What is body dysmorphic disorder?

Body dysmorphic disorder (BDD) is a condition where a person spends a lot of time worried and concerned about their appearance. A person with this disorder may:

• Focus on an apparent physical defect that other people cannot see, OR
• Have a mild physical defect, but the concern about it is out of proportion to the defect.

For example, a person may think that he or she has a skin blemish or an odd-shaped nose. However, no one else can see the defect, or the blemish would be considered trivial by most people. The person becomes preoccupied with the imagined defect, or slight defect. For example, he or she may spend a lot of time looking in the mirror at the apparent defect, or wear camouflaging make-up to hide the defect.

The thought of the defect is very distressing for people with BDD. In some cases the condition can have a great impact on day-to-day life and functioning. For example:

• Many people with BDD will avoid social situations, or even avoid going out from the home. This is because they fear that their imagined or trivial defect will get undue attention from other people.
• Some people with BDD consult a cosmetic surgeon to have the imagined or trivial defect corrected.
• Some people even become suicidal because of the distress caused by this condition.

What causes body dysmorphic disorder?

The cause of BDD is not clear.

Some people think BDD is a similar condition to obsessive compulsive disorder (OCD). There are similarities between these two conditions. For example, like people with OCD, people with BDD often feel that they have to repeat certain things. For example, checking how they look, or repeatedly combing their hair, or putting on make-up to cover an imagined defect. These compulsive acts may temporarily ease the anxiety or distress caused by the imagined defect. This is similar to the way a compulsion may temporarily ease the anxiety or distress of an obsessional thought in someone with OCD. Also, the treatment of OCD and BDD is much the same (see below).

Despite their similarities, BDD and OCD are thought to be two different conditions. People with BDD tend to have a greater tendency to suicide, substance abuse and depression. See separate leaflet called 'Obsessive-compulsive Disorder'.

Slight changes in the balance of some brain chemicals (neurotransmitters) such as serotonin may play a role in causing OCD and BDD. This is why medication is thought to help (see below). Other theories have been suggested, but none proved.

Who gets body dysmorphic disorder?

BDD can affect anyone. However, it most commonly first develops in the teenage years. The exact number of people affected is not known but studies suggest that BDD may affect about 1 in 100 people. Other studies suggest it may be even more common. When it develops it usually becomes a chronic (persistent) condition unless it is treated.

What is the treatment for body dysmorphic disorder?

The usual treatment for BDD is either cognitive behavioural therapy (CBT), or a selective serotonin reuptake inhibitor (SSRI) antidepressant medicine. Sometimes a combination of CBT plus an SSRI antidepressant medicine is used. A newer treatment is called exposure and response prevention (ERP). Each of these treatments is discussed below.

One problem with all treatments is that some people with BDD do not accept that they have a mental health problem. Getting someone to agree to treatment is, in itself, sometimes difficult.

It is tempting to think that if you had cosmetic surgery, all your problems would be over. However, research suggests that people with BDD rarely do well after surgery and do not get the relief from their symptoms that they would expect to get.

Cognitive behavioural therapy

What is CBT?

CBT is a type of specialist talking treatment (a specialised psychological therapy). It is probably the most effective treatment for BDD.

Cognitive therapy is based on the idea that certain ways of thinking can trigger, or fuel, certain mental health problems such as BDD. The therapist helps you to understand your current thought patterns. In particular, to identify any harmful, unhelpful, and false ideas or thoughts which you have. Also to help your thought patterns to be more realistic and helpful. The therapist suggests ways in which you can achieve these changes in thinking.

Behavioural therapy aims to change behaviours which are harmful or not helpful. For example, if you have BDD and you constantly check your reflection in the mirror, the therapist might encourage you to cut this down. The therapist also teaches you how to control anxiety when you face up to changing your behaviour. For example, by using breathing techniques.

Cognitive behavioural therapy (CBT) is a mixture of the two where you may benefit from changing both thoughts and behaviours. This is the most common treatment for BDD.

A particular variation of CBT called exposure and response prevention (ERP) therapy is often used for BDD. This means that you are encouraged by your therapist to face situations which arouse your BDD anxiety. That is, you are exposed to your fearful situations. For example, this may simply be to go to a social event where you would normally be anxious that people would stare at you. However, you are shown ways to cope with (respond to) your anxiety. For example, by using deep breathing techniques. ERP treatment would only be given to you after counselling and when you are fully aware of what will happen. People who have had this treatment often get great benefit from the feeling that they have faced their worst fears and nothing terrible has happened.

How can I get CBT?

Your doctor may refer you to a therapist who has been trained in CBT. This may be a psychologist, psychiatrist, psychiatric nurse, or other healthcare professional. However, there are limited numbers of CBT therapists available on the NHS and there may be waiting lists for therapists in some areas. However, government policy is to make CBT more widely available on the NHS.

Therapy is usually done in weekly sessions of about 50 minutes each, for several weeks. This is sometimes done in a group setting, and sometimes one-to-one, depending on various factors, such as the severity of the problem. Sometimes, CBT can be done via regular telephone conversations with a therapist.

How effective is CBT for BDD?

Of those who complete a course of CBT, there is a marked improvement in over half of cases. Symptoms may not go completely, but they are usually greatly eased.

Medicines used to treat body dysmorphic disorder

SSRI antidepressants

Although they are often used to treat depression, SSRI antidepressant medicines can also reduce the symptoms of BDD, even if you are not depressed. They work by interfering with brain chemicals (neurotransmitters), such as serotonin, which may be involved in causing symptoms of BDD. SSRI antidepressants include: citalopram, fluoxetine, fluvoxamine, paroxetine, and sertraline. The one most commonly used to treat BDD is fluoxetine, as this is the one with the most research evidence to say that it works well for BDD.

Note:

• SSRI antidepressants do not work straightaway. It takes 2-4 weeks before their effect builds up and they start to work. They may take up to 12 weeks to work fully. A common problem is that some people stop the medicine after a week or so as they feel that it is doing no good. You need to give them time to work.
• SSRI antidepressants are not tranquillisers, and are not usually addictive.
• The doses needed to treat BDD are often higher than those needed for depression.
• If it works, it is usual to take an SSRI antidepressant for at least a year to treat BDD.

What about side-effects with SSRIs?

Most people who take an SSRI have either minor, or no, side-effects. Possible side-effects vary between different preparations. The most common ones include: diarrhoea, feeling sick, vomiting, and headaches. Some people develop a feeling of restlessness or anxiety (see below). Sexual problems sometimes occur. It is worth keeping on with treatment if side-effects are mild at first. Minor side-effects may wear off after a week or so.

The leaflet that comes in the medicine packet gives a full list of possible side-effects. Tell your doctor if a side-effect persists or is troublesome. A switch to a different preparation may then suit you better. Drowsiness is an uncommon side-effect with SSRI antidepressants, but do not drive or operate machinery if you become drowsy whilst taking one.

SSRI antidepressants and suicidal behaviour

In recent years there have been some case reports which claim a link between taking SSRI antidepressants and feeling suicidal. The Medicines and Healthcare products Regulatory Agency (MHRA) reviewed the evidence on whether there is such a link. They were unable to find any convincing evidence of this link. The MHRA has stated that it will continue to monitor this issue.

Because of this possible link, see your doctor promptly if you become restless, anxious or agitated, or if you have any suicidal thoughts - in particular, if these develop in the early stages of treatment with an SSRI, or following an increase in dose.

Are SSRI antidepressants addictive?

SSRIs are not tranquillisers, and are not thought to be addictive. (This is disputed by some people, and so this is a controversial issue. If addiction does occur, it is only in a minority of cases.) Most people can stop an SSRI without any problem. At the end of a course of treatment you should reduce the dose gradually over about four weeks before finally stopping. This is because some people develop withdrawal symptoms if the medication is stopped abruptly.

Withdrawal symptoms that may occur include: dizziness, anxiety and agitation, sleep disturbance, flu-like symptoms, diarrhoea, abdominal cramps, pins and needles, mood swings, feeling sick, and low mood. These symptoms are unlikely to occur if you reduce the dose gradually. If withdrawal symptoms do occur, they will usually last fewer than two weeks. An option if they do occur is to restart the medicine, and then reduce the dose even more slowly before stopping.

Some other points about SSRIs and BDD

Although symptoms may not go completely, they will often greatly improve. This can make a big difference to your quality of life.

You should not stop SSRI antidepressants suddenly. You should gradually reduce the dose as advised by a doctor at the end of treatment. In some people the symptoms return when medication is stopped. An option then is to take an SSRI antidepressant on a long-term basis. However, symptoms are less likely to return once you stop an SSRI if you have had a course of CBT (described earlier).

Reasons why medication may not work so well in some people include:

• The dose is not high enough and needs to be increased.
• Medication was not taken for long enough - it may take up to 12 weeks to work.
• Side-effects became a problem and so you may stop the medication. Tell a doctor if side-effects are troublesome.

Other medicines that are used to treat BDD

If SSRIs do not help much, or cannot be taken (for example, because of side-effects), then another type of antidepressant called clomipramine is sometimes used. This is classed as a tricyclic antidepressant. Occasionally, other medicines that are used to treat mental health disorders are used.

Cognitive behavioural therapy plus antidepressants

In some situations, a combination of CBT plus an SSRI medicine is advised. This is probably better than either used alone, when BDD is severe.

Further help and information

British Association of Behavioural and Cognitive Psychotherapies (BABCP)

Imperial House, Hornby Street, Bury, Lancashire BL9 5BN
Tel: 0161 705 4304 Web: www.babcp.com
They maintain a register of qualified practitioners who can provide CBT privately.

References

• Obsessive Compulsive Disorder, NICE (2005); (Core interventions in the treatment of obsessive compulsive disorder and body dysmorphic disorder)
• Gregg Williams; Body Dysmorphic Disorder and Cognitive Behaviour Therapy, Scribd, 2007
• Picavet V, Gabriels L, Jorissen M, et al; Screening tools for body dysmorphic disorder in a cosmetic surgery setting. Laryngoscope. 2011 Dec;121(12):2535-41. doi: 10.1002/lary.21728. [abstract]
• Feng S et al, Body Dysmorphic Disorder, Medscape, May 2010
• Crerand CE, Menard W, Phillips KA; Surgical and minimally invasive cosmetic procedures among persons with body Ann Plast Surg. 2010 Jul;65(1):11-6. [abstract]
• Bjornsson AS, Didie ER, Phillips KA; Body dysmorphic disorder. Dialogues Clin Neurosci. 2010;12(2):221-32. [abstract]
• Buhlmann U, Winter A; Perceived ugliness: an update on treatment-relevant aspects of body dysmorphic Curr Psychiatry Rep. 2011 Aug;13(4):283-8. [abstract]