems which highlight links with
Antipsychotic drugs have been disappointing obsessive–compulsive disorders should help
according to retrospective case reports (Phillips establish the validity of the condition and clarify
1996). Even delusional thoughts tend to be un­ potential treatment approaches.
responsive and individuals may be troubled by
adverse effects such as weight gain, which may References
exacerbate a body image problem. Augmentation
American Psychiatric Association (1980) Diagnostic and Statistical
of SSRIs with pimozide was found to confer no Manual of Mental Disorders (3rd edn) (DSM-III). APA.
benefit over augmentation with placebo in a American Psychiatric Association (1987) Diagnostic and Statistical
controlled trial (Phillips 2005c). Manual of Mental Disorders (3rd edn revised) (DSM-III-R). APA.
American Psychiatric Association (1994) Diagnostic and Statistical
Non-psychiatric medical treatment Manual of Mental Disorders (DSM-IV). APA.
Non-psychiatric medical treatment does not appear Anonymous (2002) Understanding BDD. BDD Central (http://www.
bddcentral.com).
to be effective for the majority of people with body
dysmorphic disorder (Crerand 2006). In a study of Brunswick RM (1928) A supplement to Freud’s ‘History of an Infantile
Neurosis’. International Journal of Psychoanalysis 9: 439–76.
200 individuals with the disorder, dermatological
Coles ME, Phillips KA, Menard W, et al (2006) Body dysmorphic disorder
treatment was most frequently sought, followed by
and social phobia: cross-sectional and prospective data. Depression and
surgery (most often rhinoplasty). Of the patients in Anxiety 23: 26–33.
this series, 12% received isotretinoin (for acne), but Conroy M, Menard W, Fleming-Ives K, et al (2008) Prevalence and clinical
none of these treatments reliably improved body characteristics of body dysmorphic disorder in an adult inpatient setting.
dysmorphic disorder. General Hospital Psychiatry 30: 67–72.
Surgery is rarely helpful to patients with Crerand C, Franklin M, Sarwer D (2006) Body dysmorphic disorder and
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MCQs c commonly check their appearance in mirrors c comprising a single surgical procedure is
Select the single best option for each question stem d are highly critical of others’ appearance generally effective
e usually have a noticeable physical defect. d should include colonic irrigation
1 Females with body dysmorphic disorder:
e comprises a course of many operations.
a outnumber males by 10 to 1
b are more commonly preoccupied with their legs 3 Pharmacological treatment:
than their face a is not indicated for body dysmorphic disorder 5 The long-term outcome of body
c commonly use masking skin products b is effective in body dysmorphic disorder dysmorphic disorder:
d rarely have comorbid eating disorders c comprises a benzodiazepine or similar anxiolytic a often includes spontaneous remission
e make frequent demands on primary care d using SSRIs may require a higher dose than for b is unaffected by treatment
services. depression c is better if the preoccupation focuses on the
e may reduce comorbid depression, but not the face
underlying dysmorphia. d is better for men than women
2 Patients with body dysmorphic disorder:
e may include suicide.
a usually experience onset of the disorder before
puberty 4 Non-psychiatric medical treatment:
b are attention-seeking and enjoy social a rarely produces a lasting benefit
occasions b is more effective than psychotropic drugs

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