Body Dysmorphic Disorder and Eating Disorders
Volume 6, Issue 3
Eileen Adams, MS, LMSW
Marian C. Eberly, RN, MSW, LCSW, DAPA
Kevin Wandler, MD
Yong Lee, MD
Remuda Ranch Programs for Eating Disorders
[F]ix your attention on God. You'll be changed from the inside out… Unlike the culture around you, always dragging you down to its level…, God brings the best out of you... (Romans 12:2, The Message)
Although it may seem that body dysmorphic disorder (BDD) exists primarily in modern Western societies, it has been documented since the 1800s worldwide. In 1987, BDD entered the DSM as a somatoform disorder.
BDD can co-occur with eating disorders (ED). When it does, it can be difficult to detect since presenting symptoms overlap with EDs as well as with ED’s common comorbidities of obsessive compulsive disorder (OCD), social phobia, and major depression (Arthur & Monnell, 2005; Phillips, 2005). As such, for correct diagnosis and treatment ED professionals will benefit from understanding the differentiating features of BDD.
Powerful cognitive distortions regarding one’s appearance are a key feature of BDD. BDD patients are preoccupied with imagined or slight defects in their appearance—defects that are minimal or undetectable to others. BDD patients thus struggle with others’ lack of reaction to their perceived defects. Patients’ time consuming and profound obsessions with their perceived defects are intrusive, unwanted, ego-dystonic, potentially disabling, and of near delusional intensity. Yet patients consider their perceptions to be completely rational. The term overvalued ideation describes the high value patients place on their beliefs, arising from their strong feelings about their perceived defects—feelings that eclipse rational cognitive insight (Neziroglu, Roberts, & Yaryura-Tobias, 2004).
Compulsive reassurance behaviors such as frequent appearance checks in mirrors or reflective surfaces typify some, whereas other sufferers eschew their image at all costs, covering mirrors and going out of their way to avoid their reflection. Patients can spend excessive time and money on grooming rituals, special lighting, and magnifying mirrors. They commonly wear clothing that covers perceived imperfections or camouflages the body. Such camouflaging usually offers little relief, so patients often end up isolating themselves or becoming housebound. This can impact major areas of psychosocial functioning (Neziroglu et al., 2004). Some even quit school or lose jobs.
BDD often begins in adolescence. Sub-clinical BDD can start as young as age 12 (Neziroglu et al., 2004). Onset can be gradual or abrupt. Because of normal developmental increases in appearance concerns during adolescence, clinicians must gain skills to discern the excessive preoccupations characteristic of BDD. Importantly, BDD symptoms interfere with normal adolescent development, such as self-esteem and peer relations (Phillips, Didie, Menard, Pagano, Fay, & Weisberg, 2006).
BDD patients feel much shame about their perceived defects and associated behaviors. Secrecy is therefore common, complicating clinicians’ ability to recognize and diagnose BDD (Neziroglu et al., 2004). While symptom-free periods are rare, symptom intensity may ebb and flow. When one imagined defect is resolved, focus may change or switch to another body part. With fluctuations in symptom intensity and focal body part, BDD often goes undiagnosed for years.
BDD can lead to suicide. Suicidal ideation and attempts in BDD adolescents may be five times greater than in US adolescents in general; half the adults with BDD may have suicidal ideation and 12% make suicide gestures (Phillips et al., 2006). Up to 29% of BDD patients actually attempt suicide, with suicide risk highest in BDD women with perceived facial defects (Arthur & Monnell, 2005). Because BDD patients are at high risk for suicide, BDD evaluations always include thorough suicide assessments.
BDD is evenly distributed among males and females (Phillips, McElroy, Hudson, & Pope, 1995). In community samples, BDD prevalence ranges from 0.7% to 1.1%, with highest prevalence, 2%-13%, in non-clinical student samples. BDD occurs in 13% of psychiatric inpatients (Phillips, Menard, Fay, & Weisberg, 2005). Typically, BDD patients are unmarried, have few friends, and suffer personally, professionally, and educationally as the disorder takes over their lives (Arthur & Monnell, 2005).
Many BDD patients seek dermatological and surgical interventions. More than 12% of BDD patients are diagnosed in dermatology settings (Phillips et al., 2005). Nearly 15% of cosmetic surgery patients have BDD (Phillips et al., 2005). When multiple surgeries result in disfigurement, patients’ obsessions usually worsen.
BDD etiology is unknown. Heredity may play a role as lifetime BDD occurs four to eight times more often in BDD families. Perceptual and emotional information processing research suggests abnormalities in executive functioning, emotion recognition, and visual self-perception. Serotonin may play a role in modulating BDD behaviors (Saxena & Feusner, 2006).
Many BDD sufferers report being positively reinforced for their appearance throughout childhood. Others recall public humiliation. Significant traumatic events such as sexual assault, sexual harassment, public failure in athletics or dance, physical injury or illness, and teasing about appearance may trigger negative thoughts and shame regarding appearance and self-worth (Cororve & Gleaves, 2001). Family and personal experiences that result in feeling unloved, insecure, and rejected are also BDD risk factors. Influences from media and culture strengthen beliefs that worth and acceptability come primarily from physical beauty.
Recent research suggests that 79% of BDD patients have histories of childhood abuse and neglect (Didie, Tortolani, Pope, Menarda, Fay, & Phillips, 2006): 68% emotional neglect, 56% emotional abuse, 35% physical abuse, 33% physical neglect, and 28% sexual abuse. Abuse severity was high. History of sexual abuse also increases BDD severity.
BDD has similar psychiatric comorbidities to ED. Depression occurs frequently with both disorders and considerably more so than in the general population (Phillips, 2005; Kessler, Wai, Demler, & Walters, 2005; Wall, Eberly, & Wandler, 2007). Phillips et al. (2005) report that 75% of BDD patients in their study have comorbid depression. For ED patients, the figure can run as high as 98% (Wall & Cumella, 2006).
The obsessive and sometimes compulsive nature of BDD intuitively groups this disorder with OCD. The similarities are so numerous that experts are debating its classification as an obsessive-compulsive spectrum disorder (Phillips et al., 1995; Hollander, 2006). Up to 39% of BDD sufferers have comorbid OCD (Phillips et al., 2005). OCD and obsessional personality characteristics also occur in 11% to 69% of women with anorexia (Pearlstein, 2002). For both BDD and ED, then, lifetime prevalence of OCD is much higher than the 1.6% found in the general population (Kessler et al, 2005).
In one study, 40% of BDD patients met criteria for social phobia (Phillips et al., 2005). In ED patients, comorbid social phobia is also common, at 50% to 55% (Pearlstein, 2002). Similar clinical features exist between BDD and social phobia, such as social avoidance, feeling embarrassed and defective, and fearing public ridicule (Coles, et al., 2006). Due to the high comorbidity and clinical similarities, experts suggest routine BDD screening for patients with social phobia (Veale, et al, 1996, as cited in Coles, et al., 2006).
Diagnostic Issues
Both BDD and EDs include body image distortion and dissatisfaction as core symptoms. BDD diagnostic criteria instruct clinicians to diagnose an ED if body concerns are limited to “fatness” (American Psychiatric Association, 2000). However, some individuals have both concerns about their weight and shape—meeting ED criteria—and additional appearance concerns such that they indeed have co-occurring BDD. Studies suggest that there may be many more individuals with both disorders than once thought. Of patients with EDs, as much as 39% may have co-occurring BDD (Grant, Won Kim, & Eckert, 2002). In one study, 81% of teens with anorexia reported that BDD, not ED, was their “biggest or major problem” (Ruffolo et al., 2006). For 63%, BDD preceded ED onset. Of those with BDD, 33% may have comorbid lifetime ED—9% anorexia nervosa, 6.5% bulimia nervosa, and 17.5% ED not otherwise specified (Ruffolo, Phillips, Menard, Fay, & Weisberg, 2006).
To diagnose BDD, its DSM-IV-TR criteria cannot be better accounted for by another mental disorder, such as an ED. The similarities between ED and BDD can make assessment difficult. Both typically begin in adolescence and have a similar illness course. In addition to body image focus, both entail compulsive behaviors, such as strict diets, mirror checking, or body measuring. BDD sufferers can also be preoccupied with body areas that are characteristically seen as ED specific, such as stomach, hips, or thighs (Phillips, 2005).
Both ED and BDD patients typically do not see themselves as others do. Those emaciated with anorexia contend they look normal or overweight, whereas BDD sufferers contend their appearance is defective. Katharine Phillips, in The Broken Mirror, describes those with anorexia camouflaging with bulky clothing to stop others from discovering their thinness. BDD individuals also wear bulky clothing out of shame and to avoid subjecting others to their perceived hideous defect (Phillips, 2005).
If the only obsession is overall body weight, then the person likely does not have BDD. In BDD, there is a specific body part that is targeted as defective. BDD sufferers focus, in order of descending frequency, on their skin, hair, nose, stomach, teeth, weight, breasts, buttocks, eyes, thighs, eyebrows, overall appearance of face, legs, face size or shape, chin, lips, arms, hips, cheeks, and ears (Phillips et al., 2005). BDD can also involve a specific obsession known as muscle dysmorphia. Muscle dysmorphic individuals, typically men, believe they are too small and can never gain enough muscle. Some refer to this condition as “reverse anorexia,” yet it can be conceptualized as a form of BDD (Phillips, 2005).
Although the list of BDD foci includes body image concerns seen in EDs, the majority of foci are clearly not ED related. This long list is included here to demonstrate the idiosyncratic nature of BDD obsessions and to encourage clinicians to assess thoroughly when questioning patients’ body concerns. BDD sufferers feel profound shame for being obsessed with these body parts, shame that can prevent BDD patients from verbalizing their issues in treatment. BDD assessment tools can therefore assist in clarifying the diagnostic picture.
Assessment
Phillips (2005) has developed the Body Dysmorphic Disorder Self-Questionnaire (BDDQ) as a self-report screening tool. She provides versions for adolescents and adults. Consisting of four questions, it allows patients to reflect and write their answers without the stress of clinician presence. Since self-reports do not typically tell the whole story, this screen is best followed by an interview, especially if the person seems to be endorsing BDD symptoms.
The Structured Clinical Interview for the DSM (SCID) is a widely used assessment tool for psychiatric disorders. The SCID is administered by clinicians and detects criteria for each disorder. Phillips (2005) has developed a diagnostic module for BDD using SCID format, with different versions for adolescents and adults. The questions explore being worried about one’s appearance, preoccupation with appearance, and the effect preoccupation has had on the patient and patient’s family or friends. Clinicians also assess whether body preoccupation is solely about size and shape. If it is, the patient does not have BDD, but may have an ED. Some patients have shape and size concerns along with other body appearance issues, which could indicate the presence of both ED and BDD.
In addition to SCID results, other behavioral and cognitive characteristics of BDD can be useful to explore. Direct questions about the use of mirrors, time spent grooming, grooming rituals, or money spent on grooming can increase the patient’s awareness of the level of preoccupation and provide more data for diagnosis and treatment. Direct questions are also warranted about the following areas: use of hats, coats, makeup, or sunglasses; frequent changing of clothes to find the perfect camouflage outfit; sitting or standing a particular way or in a certain light to hide aspects of one’s appearance; frequent tardiness due to grooming, avoidance of social situations, or not leaving the house; frequent body measuring for size or symmetry; excessive exercise or dieting; reassurance seeking; frequent comparing of self to others; believing others, even strangers, are noticing or staring at the defect; depression, anxiety, panic attacks, and suicidal thoughts because of one’s appearance (Phillips, 2005).
Several of these behaviors are common to ED individuals as well, such as frequent body measuring, excessive exercise, and dieting. The important difference rests on the focus and goal of the behaviors. Are patients trying to become smaller (ED), and dieting, exercising, and measuring to that end? Or do patients believe their face is too wide and the dieting, exercise, and measuring are focusing on this instead (BDD)? Are patients attempting to look perfect (ED) or just normal (BDD)? The level of preoccupation, life interference, and the goals of the behaviors further help clinicians separate behaviors connected to an ED from concerns that are not part of an ED.
The similarities between BDD and OCD suggest that similar assessment tools may be effective. Similarities include obsessional thoughts that are interfering and difficult to control, and repeating behaviors that are difficult to stop. Although not part of the diagnostic criteria for BDD, studies suggest compulsions constitute part of BDD for more than 90% of sufferers (Phillips, Hollander, Rasmussen, Aronowitz, DeCaria, & Goodman, 1997). As such, the Yale-Brown Obsessive Compulsive Scale (YBOCS) was modified for BDD assessment (Phillips et al. 2005).
The BDD-YBOCS has been used as the primary outcome measure in most BDD treatment studies (Phillips, 2005, p.381). The test is a semi-structured interview allowing for further probing and discussion by the clinician. Because the BDD-YBOCS measures severity rather than strictly being a differential diagnostic tool, instructions indicate that clinicians must first be fairly certain the person has BDD and know which body parts are the foci. The SCID for BDD and the BDDQ can provide this background information. Then, the BDD-YBOCS can yield valuable information about obsessions, compulsions, insight, avoidance, and BDD severity (Ruffolo et al., 2006).
Presence of overvalued ideation predicts treatment outcome and informs the choice of pharmacological interventions. The clinician administered Overvalued Ideas Scale, OVIS (Neziroglu, McKay, Yaryura-Tobias, Stevens, & Todaro, 1999), has shown reliability and validity with OCD. Items address various aspects of the patient’s beliefs, such as strength, reasonableness, accuracy, extent of adherence by others, effectiveness of compulsions, insight, and belief duration. Clinicians may also administer the Brown Assessment of Beliefs Scale (BABS; Eisen, Phillips, Baer, Beer, Atala, & Rasmussen, 1998). It measures insight, assessing delusions across many psychiatric disorders, including BDD. By measuring delusionality, clinicians can identify how it might impact interventions, outcome, and prognosis (Eisen et al., 1998).
Of particular importance in assessing BDD is taking a thorough history of surgeries. Patterns may emerge that provide important diagnostic validation or discrimination for BDD, as well as its course.
For patients with co-occurring ED, a measurement tool which addresses both BDD criteria and other body image concerns is useful. The Body Dysmorphic Disorder Examination (BDDE) is a semi-structured interview designed to diagnose BDD and to measure symptoms of severely negative body image (Rosen & Reiter, 1996, p. 755). Rather than a screen, the authors suggest the BDDE be used to identify treatment goals by providing a detailed assessment and description of BDD symptoms. They developed the tool as clinician administered to help patients clarify their body image beliefs and thus identify what is BDD focused and what is not. In addition, the tool has been found to be reliable and valid for use with ED patients. Therefore, despite its 30 minute length, it has the potential to provide clinicians with valuable treatment information for intervening in BDD and EDs.
Diagnosing BDD in adolescents deserves special note. The difficulty with assessing BDD in adolescents is the normal, yet often drastic, increase in appearance concerns occurring during the teenage years. Because of this normative increase in appearance concerns, BDD is likely underdiagnosed in adolescents. Yet it is important to recognize the symptoms of increased and obsessional appearance focus early and establish treatment. Careful assessment of comorbid BDD in ED supports positive outcomes.
Phillips (2005) notes that developmental changes in the adolescent brain may contribute to the adolescent onset of this disorder. These changes increase adolescents’ self-consciousness and awareness of social status. Therefore, BDD may be a disordered response to the psychological, social, and physical changes of adolescence itself (Phillips, 2005). The clinician must tease out normative increased adolescent concerns from BDD concerns. To assist, the BDDQ and BDD SCID diagnostic module have adolescent versions. Phillips (2005) further suggests the same guidelines used for adults: Appearance concerns must be consuming and cause significant emotional distress or interfere with functioning; they must also be negative and focused on an “imagined defect” or “slight anomaly” (American Psychiatric Association, 2000). Phillips (2005) encourages clinicians to particularly consider the adolescents’ impairment in functioning. One must remember to translate the difficulties into the teen’s world experience. Adult job impairment and remaining housebound may become for the adolescent missing school, avoiding dates, or dropping out of extracurricular activities. Social isolation due to BDD could manifest itself through an increase in instant messaging, phone, or email use along with reduction of in-person social connections. It is vital not to dismiss these changes, or minimize them as normal adolescent behavior. By focusing on impairment, one can judge better if the extended time in the bathroom signals BDD or a normative increase in appearance concerns.
BDD Treatment
Since BDD is a chronic condition, patients who suffer from BDD need regular, long-term follow-up with their psychiatrists and therapists. Patients benefit from a collaborative treatment team approach. The importance of the treatment team cannot be underestimated. When treating BDD, it is essential to establish trust and rapport (Phillips, January, 2002). Patients must believe their treatment providers understand their condition and take their BDD seriously. They will typically not be responsive to reassurances that they look fine or that the problem is in their imagination. Patients need to be educated about BDD and reassured that it is a well-documented disorder that has known treatments. Establishing patient rapport in this manner is important to maintain treatment compliance over the long-term. Within six months of discontinuing treatment, 53% of patients with BDD relapse (Arthur & Monnell, 2005). Drop out and relapse are often related to lack of follow through or lack of connection with the treatment team.
The obsessive-compulsive nature of BDD intuitively suggests that treatments for OCD can be applied to BDD. Indeed, published practice guidelines for OCD include recommendations for treating BDD.
Practice Guidelines
The only published practice guideline addressing BDD, Obsessive-compulsive disorder: Core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder (2006), comes from the National Collaborating Centre for Mental Health in London. This guideline recommends the Stepped Care Model, where interventions begin with the least intrusive approach and progress to the most intensive as needed. Steps one through five are directed toward outpatient settings; step six addresses inpatient treatment.
Step 1. Awareness and recognition should address the shame which often keeps patients silent about their distress. Emphasize the involuntary nature of their behaviors and a biological and psychological understanding of BDD.
Step 2. Recognition and assessment focuses on detection, targeted education, establishing a treatment plan, and development of a support network for patient and family. Detailed assessment occurs when patients have particular BDD risk factors, such as social phobia, OCD, an ED, or seek dermatological or surgical interventions for minor blemishes. For confirmed BDD diagnoses, Stage 2 emphasizes assessment for suicide risk, self-harm, and other common comorbid conditions.
Step 3. Management and initial treatment focuses on psychological interventions for symptom reduction. Clinical judgment aids in assessing the level of impairment and appropriateness of interventions suggested. For adults, interventions include individual or group cognitive-behavioral therapy (CBT), exposure with response prevention (ERP), medication such as a selective serotonin reuptake inhibitor (SSRI), or a combination of these treatments. Involving family in treatment should be considered. For children and adolescents, CBT is recommended with family and school involvement.
Step 4. Addresses comorbidity and complicating factors affecting successful outcomes in previous stages. For adults, CBT with ERP is again recommended, combined with an SSRI or alternate medication if one has already been prescribed.
Step 5. Addresses care of patients with very complicated comorbidities, severe functional impairment, and treatment resistance. Those individuals who show only partial responses at previous levels or who have relapsed are appropriate for Step 5. Interventions are the same as Step 4, but a team specializing in BDD is now needed to replace or supplement the initial providers.
Step 6. Encourages inpatient care or intensive treatment programs. These patients’ lives are at risk, as they present with much distress and severe self-neglect. Inpatient treatment programs specializing in BDD generally combine all of the practices mentioned above, with additional intensity and optional modalities.
Psychotherapy
Clearly, practice standards suggest CBT as the treatment of choice for BDD in order to change obsessive thinking patterns and learn alternative coping skills (Massachusetts General Hospital, 2005). If BDD is relatively mild, CBT alone may be a reasonable first-line treatment. CBT is effective in both individual and group formats for therapies such as psychoeducation, self-monitoring, ERP, relaxation training, and relapse prevention (Sarwer, Gibbons, Crerand 2004). It has been shown that a majority of people with BDD respond positively to CBT (Phillips, 2005, p. 212). The National Institute for Health and Clinical Excellence in the United Kingdom identifies both psychopharmacology and cognitive-behavioral therapy as efficacious treatments for BDD (National Collaborating Centre for Mental Health, 2006). It is, however, not yet known whether CBT is more or equally effective to SSRIs.
BDD psychoeducation allows patients to break the silence and may help diminish a sense of isolation. Patients learn to recognize the ineffectiveness of their compulsive behaviors to permanently relieve anxiety and shame. Through self-monitoring activities and assignments patients learn to identify irrational thoughts and related compulsive behaviors.
CBT involves challenging negative thoughts for their validity and accuracy and restructuring new rational beliefs. In BDD, when cognitive interventions precede behavioral interventions, outcomes typically are better. In addition to mitigating compulsive symptoms, CBT has demonstrated efficacy in reducing depressive symptoms, increasing insight, and improving overall body image (Phillips, 2005).
ERP begins with developing a fear hierarchy of difficult situations for which the patient would typically use a compulsive response to reduce fear (Allen, 2006). Habituation teaches sufferers that fear will eventually diminish, and may even be extinguished, without performing ritualistic behaviors. This process is often long and arduous but can produce excellent results. Establishing a hierarchy, being honest with self about rituals, and diligent self-monitoring are keys to successful treatment plans.
Mild to severe isolation is common to BDD and must be addressed in the treatment plan. Activity scheduling confronts isolation and challenges cognitive distortions that underlie isolative behaviors. As insight improves, patients consciously schedule activities that also qualify as exposure interventions, such as going out in public without makeup (Massachusetts General Hospital, 2005).
Mirror retraining directly confronts BDD sufferers’ selective attention. This process of over-focusing or over-attending to one area to the exclusion of other body parts hampers patient ability to keep the defect in perspective. The body part is over-emphasized and the reaction becomes extremely negative (Phillips, 2005). Some patients narrow their focus so intently that they can actually see the body part change in the moment (Phillips, 2005). Although some research suggests that selective attention in BDD may have a neuropsychological basis (Feusner, Granet, & Winograd, 2006 August; Phillips, 2005), behavioral interventions for selective attention seem effective in reducing symptoms and improving functioning. For example, patients seem to benefit from learning to stand an arm’s length from the mirror and from reducing the number of mirror checks they perform throughout the day (Feusner, Winograd, & Saxena, 2005).
Research shows several alternative interventions to be ineffective in treating BDD: supportive or insight oriented therapy, natural remedies, diet, hypnosis, reassurance, and uncovering suspected trauma. Each has been attempted without demonstrated successful outcomes (Massachusetts General Hospital, 2005). Dermatological and surgical treatments in particular are counterproductive for BDD. For example, 81% of BDD patients were dissatisfied or very dissatisfied with the results of surgery. Furthermore, 88% reported that non-psychiatric treatments for BDD defects led to no change or a worsening of the overall disorder (Phillips et al., 2005, p.323).
Psychopharmacologic Treatments
Between half and three quarters of BDD sufferers improve significantly with SSRI treatment (Phillips, 2005, p.212). Of those with BDD, 80%-90% eventually respond to one of the SSRIs. As such, psychiatric medication options should be considered for BDD, particularly when it proves to be refractory to CBT alone.
No medications have been FDA approved for treating BDD. Thus far, the most efficacious pharmacological treatment for BDD has been high-dose SSRIs, at doses similar to those used in OCD (Arthur & Monnell, 2005). The prescribing professional educates the patient about BDD and explains the costs, benefits, and alternatives to medications. Patients should be invested in treatment and be hopeful for success. In addition to communicating hope, enthusiasm, and empathy, practitioners present scientific, evidence-based information. Patients learn that they may need to use the high end of clinically effective medication dosing, which may exceed FDA-recommended dosages (Phillips, 2005). Treatment failures on psychiatric medications can often be attributed to under-dosing or an inadequate length of a medication trial.
Examples of common daily dosages used in BDD are: 40-80mg of Prozac (Fluoxetine), 40-60mg of Paxil (Paroxetine), 200mg of Zoloft (Sertraline), 60-80mg of Celexa (Citalopram), and 200-300mg of Luvox (Fluvoxamine). Phillips (2004) suggests aggressive trials with SSRIs, with rapid titrations to the maximally tolerated safe dosages as the first-line pharmacologic treatment of BDD. She suggests that these trials may take up to 16 weeks before reaching full benefit. Before positive benefits can be felt, patients may experience disturbing side effects. In some cases education about the benefits of the SSRI and direct intervention on the side effects may suffice. For other patients the side effects may be so intolerable or the benefits suboptimal that the physician will want to switch to an alternate SSRI.
Patients with BDD, on the whole, seem to tolerate the side effects of SSRIs fairly well, especially if psychiatric providers prepare them through psycho-education. Some typical side effects of SSRIs are nausea, sexual dysfunction, headaches, sedation, insomnia, and increased sweating (Stahl, 2006). Most of these side effects dissipate over time. BDD patients need to be encouraged to wait and see if these side effects eventually resolve.
If an SSRI proves to be ineffective in treating BDD or side effects prove intolerable, the next step would likely be to try another SSRI (Phillips, 2005). After multiple failed SSRI trials, the serotonin-norepinephrine reuptake inhibitors (SNRIs), such as Effexor XR (Venlafaxine) and Cymbalta (Duloxetine) are possible alternatives. SNRIs also have transient side effects similar to SSRIs. Another option is the serotonin-reuptake blocking, tricyclic antidepressant, Anafranil (Clomipramine) (Phillips, June, 2002). Anafranil can be used alone at doses of 150mg to 250mg, or as an adjunct to an SSRI. If used adjunctively, blood levels of Anafranil should be monitored to avoid toxicity and seizures. Because of weight gain and lack of tolerability in high doses, we seldom use Anafranil in Remuda’s Programs.
In cases when only a partial response is achieved, it is also reasonable to use other adjunctive medications with the SSRIs (Phillips, 2005). The use of antipsychotic medication has not been well established in BDD; however, if the thoughts associated with BDD are delusional in nature, one could add an antipsychotic, such as Risperdal (Risperidone), Abilify (Aripiprazole), Geoden (Ziprasidone), or Zyprexa (Olanzapine). Antipsychotics used alone do not seem helpful. Abilify or Geodon might be used preferentially over Risperdal or Zyprexa due to significant weight gain with the latter.
Anxiety symptoms are prominent in BDD. If they are not helped by an SSRI/SNRI with or without an antipsychotic, Buspar (Buspirone) at 30-60mg daily can be helpful to reduce their intensity. In addition, benzodiazepines, whether used for the short-term until the SSRIs take effect or for the long-term, can be helpful for agitated, severely anxious patients. The risk for dependency should be weighed against the benefits of symptomatic relief. Klonopin (Clonazepam), beginning at 0.5mg twice daily, may be an option because of its relatively long half-life and possible lesser potential for psychological and physical dependence than other benzodiazepines.
When treating children and adolescents with BDD, the same medications also work (Phillips, 2005). Special considerations involve working closely with parents to observe any untoward changes in the patient. Parents need to be warned of the possible increase in suicidal thinking that might be precipitated by the initiation of SSRI treatment. Children and adolescents need close monitoring by their psychiatric provider, initially weekly or bi-weekly until stabilized on their medications. Parents should feel free to call the psychiatric provider with any questions or concerns and take part in psychoeducation about the condition and its treatments.
Ethical Considerations
An ethical consideration of primary concern relates to proper diagnosis. Practitioners must be well informed about BDD diagnostic criteria, differential diagnosis, comorbidity, treatment guidelines, and efficacious medication regimes. BDD patients do not respond well to pat reassurances. This may give the impression that the practitioner does not take their concerns seriously or understand the depth of despair they encounter daily. Proficiency in BDD gained through specialized continuing education and supervision is therefore urged before one treats the disorder.
Patients need to be comfortable with the diagnosis of BDD. They need to know they have a clearly defined, well-documented condition that is amenable to CBT and medication treatments. It is important to emphasize that most patients with BDD get better with the appropriate course of treatment designed specifically for BDD (Phillips, 2005). Almost 75% significantly improve; of the rest, most get some relief; only a small minority do not get any better. The odds, therefore, are good that patients will improve. To increase their odds of success, treatment providers need to operate as a team, supporting each other by communicating their collaborative approach to patients and families. Teams should encourage patients to maintain treatment for the long-term, instruct them to take their medications consistently at the doses recommended and at the same time everyday, and enlist the help of family members and other interested parties when appropriate.
About half of all successfully treated patients with BDD relapse within six months after dropping out of treatment (Arthur & Monnell, 2005). Relapse prevention and ongoing care are therefore essential to ensure patients’ well-being. Relapse prevention work should be routinely built into treatment plans.
Spiritual Considerations
“May the Lord bring you into an ever deepening understanding of the love of God” (2 Thessalonians 3:5).
Spiritual issues related to BDD vary from fear and shame about body image to confusion about the nature of God. The perception of being unacceptable to others due to defective appearance carries fear and shame that can damage spirituality. It becomes easy to make assumptions that one lacks worth and value; is less than; is a distortion, if not a defective human being altogether. Conclusions may move from perceptions of the outer self to the inner self, and negative beliefs may become internalized. It is here, in this lonely, perplexing place that patients often struggle with thoughts and feelings about God.
The shame associated with BDD can create a desperate desire to hide from God and others. Isolation and feelings of shame go hand in hand. Those with BDD recognize that others do not perceive their defects as deformities. On one level they may understand that their beliefs about their appearance are irrational; on the other, they may feel misunderstood or abandoned by both God and others.
At times like this, healthcare professionals can be caught off guard. How can we help a patient struggling with the spiritual aspects of a disabling disorder? Healthcare professionals are in a strategic position to assist those searching and struggling with spiritual matters. Surveys indicate that two-thirds of Americans would like their healthcare providers to address religion with them, and half want their doctors to pray with them (Gunderson, 2000).
The healing of the spirit is essential for complete wholeness. One can heal physically and mentally and still have a broken spirit within. At Remuda, we treat the whole person, body, soul, social relations, and spirit. Some need only to be guided back gently to the arms of God. Some may need to see and experience the love of God again or for the first time through professionals who demonstrate God’s love and grace “with skin on”. Still others feel they need to ask forgiveness and experience redemption. Whatever the spiritual brokenness, we strive to guide people toward complete healing.
It is helpful to avoid debating physical imperfections and instead move to matters of the heart. Addressing patients’ innate worth and value can help to heal the broken places. BDD sufferers often believe they are inferior and unacceptable to the rest of the world. This is a great place to introduce Biblical truth. To begin, God does not view us as we view ourselves. Human beings look at the outward appearance but God looks at the heart (1 Samuel 16:7). In the Bible, we are reminded that our worth and value have nothing to do with being physically or aesthetically beautiful or perfect as defined by human beings.
Psalm 139:14, a familiar verse to those working with EDs, says: “I praise you because I am fearfully and wonderfully made: your works are wonderful.” Meditating on this truth can help heal a fragmented heart. God made us wonderful. What does that mean to those who perceive themselves as grotesque, who literally despise their bodies? What does it mean to hear that it was God who formed us? The implications this may have for the relationship with God are evident. There may be anger at God for afflicting the individual with what is perceived as a deformity. This anger can be expressed in therapy and prayer and ultimately lead to a place of greater self-acceptance. The goal is to transcend the outer perceptions and to see ourselves as God sees us, having great value and worth. It can be helpful to meditate on and appropriate for oneself the truth that we are made in God’s image; are “the temple of the living God” (2 Corinthians 6:16), that God’s Spirit dwells within us. These ideas call us to an intimate relationship with a God who created us in love and declared this creation “good” (Genesis 1:31), even “wonderful” (Psalm 139:14).
For many who suffer with BDD, acceptance is a core issue. God offers us his unconditional acceptance and love. To develop or restore a relationship with God, with accurate understandings, brings spiritual renewal. A right relationship with God brings many concerns back into perspective. The reality that the God of the universe has chosen to live within us reinforces the truth that we are of the greatest value and worth. For those who consider themselves “damaged goods,” this truth is difficult to grasp, yet to do so can bring long awaited healing. As this truth unfurls in our lives it brings greater self-awareness and self-acceptance. Grasping and holding fast to this truth through prayer, meditation, worship, spiritual readings, and other methods may restore hope.
In faith, we journey together with our patients to better comprehend the great love God has for us and to find acceptance of ourselves through the One who made us. The journey for someone with BDD may not be easy; but with the assistance of appropriate medication and psychotherapy, those with BDD may be ready to wrestle with the deeper spiritual question of why God made them as they are, seeking their identity in his love and finding there a refuge of self-acceptance, peace, and one day joy in their skin.
References
Allen, A. (2006). Cognitive-behavioral treatment of body dysmorphic disorder. Primary Psychiatry, 13, 70-76.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th Ed-TR). Washington, DC: Author.
Arthur, G. K., & Monnell, K. (2005). Body dysmorphic disorder. In eMedicine. Retrieved July 9, 2007, from http://emedicine.com/med/topic3124.htm
Coles, M.E., Phillips, K.A., Menard, W., Pagano, M.E., Fay, C., & Weisberg, R.B., et al. (2006). Body dysmorphic disorder and social phobia: Cross-sectional and prospective data. Depression and Anxiety, 23, 26-33.
Cororve, M.B., & Gleaves, D.H. (2001). Body dysmorphic disorder: A review of conceptualizations, assessment, and treatment strategies. Clinical Psychology Review, 21, 949-970.
Didie, E.R., Tortolani, C.C., Pope, C.G., Menarda, W., Fay, C., & Phillips, K.A. (2006). Childhood abuse and neglect in body dysmorphic disorder. Child Abuse and Neglect, 30, 1105-1115.
Eisen, J.L., Phillips, K.A., Baer, L., Beer, D.A., Atala, K.D., & Rasmussen, S.A. (1998). The Brown Assessment of Beliefs Scale: Reliability and validity. American Journal of Psychiatry, 155, 102-108.
Feusner, J., Granet, S., & Winograd, A. (2006, August). A comprehensive, multimodal approach to treating body dysmorphic disorder. Seminar presented at the OCF Annual Conference, Atlanta, GA.
Feusner, J., Winograd, A., & Saxena, S. (2005). Beyond the mirror: Treating body dysmorphic disorder. The Journal of
Family Practice, 4. Retrieved July 18, 2007, from http://www.jfponline.com/Pages.asp?AID=2737
Grant, J.E., Won Kim, S., & Eckert, E.D. (2002). Body dysmorphic disorder in patients with anorexia nervosa: Prevalence, clinical features, and delusionality of body image. International Journal of Eating Disorders, 32, 291-300.
Gunderson, L. (2000). Faith and healing. Annals of Internal Medicine, 132, 169-172.
Hollander, E. (Speaker). (October, 2006). How should BDD be conceptualized: OC spectrum, somatoform, or affective disorder? (CD recording of Keynote address of the Second Annual Body Dysmorphic Conference, New York). Atlanta, GA: Neysa Jane Body Dysmorphic Disorder Fund.
Kessler, R.C., Wai, T.C., Demler, O., & Walters, E.E. (2005). Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 617-627.
Massachusetts General Hospital. (2005). Patient care and treatment. Retrieved August 3, 2006, from the Massachusetts General Hospital Body Dysmorphic Disorder Clinic and Research Unit web site: http://www.mgh.harvard.edu/ bdd/pages/patientCare.htm.
National Collaborating Centre for Mental Health. (2006). Obsessive compulsive disorder: Core interventions in the treatment of obsessive compulsive disorder and body dysmorphic disorder. Leicester, UK: The British Psychological Society. Retrieved July 2, 2007, from the National Institute for Health and Clinical Excellence web site: http://www.nice.org.uk.
Neziroglu, F., McKay, D., Yaryura-Tobias, J.A., Stevens, K.P., & Todaro, J. (1999). The overvalued ideas scale: Development, reliability and validity in obsessive-compulsive disorder. Behaviour Research and Therapy, 37, 881-902.
Neziroglu, F., Roberts, M., & Yaryura-Tobias, J.A. (2004). A behavioral model for body dysmorphic disorder. Psychiatric Annals, 34, 915-920.
Pearlstein, T. (2002). Eating disorders and comorbidity. Archives of Women’s Mental Health, 4, 67-78.
Peterson, E.H. (2007). The message: The Bible in contemporary language. Colorado Springs: NavPress.
Phillips, K. A. (2002, January). How to recognize and treat body dysmorphic disorder. Current Psychiatry, 1(1), 58-65.
Phillips, K. A. (2002, June). Pharmacologic treatment of body dysmorphic disorder: Review of the evidence and a recommended treatment approach. CNS Spectrums, 7, 453-460.
Phillips, K. A. (2004, December). Treating body dysmorphic disorder with medication. Psychiatric Annals, 34, 945-950.
Phillips, K.A. (2005). The broken mirror: Understanding and treating body dysmorphic disorder (Rev. and expanded ed.). NY: Oxford University Press.
Phillips, K.A., Didie, E.R., Menard, W., Pagano, M.E., Fay, C., & Weisberg, R.B. (2006). Clinical features of body dysmorphic disorder in adolescents and adults. Psychiatry Research, 141, 305-314.
Phillips, K.A., Hollander, E., Rasmussen, S.A., Aronowitz, B.R., DeCaria, C., & Goodman, W.K. (1997). A severity rating scale for body dysmorphic disorder: Development, reliability, and validity of a modified version of the Yale-Brown Obsessive Compulsive Scale. Psychopharmacology Bulletin, 33, 17-22.
Phillips, K.A., McElroy, S.L., Hudson, J.I., & Pope, H.G. (1995). Body dysmorphic disorder: An obsessive-compulsive spectrum disorder, a form of affective spectrum disorder, or both? Journal of Clinical Psychiatry, 56 (S4), 41-51.
Phillips, K.A., Menard, W., Fay, C., & Weisberg, R.B. (2005). Demographic characteristics, phenomenology, comorbidity, and family history in 200 individuals with body dysmorphic disorder. Psychosomatics, 46, 317-325.
Rosen, J. & Reiter, J. (1996). Development of the body dysmorphic disorder examination. Behavior, Research and Therapy, 34, 755-766.
Ruffolo, J.S., Phillips, K.A., Menard, W., Fay, C., & Weisberg, R.B. (2006). Comorbidity of body dysmorphic disorder and eating disorders: Severity of psychopathology and body image disturbance. International Journal of Eating Disorders, 31, 11-19.
Sarwer, D. B., Gibbons, L. M., & Crerand, C. E. (2004). Treating body dysmorphic disorder with cognitive-behavior therapy. Psychiatric Annals, 34, 934-941.
Saxena, S. & Feusner, J.D. (2006). Toward a neurobiology of body dysmorphic disorder. Primary Psychiatry, 13, 41-48.
Stahl, S.M. (2006). Essential psychopharmacology: The prescriber’s guide. New York: Cambridge University Press.
Wall, A.D., & Cumella, E.J. (2006, Spring). Depression and eating disorders. The Remuda Review: The Christian Journal of Eating Disorders, 5, 14-21.
Wall, A.D., Eberly, M.C., & Wandler, K. (2007, Winter). Substance use and eating disorders. The Remuda Review: The Christian Journal of Eating Disorders, 6, 2-9.
