Recognising and responding to body dysmorphic disorder

Case scenario

Priya, 31, has been a customer of your pharmacy for some years. She is typically quiet and reserved when interacting with staff at the pharmacy. Well dressed and groomed, Priya tends to wear her hair loose, covering some of her face. You are aware that Priya has a history of depressed mood, and she has taken different SSRI medicines on and off for the last few years. She is currently taking sertraline 50 mg daily for major depression. Although Priya has clear skin, she frequently purchases cosmetic and skincare products. At times, she has appeared very distressed by minor skin blemishes and has sought your opinion on how to manage them. Priya is in your pharmacy asking for some non-prescription benzoyl peroxide cream for a new blemish she has noticed.

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Introduction

Most people, at some time or another, will feel dissatisfied with an aspect of their appearance. For some people, appearance dissatisfaction goes beyond mild or transitory concerns and can be enduring, distressing and impairing. Body dysmorphic disorder (BDD) is a serious mental health condition characterised by an intense and distressing preoccupation with a perceived flaw in one’s appearance, as well as repetitive behaviours intended to conceal, improve or cope with the perceived flaw. The perceived flaw can be entirely imagined (i.e. the flaw is objectively imperceptible to other people), or there may be a marked exaggeration in the perception of a physical anomaly that others would perceive as slight.¹ Common points of fixation for individuals with BDD include²:

• appearance of skin (e.g. complexion, blemishes, wrinkles, scars)
• appearance of hair (e.g. hair line, thinning hair)
• size, shape and symmetry of facial features (e.g. nose, ears, mouth). 

It is important to realise that this list is not exhaustive and people with BDD may be distressed by any aspect of their appearance. Some individuals with BDD may have more than one point of appearance fixation at the same time, or the area of fixation can change over time.²   

Common symptoms of BDD

People with BDD spend hours each day preoccupied with distressing thoughts about their appearance. These thoughts are experienced as intrusive, upsetting and difficult to resist or control.³ Prior to effective treatment, most people with BDD had poor insight into their perceived appearance defects and were convinced that their beliefs about their appearance were accurate and shared by others.⁴ People with BDD engage in repetitive, time-consuming behaviours related to their concerns about their appearance. These behaviours can include⁵:

• repeated checking of their appearance in a mirror or other reflective surfaces
• measuring or repeatedly touching areas of concern
• excessive grooming (e.g. washing skin or hair repeatedly, using topical products in excess of recommended guidelines)
• attempts to conceal perceived appearance defects through make-up, clothing choices or hairstyle
• seeking reassurance about appearance from other people
• researching and seeking cosmetic surgery procedures
• social avoidance. 

These behaviours cause significant functional impairment and can consume significant time and financial resources. 

Prevalence of BDD

BDD is a common mental health problem with an estimated community prevalence of approximately 2%.⁶ Some research suggests it is equally prevalent in males and females, while other studies show a slightly higher prevalence in females.⁶ 

It is likely that prevalence is under-reported, given that many people with BDD feel intense shame about their symptoms and are unlikely to disclose them without appropriate assessment.⁷ 

The prevalence of BDD can be much higher in certain medical settings. For example, studies show that approximately 20% of people presenting for rhinoplasty and about 11% of patients in dermatology settings meet the criteria for diagnosis of BDD.⁶ These figures are alarming, as cosmetic procedures are almost always ineffective in resolving BDD.⁸ 

There are no studies directly examining the prevalence of BDD in consumers presenting in pharmacy settings. However, it is likely that the prevalence of BDD in pharmacy settings may exceed the general community prevalence. Many people with BDD have concerns about their skin or hair and will purchase prescription and non-prescription dermatological products or hair loss products. 

How does BDD develop?

BDD typically has onset in mid-adolescence, and the disorder is generally unremitting without appropriate treatment.⁹ As with other mental health problems, both genetic and environmental factors contribute to the development of BDD.¹⁰ Physical changes during puberty (e.g. weight gain, hair growth, acne) can trigger increased appearance preoccupation, which can lead to the development of BDD. 

Appearance changes that occur at other times of life (e.g. hair loss, changes in skin elasticity, scarring) can also trigger the onset of BDD. 

Some people with BDD identify teasing and bullying as having contributed to the onset of their appearance concerns.³ 

Impact of BDD

People with BDD expect to be judged and rejected by others and try to minimise the chances of this by avoiding social situations, or only entering social situations if they believe they have been able to conceal their perceived defect (e.g. covering it with make-up, clothing or hairstyling).⁵ 

Social avoidance severely restricts day-to-day activities, and people with BDD are more likely to be unemployed, drop out of their studies, and less likely to be in relationships compared to their peers.¹¹ 

BDD is usually comorbid with other secondary mental health problems, most commonly depression (lifetime prevalence 75%), substance use disorders, obsessive compulsive disorder (OCD) and social anxiety.⁹ Suicidality is particularly concerning, as people with BDD have markedly high rates of suicidal ideation, suicide attempts and completed suicides. Research suggests that almost 80% of individuals with BDD experience suicidal ideation primarily related to their BDD, and over a quarter of people diagnosed with BDD have attempted suicide.^12,13 

Most people with BDD have poor insight into the psychological nature of their condition. As a result, many seek medical and surgical interventions to try to fix their perceived defects, rather than psychological help. 

Unfortunately, the vast majority of people with BDD who undergo cosmetic procedures are dissatisfied with the outcome and typically experience no change in the severity of their condition.¹⁴ 

In desperation to ‘fix’ their appearance, people with BDD can sometimes overuse products in ways that can inadvertently cause harm and exacerbate their concerns.¹⁵ 

For example, a person with BDD who is fixated on their skin may overuse face washes, chemical peels or exfoliation treatments, causing harm to their skin (e.g. redness, drying), which then heightens their concerns and drives them to continue trying to fix the problem by using dermatological treatments, creating a vicious cycle. 

Treatment of BDD

Pharmacological treatment

Despite the prevalence and severity of BDD, remarkably few clinical trials for pharmaceutical treatments exist, and only three have been randomised controlled trials. These trials, supported with evidence from open-label trials, show that selective serotonin reuptake inhibitors (SSRIs) are broadly more efficacious than placebo.¹⁶ Response rates across trials vary from 53% to 70%.¹⁷

No SSRI demonstrates superior efficacy over another, and most studies have used escitalopram or fluoxetine. SSRIs are recommended first-line for BDD treatment. Serotonin noradrenaline reuptake inhibitors (SNRIs) are recommended as a second-line option in an Australian guideline for patients who cannot tolerate or have a poor response to SSRIs; however, they are not currently recommended in European guidelines.^18,24 

Clomipramine (a tricyclic antidepressant) has been found to be an alternative for those with no response to initial pharmacotherapy; however, intolerance commonly limits its use.²⁴ The potential for clomipramine to cause changes in cardiac conduction and toxicity in overdose must be considered in this patient population.²⁴ A baseline electrocardiogram (ECG) should be obtained before clomipramine is initiated, and repeated once the dose is stabilised (usually after 6 weeks). Lower clomipramine doses should be used in older or frail patients.²⁴

No studies exist to establish the most effective dose of antidepressant for BDD. Due to limited evidence, treatment recommendations use doses similar to those with evidence for OCD (i.e. 2–3 times ‘standard’ antidepressant dosing; see Table 1).¹⁸ It is recommended that patients are titrated to these high doses, every 2–4 weeks if tolerated, over 12–14 weeks. Patients should be maintained on a dose for 3–4 weeks to determine effectiveness.¹⁸ Once the response is acceptable, maintain the patient on that dose for 6–12 months, then reassess. Patients may need encouragement to continue treatment during this time and need to be counselled on the increased likelihood of side effects (e.g. nausea, restlessness, agitation).²⁴ Australian guidelines recommend the patient be monitored for QT prolongation with an ECG if a dose is in the higher than standard, as is recommended in Table 1.²⁴

Table 1 – Suggested daily dosages for antidepressants in treatment of BDD

Castle et al¹⁸,TG²⁴

In one of the more recent studies, patients with BDD were treated with escitalopram in an open trial for 14 weeks before being randomised to continue with escitalopram or placebo from week 15 to 40.¹⁹ The authors found that 18% of the escitalopram continuation group relapsed, whereas 40% of the placebo group relapsed, and those in the escitalopram group continued to make further gains. International consensus guidelines recommend ongoing treatment for patients with multiple hospitalisations and/or suicide attempts.¹⁸

There is currently no approved pharmacological treatment for BDD in Australia; the medicines used are those approved for the treatment of OCD. Therefore, these medicines are used off-label. Pharmacists should be aware of their professional obligations when supplying a medicine for off-label use, as outlined in the PSA Dispensing Practice Guidelines 2019. As such, these medicines help with BDD-related preoccupations, distress and compulsive behaviours. They do not, however, alter the misperception of the apparent appearance defect. 

An important benefit is that pharmacotherapy often improves associated symptoms of comorbid depression, anxiety and OCD.¹⁶

Very few studies have investigated augmentation strategies to improve the response to SSRIs. Despite the often-delusional nature of patients’ beliefs, antipsychotics have not been found to be effective.¹⁸ Pimozide and olanzapine have been used to augment fluoxetine with no benefit.^20,21 However, augmentation with antipsychotics is common in non-responsive patients; case reports suggest beneficial effects with the use of olanzapine, quetiapine or risperidone in addition to serotonergic medicines. 

A single case report showed success with aripiprazole augmenting fluvoxamine²² and with risperidone augmenting venlafaxine²³ in BDD. 

Other medicines being investigated include buspirone (not available in Australia), intranasal esketamine, and levetiracetam.¹⁸

It is clear that more research is needed to ascertain the relative efficacy of pharmacotherapy in BDD, its role with and without psychological therapy, dose-finding studies, and augmentation strategies.

Psychological treatment

Cognitive behavioural therapy (CBT) is the preferred type of psychological treatment for BDD.^24,25 

CBT is a relatively short-term treatment (typically 12–14 weekly sessions). It focuses on psycho­education, as well as training the person to develop skills to help eliminate unhelpful behaviours (e.g. reassurance seeking, appearance altering behaviours, social avoidance), to help challenge misperceptions about their appearance, and to help develop more realistic beliefs about their appearance. CBT has been shown to be efficacious and can significantly reduce symptoms, as well as those of comorbid mental health conditions, such as depression.^15,26 These effects are generally maintained after the completion of treatment.^15,26 

Combination therapy of CBT and pharmacotherapy can also be effective and may be beneficial to consider for people with more severe BDD symptoms or poorer insight.²⁷  

Knowledge to practice

The appearance of skin and hair are common fixations for people with BDD. These people may present in the pharmacy seeking remedies for their perceived flaws (e.g. purchasing make-up, non-prescription and prescription skincare, or hair loss products). They may purchase such products excessively or seek your opinion regarding how to manage their perceived defects, which may be either imperceptible or only slightly noticeable. 

As BDD is unlikely to resolve without diagnosis and intervention, if you suspect that someone may have BDD, it is important to investigate this further. The following questions can be helpful in identifying people with BDD¹⁷:

• Do you worry a lot about the way you look and wish you could think about it less?
• What specific concerns do you have about your appearance? 
• On a typical day, how many hours do you spend thinking about your appearance? (More than an hour a day is considered excessive.) 
• What effect do concerns about your appearance have on your life?
• Do the concerns make it hard for you to work or be with friends?

If an individual’s responses to these questions indicate that they have significant and impairing appearance concerns, they may have BDD. These people should be provided with information about BDD and informed that treatment options are available; they should also be referred to their GP for further investigation. 

As many individuals with BDD may lack insight into the psychological nature of their illness, it is possible that they may be defensive or guarded if you attempt to discuss this with them. Should this be the case, a focus on harm minimisation can still be helpful (e.g. making sure the individual has a clear understanding of how often the cosmetic or dermatological products they purchase should be used, and the potential detrimental consequences of overuse). 

Signposting people to organisations (e.g. Butterfly Foundation) or letting them know where they can access further information about the condition can help in these situations. 

People with BDD may seek your reassurance or opinions regarding their perceived defects. It is important to be aware that providing reassurance to someone with BDD is unlikely to be of benefit, and where possible the discussion should be reoriented to how to manage their anxiety about their appearance. 

Further information

Free, evidence-based self-help resources for BDD and support for patients can be found at the following: 

• Centre for Clinical Interventions:
  www.cci.health.wa.gov.au/Resources/Looking-After-Yourself/Body-Dysmorphia 
• ReachOut Australia: https://au.reachout.com/articles/body-dysmorphic-disorder
• BDD Support group: www.bddseeingitthroughoureyes.com.au/

BDD is a serious and common mental health disorder. BDD tends to be under-recognised, as people with BDD are unlikely to spontaneously disclose their difficulties due to factors including poor insight and feelings of shame. It is important for health professionals to be able to recognise BDD, as without appropriate diagnosis and intervention the condition is likely to take a chronic course and cause significant distress and functional impairment. It is likely that BDD is even more prevalent in pharmacy settings than general community settings, as skin and hair concerns are a common fixation for people with BDD, and they often seek products to address their perceived defects. If a pharmacist suspects a consumer has BDD, they can assist in several ways, including: harm minimisation (e.g. thoroughly explaining risks of product overuse), asking the consumer questions to screen for BDD, raising concerns with prescribers, and providing information about treatment options for BDD, where appropriate.  

Key points

• Body dysmorphic disorder (BDD) is a serious and common mental health disorder characterised by a preoccupation with a perceived appearance flaw.
• People with BDD may present in a pharmacy to purchase skincare or hair loss products to conceal their perceived flaw.  
• BDD can be effectively treated with antidepressant pharmacotherapy, psychological therapy, or both. 
• Pharmacists can help by recognising when people may have BDD, asking screening questions, explaining the risks of product overuse, and providing information about the disorder and treatment where appropriate. 

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References

1. American Psychiatric Association, DSM-5 Task Force. Diagnostic and statistical manual of mental disorders:DSM-5(5th ed.). Washington: American Psychiatric Association Publishing; 2013.
2. Phillips KA. The presentation of body dysmorphic disorder in medical settings. Prim Psychiatry 2006;13(7):51–9.
3. Phillips KA. The broken mirror: understanding and treating body dysmorphic disorder (2nd ed, revised). New York: Oxford University Press; 2005.
4. Eisen JL, Phillips KA, Coles ME, et al. Insight in obsessive compulsive disorder and body dysmorphic disorder. Compr Psychiatry 2004;45(1):10–5.
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6. Veale D, Gledhill LJ, Christodoulou P, et al. Body dysmorphic disorder in different settings: A systematic review and estimated weighted prevalence. Body Image 2016;18:168–86.
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8. Crerand CE, Phillips KA, Menard W, et al. Nonpsychiatric medical treatment of body dysmorphic disorder. Psychosomatics 2005;46(6):549–55.
9. Phillips KA, Menard W, Fay C, et al. Demographic characteristics, phenomenology, comorbidity, and family history in 200 individuals with body dysmorphic disorder. Psychosomatics 2005;46(4):317–25.
10. Monzani B, Rijsdijk F, Anson M, et al. A twin study of body dysmorphic concerns. Psychol Med 2012;42(9):1949–55.
11. Koran LM, Abujaoude E, Large MD, et al. The prevalence of body dysmorphic disorder in the United States adult population. CNS Spectr 2008;13(4):316–22.
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14. Crerand CE, Menard W, Phillips KA. Surgical and minimally invasive cosmetic procedures among persons with body dysmorphic disorder. Ann Plast Surg 2010;65(1):11–6.
15. Veale D, Neziroglu F. Body dysmorphic disorder: A treatment manual. Chichester: John Wiley & Sons; 2010.
16. Sjögren JM. An update on psychopharmacological treatment of body dysmorphic disorder (BDD). JPCPY 2019;10(6):228–32.
17. 17. Krebs G, de la Cruz LF, Mataix-Cols D. Recent advances in understanding and managing body dysmorphic disorder. EBMH 2017;20(3):71–5.
18. Castle D, Beilharz F, Phillips KA, et al. Body dysmorphic disorder: a treatment synthesis and consensus on behalf of the International College of Obsessive-Compulsive Spectrum Disorders and the Obsessive Compulsive and Related Disorders Network of the European College of Neuropsychopharmacology. Int Clin Psychopharmacol 2021;36(2):61.
19. Phillips KA, Keshaviah A, Dougherty DD, et al. Pharmacotherapy relapse prevention in body dysmorphic disorder: a double-blind, placebo-controlled trial. Am J Psychiatry 2016;173(9):887–95.
20. Phillips KA. Placebo-controlled study of pimozide augmentation of fluoxetine in body dysmorphic disorder. Am J Psychiatry 2005;162(2):377–9.
21. Phillips KA. Olanzapine augmentation of fluoxetine in body dysmorphic disorder. Am J Psychiatry 2005;162(5):1022–3.
22. Uzun Ö, Özdemir B. Aripiprazole as an augmentation agent in treatment-resistant body dysmorphic disorder. Clin Drug Investig 2010;30(10):707–10.
23. Goulia P, Mantas C, Bassukas ID, et al. Treatment with risperidone and venlafaxine of a patient with double-coded diagnosis of body dysmorphic disorder and delusional disorder somatic type. Hippokratia 2011:15:286–7.
24. Body dysmorphic disorder [revised Mar 2021]. In: eTG complete. Melbourne: Therapeutic Guidelines Limited; 2021.
25. National Collaborating Centre for Mental Health. Obsessive-compulsive disorder: core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic. Leicester: British Psychological Society; 2006.
26. Harrison A, de la Cruz LF, Enander J, et al. Cognitive-behavioral therapy for body dysmorphic disorder: a systematic review and meta-analysis of randomized controlled trials. Clin Psychol Rev 2016;48:43–51.
27. Morgan S. Mental disorders: obsessive-compulsive disorder and body dysmorphic disorder. FP Essent. 2020;495:17–22.

MELISSA BURGESS BSc(Hons), MPsych is a clinical psychologist working at the Centre for Clinical Interventions in Perth, providing evidence-based psychological treatments for a range of mental health problems, including body dysmorphic disorder. She has helped develop a workshop to train other health professionals to recognise and treat body dysmorphic disorder. 

DR BRUCE CAMPBELL BPharm, MPsych, DPsych, is the director and consultant clinical psychologist at the Centre for Clinical Interventions in Perth. He is also a practising community pharmacist and presents psychopharmacology lectures to postgraduate clinical psychology students.