Dermatology

Body Dysmorphic Disorder (Dermatologic Non-Disease and Dysmorphophobia)

Are You Confident of the Diagnosis?

  • What you should be alert for in the history

Patients with body dysmorphic disorder (BDD) show an obsessive preoccupation with real or imagined cosmetic imperfection or defect: acne, scars, pigmentation, oiliness, redness, paleness, facial vessels, hair loss, excessive facial hair. Complaint may involve a dysesthesia (ie, burning, itch, crawling sensation). Preoccupation usually involves the face and head, skin and hair being the most common focus. Scalp and genital region can be involved. BDD may affect 2% to 15% of the population. BDD can be considered a delusional disorder, therefore by definition, reassurance is futile since one cannot be "talked out of a delusion."

BDD may consume an enormous amount of emotional energy and time. Obsession, rumination, and extreme psychological distress are striking features. Patients often spend long periods in front of the mirror, minutes to hours several times daily. Skin picking, excessive tanning, or excessive grooming is common.

Symptoms can be incapacitating. Depression is frequently evident. Previous suicide attempts are not uncommon. Dissatisfaction with previous physicians and medical-surgical procedures is common. Interactions with BDD patients are often long, difficult, and emotionally draining.

  • Characteristic findings on physical examination

Findings on physical examination are usually unremarkable. Sometimes mild clinical disease or a subtle “imperfection” is present.

  • Expected results of diagnostic studies

Biopsy of normal appearing "affected skin" or distressing skin lesion typically reveals normal skin or a benign neoplasm.

  • Diagnosis confirmation

Consider obsessive compulsive disorder, evolving subclinical primary dermatologic lesion, borderline personality disorder, narcissistic personality disorder, delusional disorder. None are mutually exclusive. Degree of distress and extent of preoccupation with symptom or skin "imperfection" is strongly suggestive. Comorbid psychiatric conditions make treatment more challenging.

Who is at Risk for Developing this Disease?

Persons at risk for BDD have any or all of the following:

- Biological relatives with body dysmorphic disorder

- Low self-esteem

- Oversensitivity to societal images and expectations of beauty

- Concomitant psychiatric disorder, such as anxiety, obsessive compulsive disorder, or depression

- History of childhood teasing or taunting

What is the Cause of the Disease?

  • Etiology Unknown

  • Pathophysiology

BDD is often a severe and disabling condition. A combination of dysfunctions in frontal-subcortical circuits, temporal, parietal, and limbic structures, and possibly involving hemispheric imbalances in information processing, may produce both the characteristic symptoms and neurocognitive deficits seen in BDD.

Systemic Implications and Complications

BDD patients are at high risk for attempted and completed suicide. Some studies suggest 25% of patients with BDD attempt suicide.

BDD patients are probably at higher risk for medical and surgical complications owing to the increased number and aggressiveness of procedures sought to "fix their imperfection." Up to 25% of patients with anorexia nervosa meet criteria for BDD. The presence of anorexia worsens the prognosis.

Treatment Options

PROVIDE PSYCHOEDUCATION ABOUT BDD

- Empathize with their degree of distress by telling them that you are concerned about how much of their time, energy, and happiness are being usurped by their symptom or complaint.

- Suggest that the intensity of the emotional attachment may indicate a body image disorder.

- Validate that their concerns are important to you. Dismissive or disparaging comments can be potentially devastating for the patient, potentially increasing the risk for suicide.

- Psychiatric referral is preferable but not always feasible.

- Euphemisms for psychiatrist or psychologist that de-emphasize mental illness such as "skin-emotion specialist" may increase the likelihood of patient acceptance.

- Consider recommending mental health professional supervised support groups.

- Advise caution regarding information and recommendations from on-line sources and groups.

OTHER NONPHARMACOLOGIC TREATMENTS

Cognitive-behavioral psychotherapy: Only psychotherapeutic intervention proven to help the patient reduce the frequency, severity, and intrusiveness of symptoms. These are active, "here and now" reality-based interventions with reasonably good efficacy for the majority of treated patients.

PHARMACOLOGIC TREATMENTS

Serotonin selective reuptake inhibitors (SSRIs) are most effective. Serotonin and norepinephrine reuptake inhibitors (SNRIs) may also be effective. No single agent is proven superior. All SSRIs and SNRIs carry a theoretical risk for mania and increased risk of suicidality. Both are helpful for obsessive preoccupations, depressive symptoms, anxiety, and repetitive behaviors (ie, picking).

SSRIs: Fluoxetine (Prozac) 20 to 60 mg daily, sertraline (Zoloft) 50 to 150 mg daily, paroxetine (Paxil) 10 to 60 mg daily, or escitalopram (Lexapro) 10 mg daily.

SNRIs: Venlafaxine (Effexor) 150 mg XR daily, duloxetine (Cymbalta) 60 mg daily.

Nonbenzodiazepine agent buspirone 5 to 10 mg twice a day may augment the effectiveness of SSRI or SNRI. Consider low-dose beta blocker (ie, propranolol 20 mg twice a day) for an additional anxiolytic effect if not contraindicated. Atypical antipsychotics (ie, olanzapine 2.5 to 5 mg daily, risperidal 0.5 to 2 mg daily may be considered for severe refractory disease. Atypical antipsychotics carry the risk of tardive dyskinesia and altered glucose metabolism.

SURGICAL-PROCEDURAL

If at all possible, avoid any cosmetic interventions. The BDD patient will almost invariably be dissatisfied with the result, and they may worsen the disorder and possibly increase liability and other risks to the clinician.

Optimal Therapeutic Approach for this Disease

- Identify the patient early, before cosmetic or any other medical-surgical procedure is performed.

- Avoid cosmetic procedures!

- Initiate psychiatric referral or pharmacologic treatment as soon as possible.

- Increase dosage of SSRI or SNRI every 3 to 6 weeks as needed. Add additional oral agents as necessary.

- Severe cases may require anti-psychotic medications and psychiatric hospitalization if there is active suicidal ideation, self-destructive behavior, or a suicide attempt.

Patient Management

- Ideally, share management of patient with a mental health professional.

- Maintain vigilance for increased depressive symptoms or emergence of aggressive impulses directed toward self or others (suicidal or homicidal ideation or intent).

- Observe for positive response to treatment as manifested by decreased obsession and preoccupation with identified concern.

- Mandatory psychiatric referral if evidence of deteriorating functional state.

- Medications should be continued for minimum of 6 months after improvement in symptoms. May need continuous treatment to avoid relapse.

- If patient is a minor, educating parents is important to facilitate treatment and avoid cosmetic procedures.

Unusual Clinical Scenarios to Consider in Patient Management

If a patient presents with severe BDD symptoms, extensive skin excoriation with obvious scarring, the degree of clinical suspicion should be high for an active suicide risk. This patient needs an emergent psychiatric referral and/or family notification of the perceived imminent risk.

What is the Evidence?

"Body dysmorphic disorder. The Merck Manuals: The Merck Manual for Healthcare Professionals".

(Provides succinct description of BDD.)

Ford, CV, Ebert, MH, Lossen, PT, Nurcombe, B. "Somatoform disorders". Current diagnosis and treatment: Psychiatry. McGrawHill. 2008.

(Provides context of BDD among other somatoform disorders.)

"Body dysmorphic disorder". Diagnostic and statistical manual of mental disorders DSM-V- 5th ed. American Psychiatric Association. 2013.

(Provides strict American Psychiatric Association criteria for diagnosis.)

Feusner, JD, Yaryura-Tobias, J, Saxena, S. "The pathophysiology of body dysmorphic disorder". Body Image. vol. 1. 2008. pp. 3-12.

(This article reviews many aspects of the pathophysiology in which the authors developed a tentative model of the neuroanatomy and pathophysiology of BDD.)

Conrado, LA. "Body dysmorphic disorder among dermatologic patients: Prevalence and clinical features". J Am Acad Dermatol. vol. 63. 2010. pp. 235.

(This study looked at the prevalence of BDD in cosmetic patients [14%], general [6.7%] and control group [2%]. They discuss the clinical characteristics of patients with BDD to allow providers to refer these patients to mental health professionals.)

Fiora, P, Giannetti, LM. "Body dysmorphic disorder: A complex and polymorphic affection". Neuropsychiatric Dis Treat. vol. 5. 2009. pp. 477.

(Supports effectiveness of cognitive behavioral psychotherapy.)

Phillips, KA, Didie, ER, Feusner, J, Wilhelm, S. "Body dysmorphic disorder: Treating an underrecognized disorder". Am J Psych. vol. 9. 2008. pp. 165.

(Article reviews the diagnosis and treatment of BDD including pharmacologic and cognitive behavior therapy. It also includes useful charts with questions to help aid in the diagnosis of BDD.)

Wilhelm, S, Phillips, KA. "Modular cognitive behavior therapy for body dysmorphic disorder". Behav Ther. vol. 42. 2011. pp. 624-633.

(Additional recent evidence for efficacy of CBT for treatment of BDD.)

Prazeres, AM. "Cognitive-behavioral therapy for body dysmorphic disorder: a review of its efficacy". Neuropsychiatr Dis Treat. vol. 9. 2013. pp. 307-16.

(Substantiates efficacy of cognitive-behavioral treatments of BDD, superior to SSRI’s in some studies.)

Phillips, KA. "An open study of buspirone augmentation of serotonin selective reuptake inhibitors in body dysmorphic disorder". Psychopharmacol Bull. vol. 32. 1996. pp. 175-80.

(Thirteen patients without improvement of BDD symptoms on SSRI; 46% improved with addition of buspirone.)

Fried, RG, Lebwohl, Heymann. "Dermatologic non-disease". Treatment of skin disease: Comprehensive therapeutic strategies. 2009. pp. 177.

(Review of diagnosis and evidence-based treatments.)

Ipser, JC, Sander, C, Stein, DJ. "Pharmacotherapy and psychotherapy for bodydysmorphic disorder (Review)". Cochrane Database of Systematic Reviews. 2009. pp. CD005332.

(Review of available treatments.)

Mufaddel, A, Osman, O, Almugaddam, F, Jafferany, M. "A review of body dysmorphic disorder and its presentation in different clinical settings". Prim Care Companion CNS Disor. vol. 15. 2013. pp. PCC.12r01464.

Veale, D, Bewley, A. "Body dysmorphic disorder". BMJ. vol. 350. 2015. pp. h2278.

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