Body dysmorphic disease (dermatologic nondisease): Synonyms: body dysmorphic disorder, dysmorphophobia (not good as the condition is not a ‘phobia’), dermatological nondisease (not good as it is not particularly accurate)

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Body dysmorphic disease (dermatologic nondisease)

Synonyms: body dysmorphic disorder, dysmorphophobia (not good as the condition is not a ‘phobia’), dermatological nondisease (not good as it is not particularly accurate)

Anthony Bewley

Evidence Levels:  A Double-blind study  B Clinical trial ≥ 20 subjects  C Clinical trial < 20 subjects  D Series ≥ 5 subjects  E Anecdotal case reports

Body dysmorphic disorder (BDD) is characterized by a preoccupation with an imagined defect in physical appearance, or if there is a slight physical anomaly, concern is out of proportion to the anomaly. There is a spectrum from patients with overvalued ideas to those whose beliefs are held with delusional conviction. The prevalence of BDD is surprisingly common, occurring 1–2% in of the general population; the average age at onset is late adolescence. There is a high degree of comorbidity with mood disorders, obsessive compulsive disorder, and social phobia. These are a very difficult group of patients to treat, one of the main obstacles being that most patients lack insight and will not accept psychiatric treatment or referral. They are therefore best seen in a joint psychodermatology clinic where they can be supported, and gradually encouraged to accept psychological interventions. Their help-seeking behavior should also be contained as they may repeatedly try to consult other dermatologists or plastic surgeons.

Preoccupations commonly involve the face and head, the skin and hair being the most frequent areas of concern, but any area of the body can be affected. Dermatologic preoccupations are distressing, time-consuming, and difficult or impossible for patients to resist. Insight is typically poor, and alterations in perception often reach delusional proportions. Most patients have ideas of reference, thinking that others take special notice or mock them for their perceived defect. Repetitive behaviors are present in almost all patients: excessive checking or grooming, constant need for reassurance, and skin picking are common. The risk of suicide is high, with approximately one-quarter of patients attempting suicide.

Management strategy

BDD is common in dermatologic settings, especially in dermatological surgery where the prevalence is estimated at 11.9%. In aesthetic surgery and laser suites the prevalence may be as high as 25–30% of patients, and so identification of these patients is extremely important, as they typically have a poor response to cosmetic dermatological treatments. Dissatisfaction, anger, and even aggression toward the treating dermatologist are known. Patients with BDD may have underlying psychiatric disorders, including depression, alcohol and other recreational substance abuse and obsessive–compulsive disorder.

Body areas on which patients with BDD may focus:

Patients presenting with extreme concern that appears out of proportion to their chief complaint, accompanied by a paucity of objective physical findings, should raise suspicion that dermatologic nondisease may be present. Obsession, rumination, and extreme psychological distress are striking features. These patients usually report dissatisfaction with previous physicians and describe poor outcomes from past medical and surgical interventions. Skin picking and related behaviors such as excessive grooming, and relentless need for reassurance are characteristic. Attempts at reassurance are inevitably futile, as their perceptions are at least fixed, and in some cases, delusional, which by definition suggests that the distorted perceptions are unresponsive to logic and persuasion. The frequent presence of referential thinking further substantiates the delusional nature of the perceptions. Patients often wear heavy makeup and hats to hide their imperfections and perceived ugliness. Patients with BDD make unusual and excessive requests for cosmetic procedures in the belief that they will transform or fix their lives. Clinical interactions and consultations with these patients are typically long, difficult, and emotionally draining.

In the management of patients with BDD, appropriate treatment of any actual skin disease should not be overlooked. Selective serotonin reuptake inhibitors are first-line therapies, and can be administered in conjunction with cognitive behavioral therapy. If patients fail to respond and the disorder is severe, or where there is delusional BDD, antipsychotics may be a second line alternative (though the evidence for the successful usage in these circumstances is anecdotal).

Specific investigations

A screening questionnaire for body dysmorphic disorder in a cosmetic dermatologic surgery practice.

Dufresne Jr RG, Phillips KA, Vittorio CC, Wilkel CS. Dermatol Surg 2001; 27:457–62.

The Body Dysmorphic Disorder questionnaire is an alternative screening tool for BDD.

It is important to have a series of screening questions to ascertain if BDD is an issue for patients (Table 30.1).

image

(Adapted from Veale D, Ellison N, Werner TG, et al. Development of a cosmetic procedure screening questionnaire (COPSs) for body dysmorphic disorder. J Plast Reconstr Aesthet Surg 2012;65(4): 530–532.)

First-line therapies

image Treatment of the skin A
image Selective serotonin reuptake inhibitors A
image Cognitive behavioral therapy B

Obsessive-compulsive disorder: Core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder.

National Institute of Health and Clinical Excellence (NICE). Clinical guideline no 31, 2005. London: NICE.

It is very important in all areas of psychodermatology to treat the skin and the underlying psychiatric disease. Appropriate management of skin changes is important to both engage the patient and also to manage any skin changes appropriately. This may mean appropriate management of hair loss, or appropriate management of genuine skin disease (such as acne). It DOES NOT mean offering inappropriate treatment, and especially inappropriate aesthetic treatments such as laser treatments and cosmetic peels where little skin change is evidenced and where patient’s preoccupation with skin changes seems excessive (see screening tools above).

A randomized placebo-controlled trial of fluoxetine in body dysmorphic disorder.

Phillips KA, Albertini RS, Rasmussen SA. Arch Gen Psychiatry 2002; 59: 381–8.

Selective serotonin reuptake inhibitors (SSRIs) and cognitive behavioral psychotherapy are the treatments of choice. Fluoxetine, fluvoxamine, and citalopram are the best-studied SSRI agents, but recent evidence suggests that all SSRIs are probably effective. Higher dosing regimens than those used for depression are usually required. Patients should receive a trial of 12–16 weeks before efficacy is assessed. If one agent fails another should be substituted, as some patients idiosyncratically respond more favorably to one agent over another. Interestingly, SSRIs appear to be more effective than antipsychotic agents, despite the fact that BDD may sometimes be a delusional disorder. Only about 20% of delusional BDD patients will become free of their delusional thinking with SSRIs however. But, in delusional patients with BDD, the intrusiveness of the thoughts and distress will diminish sufficiently, such that many patients will be able to resume some social and vocational functioning.

Cognitive behavioural body image therapy for BDD.

Rosen JC, Reiter J, Orosan P. J Consult Clin Psychol 1995; 63: 263–9.

Cognitive behavioral therapy (CBT) is a reality-based, in-the-present therapy that focuses specifically on the symptoms of dermatologic nondisease. The key elements are known as exposure, response prevention, and cognitive restructuring. Exposure consists of having patients expose the perceived defect in social situations. Response prevention consists of helping patients avoid their repetitive behaviors. Cognitive restructuring helps patients change their erroneous beliefs about their appearance and the importance they attribute to it. Ideally, treatment of dermatologic nondisease should encompass both CBT and an SSRI. To initiate treatment or referral, suggest to the patient in a gentle manner that they may have a body image disorder called body dysmorphic disorder. Convey your concern regarding the amount of their time being usurped by their preoccupation and their emotional distress. Psychodermatology (dermatology clinics specializing in psycho-cutaneous medicine) referral is preferable, but often not feasible. Dermatologists are encouraged to align themselves if possible with mental health professionals who are experienced in treating this entity. If referral is not possible, treatment with an SSRI may be successful. If suicidal ideation or intent is present, immediate hospitalization is recommended.

CBT may be used in conjunction with SSRIs or independently of SSRIs. CBT has been shown to be effective in the management of patients with BDD, but trials are often open-labeled or uncontrolled. There are a few randomized-controlled clinical trials which clearly demonstrate the benefit of CBT, though the numbers of patients in these trials is small. Also there are various CBT techniques which can be used in the management of CBT, though there are no trials comparing the different CBT techniques in a randomized controlled clinical setting.

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