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Body Dysmorphic Disorder
Diagnostic criteria for 300.7 Body Dysmorphic Disorder
1. Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person's concern is markedly excessive.
2. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
3. The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in Anorexia Nervosa).
General approach to patients who want dermatologic treatment, surgery, or other nonpsychiatric treatment (e.g., electrolysis)
is to say that no one can predict how an individual patient will respond to such treatment, but as best we know it is usually ineffective for BDD and can even worsen the appearance concerns (Phillips 1996, 2001). We have seen many patients who seriously regret having had such treatment. (Patients who damage their skin by picking at it, however, may require dermatologic as well as psychiatric care.) We explain that psychiatric treatment is much less risky, does not make patients think they look worse, is likely to help them feel better and improve their life, and is worth a try.
Serotonin reuptake inhibitor (SRI) and cognitive-behavioral therapy (CBT)
It isn't known which treatment is more effective or whether the combination is better than either treatment alone.
Two controlled studies, three open-label trials, and case reports and series indicate that SRIs are often efficacious for BDD (Hollander et al. 1999; Phillips 1996, 2002; Phillips et al. 2001, 2002).
It is very important to use a high enough SRI dose for a long enough time (Phillips 2001, 2002). Although no studies have compared different SRI doses, clinical experience indicates that patients with BDD usually require higher doses than those typically used for depression.
For mild BDD, it may be preferable to start with CBT. For moderate or mild BDD, however, it is important to also consider other factors, such as comorbidity, the patient's preference, and the availability of CBT therapists knowledgeable about BDD, when choosing treatment.
CBT has also been shown to be efficacious for BDD (Neziroglu and Khemlani-Patel 2002; Phillips 1996). Evidence of the efficacy of CBT comes from case series (Marks and Mishan 1988) as well as two randomized studies in which BDD was compared to a no-treatment waiting-list control (Rosen et al. 1995; Veale et al. 1996).
Hollander E, Allen A, Kwon J, et al: Clomipramine vs desipramine crossover trial in body dysmorphic disorder: selective efficacy of a serotonin reuptake inhibitor in imagined ugliness. Arch Gen Psychiatry 56:1033–1039, 1999 [PubMed]
Marks IM, Mishan J: Dysmorphophobic avoidance with disturbed bodily perception: a pilot study of exposure therapy. Br J Psychiatry 152:674–678, 1988 [PubMed]
Neziroglu F, Khemlani-Patel S: A review of cognitive and behavioral treatment for body dysmorphic disorder. CNS Spectrums 7:464–471, 2002 [PubMed]
Phillips KA: Body dysmorphic disorder, in Somatoform and Factitious Disorders (Review of Psychiatry Series, Volume 20, Number 3). Edited by Phillips KA. Washington, DC, American Psychiatric Publishing, 2001, pp 67–94
Phillips KA: Pharmacologic treatment of body dysmorphic disorder: review of the evidence and a recommended treatment approach. CNS Spectrums 7:453–460, 2002 [PubMed]
Phillips KA: The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder. Revised and expanded edition. New York, Oxford University Press, 2004
Phillips KA, Albertini RS, Siniscalchi J, et al: Effectiveness of pharmacotherapy for body dysmorphic disorder: a chart-review study. J Clin Psychiatry 62:721–727, 2001 [PubMed]
Phillips KA, Albertini RS, Rasmussen SA: A randomized placebo-controlled trial of fluoxetine in body dysmorphic disorder. Arch Gen Psychiatry 59:381–388, 2002 [PubMed]
Rosen JC, Reiter J, Orosan P: Cognitive behavioral body image therapy for body dysmorphic disorder. J Consulting Clin Psychol 63:263–269, 1995 [PubMed]
Veale D, Gournay K, Dryden W, et al: Body dysmorphic disorder: a cognitive behavioral model and pilot randomized controlled trial. Behav Res Ther 34:717–729, 1996
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