CME #124 October 2005 Skin & Aging is proud to bring you this latest installment in its CME series. This series consists of regular CME activities that qualify you for two category 1 physician credit hours. As a reader of Skin & Aging, this course is brought to you free of charge — you aren’t required to pay a processing fee. This CME article focuses on body dysmorphic disorder and how it affects many patients. As the number of elective cosmetic procedures continues to grow, it’s important to be aware of this disorder and know how to recognize it. Lucinda S. Buescher, M.D., offers tips for how to screen cosmetic patients for this disorder and also discusses possible treatment options. At the end of this article, you’ll find a PDF of the exam and evaluation. Mark your responses in the designated area, and fax to HMP Communications at (610) 560-0501. Amy McMichael, M.D., CME Editor Amy McMichael, M.D., is Associate Professor in the Department of Dermatology, Director of the Hair Disorders Clinic and Residency Program Director at Wake Forest University Medical Center in Winston-Salem, NC. Principal Faculty: Lucinda Buescher, M.D. Method of Participation: Physicians may receive two category 1 credits by reading the article on pp. 89-94 and successfully answering the questions found on pp. 94-95. A score of 70% is required for passing. Submit your answers and evaluation via fax or log on to our Web site at www.skinandaging.com. Estimated Time to Complete Activity: 2 hours Date of Original Release: October 2005 Expiration Date: October 2006 Accreditation Statement: This activity is sponsored by the North American Center for Continuing Medical Education (NACCME). NACCME is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Designation Statement: NACCME designates this continuing medical education activity for a maximum of two category 1 credit(s) toward the AMA Physician’s Recognition Award. Each physician should claim only those credits that he/she actually spent in the educational activity. This activity has been planned and produced in accordance with the ACCME Essential Areas and Policies. Off-Label Disclosures: This educational activity contains discussion of published and/or investigational uses of agents that are not indicated by the FDA. Neither the North American Center for Continuing Medical Education, nor Mylan, Lilly, or Forest recommends the use of any agent outside of the labeled indications. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications and warnings. Disclosure Policy: All faculty participating in Continuing Medical Education programs sponsored by The North American Center for Continuing Medical Education are expected to disclose to the audience any real or apparent conflict(s) of interest related to the content of their presentation. Faculty Disclosures: Dr. Buescher has disclosed that she has no significant financial relationship with any organization that could be perceived as a real or apparent conflict of interest in the contexts of the subject of her presentation. Learning Objectives: 1. Raise physicians’ awareness of body dysmorphic disorder. 2. Learn simple screening questions to detect body dysmorphic disorder. 3. Learn appropriate treatment options for body dysmorphic disorder. Target Audience: Dermatologists, Plastic Surgeons, Internists Commercial Support: None Sponsor: NACCME Recognizing Body Dysmorphic Disorder T here is no doubt that we live in a culture that emphasizes physical beauty. You only need to look at images on television, magazine covers and billboards to realize that we are barraged with images of beauty perfection on a daily, and sometimes hourly, basis. Intellectually, we know that media photographs today are digitally modified, but in our quest for perfection it is easy to forget. Even children’s cartoons, publications and toys reflect the physical perfection that adults seek. We certainly can’t hold Barbie responsible for our unachievable physical expectations, but the doll is often used as an example of our tendency to portray humanly impossible (or at least improbable) physical beauty. There are many references to Barbie’s measurements if she were her real life size of 5’9” tall. On this scale she would measure 38-18-28.1 Compare that to the measurements of an “average” woman, 37-29-40, and the chance that a real woman would have Barbie’s measurements (without the assistance of a cosmetic surgeon) is less than 1 in 100,000.2 Girls are not alone in the subliminal exposure to superhuman physiques; boys have grown up with G. I. Joe as his muscularity has increased beyond average human proportion over the years. Still, nearly 90% of all cosmetic procedures are performed on women. Thompson et al comments on the cultural impact on body image satisfaction in their text “Exacting Beauty”: “Although thinness is at least partially under an individual’s control, many other socioculturally endorsed aspects of appearance, such as youth, height, and Caucasoid features, are less amenable to alteration. Thus, it has been hypothesized that although some changes may be possible through cosmetics or plastic surgery, sociohistorical changes favoring an aging population and expanding numbers of women of color will inevitably result in increasingly fewer women who are able to achieve the society’s ideal. Perhaps, as a result, increasing numbers of women have reported significant body image discontent. This places culture and physiology in conflict3; judging from the normative degree of dissatisfaction with one’s body among women4, culture appears to be winning.”5 Cosmetic Procedures on the Rise Is it any wonder that the number of cosmetic procedures performed in the last 7 years has increased nearly 400%?6 The cosmetic surgery data have been compiled annually by the American Society for Aesthetic Plastic Surgery (ASAPS) since 1997. In 2004, this organization surveyed cosmetic surgeons in the United States, including plastic surgeons, otolaryngologists and dermatologists. The non-surgical procedures far outnumber the surgical procedures performed (Figure 1). In fact, more botulinum toxin injections are performed than all other surgical procedures combined (Figure 2). Among the millions of patients seeking physical beautification through cosmetic procedures, approximately 10% suffer from body dysmorphic disorder (BDD). Treating these patients with cosmetic procedures can be unrewarding for you and for your patient because the expectations of these patients are unrealistic. This article will raise raise your awareness of this disorder, discuss some simple screening questions and review alternative strategies for managing this challenging disease. What is Body Dysmorphic Disorder? In 1891, dysmorphophobia7 was published in the medical literature and since then BDD has had many names including beauty hypochondria,8 dermatologic hypochondriasis9 and more recent publications refer to patients as “polysurgery addicts”10 and “insatiable.”11 Finally, in 1987, body dysmorphic disorder was given separate diagnostic status in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM III).12 One of the leading researchers of BDD, Dr. Katharine Phillips, was largely responsible for bringing this disease into public awareness with the publication of her text, “The Broken Mirror; Understanding and Treating Body Dysmorphic Disorder.”13 She also provided the most succinct, but descriptive, definition of this disorder: “the distress of imagined ugliness.”14 The most recent edition of the Diagnostic and Statistical Manual of Mental Disorders defines BDD as a preoccupation with an imagined defect in appearance; “if a slight physical anomaly is present; the individual’s concern is markedly excessive.”15 This is only the first criterion. Additionally, the preoccupation must cause significant distress or impairment in social, occupational or other important areas of functioning. This helps guard against overdiagnosis since researchers suggest that some degree of body image concern may be beneficial. A normal level of concern leads to regular grooming and hygiene which facilitate our interactions in society and maintain health. A final requirement for the diagnosis of BDD is that other mental disorders are ruled out, especially anorexia nervosa. Clinical Features of Body Dysmorphic Disorder The major feature of this disorder is a preoccupation with appearance. Usually the perceived flaw is located on the face or head, but any visible body part may be the focus of concern. Most frequently the preoccupation centers on the skin, hair or nose. Often there is more than one problematic area and there is a perception of disturbing asymmetry. The thoughts are difficult to resist and lead to low self-esteem. Most patients report feelings of unworthiness, embarrassment and shame, which results in avoidance of social and occupational activities in 97% of those studied.16 The degree of insight a patient has is highly variable and exists on a continuum in every individual. It’s estimated that at least 40% are delusional for a period of time during their illness and during this time they are less likely to accept appropriate therapeutic intervention.17,18 Insight may also lessen with stress and social exposure. Fortunately, treatment often improves insight and patients may sympathize with their medical professionals and family for tolerating their sometimes difficult behavior. Repetitive behaviors are a major component of the behavior of BDD patients. Mirror gazing is the most common of these behaviors. Nearly 80% will pathologically gaze at their reflection; others may avoid reflective surfaces in an exaggerated way. The majority who mirror gaze are secretive about it and fear they will be perceived as vain or narcissistic. They are uniformly disgusted by their reflection. The drive to mirror gaze is so great that they will use any reflective surface available to gaze into, even a poorly reflective surface such as a spoon. A study in 2001 quantitated differences in mirror use between BDD patients (n=52) and controls (n=55).19 The mean duration of the longest session in front of the mirror was 73 minutes in the BDD patients and 21 minutes in the controls; while the maximum time spent was 174 minutes vs. 36 minutes, respectively. Participants rated the amount of distress they felt before starting their session on a scale of 1 to 10 (10 being the most distress). The BDD patients felt significantly more distress before beginning than controls (6.4 vs. 1.6). Motivation for using a mirror was different between patients with BDD and controls. Control subjects said they used the mirror for functional purposes, such as shaving or combing. On the other hand, patients with BDD used mirrors to constantly compare three different images; what they saw in the mirror, what they perceived to be the ideal image of themselves and the distorted image of themselves. This type of behavior led to uncertainty about how they really looked and started the vicious cycle of more mirror gazing to rectify the images. In general, BDD patients gaze in the mirror each time with a hope that they will finally look ideal and feel more comfortable. They also feel worse if they resist the impulse to look and need excessive amounts of time to perform another characteristic behavior: camouflaging. Camouflaging, comparing, and reassurance-seeking are all behaviors that become characteristically repetitive in BDD. Camouflaging is necessary for most of these patients to endure social situations and may involve wigs, makeup, body positioning, sunglasses, hats or clothing. They also constantly compare themselves with others, usually celebrities or models. Reassurance-seeking can frustrate family, friends and medical professionals when the patient requires reassurance that the defect is sufficiently camouflaged. This reassurance may reduce their stress for a short time, but then further reassurance is sought. Another form of reassurance is persuading others that the perceived flaw is real and it is, indeed, unattractive. Compulsive skin picking may be a sign of BDD (Figure 3). About 27% of people with the disorder pick at their skin to improve its appearance.20 Patients with BDD report that the urge to pick is difficult to resist and some may do it for hours each day. Patients may use various implements, such as needles, razors or knives. In one case report, a woman picked at her neck until she exposed her carotid artery.21 These patients are also more likely to report suicidal ideation and attempts. It is important to be aware that psychiatric co-morbidities are prevalent in BDD patients — 60% of BDD patients have concurrent depression and there is an 80% lifetime risk of depression. The BDD usually precedes the onset of depression, which may be secondary to BDD. One-third of patients will have social phobia, substance abuse or obsessive compulsive disorder. More that 50% will have avoidant personality disorder, which may explain why up to 20% of school-aged patients will drop out because of BDD.22 What Causes Body Dysmorphic Disorder? The pathophysiology of this disorder is still obscure but research in epidemiology, neurobiology, pharmacology and sociology are all contributing to a greater understanding of the condition. Although this condition is multifactorial, there appears to be a familial contribution to developing the disorder because a patient is four times more likely to have a first-degree relative with BDD than an individual without the diagnosis.23 It is therefore most likely that a nature and a nurture component to the familial predisposition exists. The neurobiological literature is extensive and gathered from imaging studies from patients with known BDD and other body image disorders, sometimes following neurologic trauma. It is well known that the temporal and occipital lobes of the brain process facial images. These areas, along with the parietal lobes, are involved in disorders with disturbed body image. Indirectly, treatment data support a neurochemical basis for the disorder. Antagonism of the serotonin system is known to exacerbate BDD symptoms. Based on this knowledge, it was presumed that under functioning, or lack of, serotonin contributed to the symptoms in BDD. Fortunately, treatment with serotonin reuptake inhibitors has proved beneficial to many patients and provides further evidence for the neurochemical imbalance.23 Epidemiology of Body Dysmorphic Disorder Few studies have focused on the epidemiology of BDD and the prevalence, and clinical features of the disorder vary depending on the population studied. The best evidence of lifetime prevalence in the general population is 1%.24 When a group of German college students was studied, 5.3% fit the criteria for BDD,25 whereas 13% of a cohort of American psychology students qualified.26 When patients in cosmetic surgery practices were screened in two studies, 6% to 15% fit the criteria for BDD.27,28 In 2001, 23% of patients seeking treatment with botulinum toxin type A (Botox) at a dermatology clinic matched the BDD profile.29 It is thought that many of the patients in these clinical settings would benefit more from psychotherapy than from the cosmetic procedures they desire. Even though the average age at which a BDD patient presents to a dermatologist is about 34 years old,30 the disorder usually begins in adolescence and affects an estimated 2.2% of 14 to 19 year olds.31 Most published clinical studies involve patients in their mid thirties, but those who have evaluated adolescents have found some troubling statistics. Two-thirds of adolescents with BDD report suicidal ideation, 21% have attempted suicide, 38% have engaged in violent behavior and 39% have been psychiatrically hospitalized.32 As a comparison, the suicide rate in the general population in 1999 was 11 per 100,000 and estimated attempts were just under 1%. In 1998, a study reported a 5% to 7% rate of suicidal ideation in patients with psoriasis and acne.34 This disorder affects men and women equally, but there are some interesting gender-related differences in the clinical features of BDD. Women are more frequently focused on breasts, hips, thighs and weight; whereas men are concerned more with body build, genitalia, hair and height. Women perform more repetitive behaviors such as mirror checking, camouflaging and skin picking. Men are more likely to abuse alcohol and have bi-polar affective disorder, while women suffer from bulimia, panic disorder and generalized anxiety disorder.30 A new subtype of BDD, muscle dysmorphia, has developed primarily in men.35 In these cases, men are fixated on muscle size and shape, and they perform repetitive behaviors such as camouflaging with clothing, mirror checking and reassurance-seeking. They may also exercise and take food supplements in excess. What are the Implications for Dermatologists? In a cohort of patients undergoing psychiatric treatment for BDD, nearly half had sought treatment from a dermatologist and one-third had requested cosmetic surgery. Approximately 20% had cosmetic surgery and two-thirds of these patients reported “no change” in or worsening of their appearance.30 Surgery may change their physical appearance but it does not alter their internal body image or mental state. When patients in general dermatology practices were screened in 2000, 10% to 14% had BDD, and their most frequent concerns were skin elasticity, skin coloring and perceived imperfections such as acne, scars, moles and cellulite.36 Physicians may underestimate the prevalence of this condition in their practices. In 2001, a survey by the American Society for Aesthetic Plastic Surgery showed that their physician members who responded estimated that only 2% of the patients in their practices had symptoms of BDD.6 How Do We Make the Diagnosis? Katharine Phillips devised a brief screening questionnaire called the Body Dysmorphic Disorder Questionnaire (BDDQ) (Figure 4).37 The questions reflect the DSM-IV criteria, but are only intended as a screening tool, not a diagnostic one. The first question establishes whether there is a preoccupation present. Many individuals might admit to being worried about how they look, but because we live in a society that places an extraordinarily high level of importance on the way we look, an affirmative answer to this question only hints at the possible presence of BDD. The second question addresses the issue of an eating disorder. The third question establishes whether the preoccupation causes significant distress or impairment. This is the most important factor in determining if clear BDD symptoms are present. Finally, quantifying the amount of time spent thinking about how they look is addressed. On average, people spend less than 1 hour per day thinking about their appearance; more than that is considered pathological. If this simple questionnaire is offered to patients waiting for a cosmetic consultation, the results can be discussed with them in an objective manner. They are likely to have BDD (or an “altered body image”) if: they are very worried about how they look; they think about their appearance more than 1 hour per day and wish they could think about it less; and their appearance has gotten in the way of work, school or interpersonal relationships. Treating Body Dysmorphic Disorder Psychotherapy. The treatment of choice for patients with BDD is psychotherapy, specifically cognitive behavioral therapy, which has been likened to “cosmetic surgery for the mind.” There are two components to cognitive behavioral therapy. Cognitive restructuring involves identifying and modifying automatic thoughts of the perceived physical defects. Then, behavioral techniques are prescribed to break the repetitive and self-destructive habits that characterize this disorder. When the patient starts substituting “healthier” behaviors for the problematic ones, they may feel more distressed, but this lessens with time. An example would be the therapeutic strategies often recommended for mirror gazing: only look into mirrors at a distance; do not use magnifying mirrors; limit the amount of time spent in front of the mirror; do not look into ambiguous reflective surfaces; focus on the whole area not one specific part; delay the urge to look in the mirror until the urge diminishes. An excellent tool to diminish skin picking using a cognitive behavioral approach was developed for the Internet by licensed psychologists Suzanne Mouton-Odom, Ph.D., and Nancy Keuthen, Ph.D., and dermatologist Allison Jones Stocker, M.D. The interactive Web site, www.stoppicking.com, encourages participants to record in a journal details about time spent picking at their skin.38 The journal is then used to illustrate patterns in their picking behavior and recommend alternate behaviors and coping strategies based on their picking patterns. Details are all plotted in graphs so patients can monitor their progress as they implement recommendations. The design is similar to many successful weight loss programs. Pharmacotherapy. Although early trials with antipsychotics, tricyclic antidepressants and electroconvulsive therapy were unsuccessful, the serotonin reuptake inhibitors (SRIs) showed promise. Nearly 60% of patients achieved partial remission or better, meaning decreased distress and depression, less time spent on obsessional thoughts, decreased ritualistic behavior, improved social function and improved insight. The improved insight is interesting because delusional symptoms in other disorders do not usually respond to SRIs.39 The first controlled pharmacologic study of BDD assessed clomipramine, a potent but non-selective SRI, and desipramine, a selective norepinephrine reuptake inhibitor.40 Desipramine had no effect on BDD symptoms but clomipramine was significantly better. Patients were started on 25 mg/day and increased slowly to a maximum of 250 mg/day or the highest tolerated dose. The mean dosage was 150 mg/day. An open-label trial of fluvoxamine, a selective SRI, demonstrated 70% of patients had “much” or “very much” improvement on the Clinical Global Impressions Scale (validated by the NIH).41 Uniquely, patients reported less anger and hostility while on treatment. The initial dose was 50 mg qhs, and it was increased by 50 mg every 4 to 7 days; doses of more than 100 mg were divided. The maximum dosage patients received during the trial was as high as 300 mg, but the mean was 260 mg/day. Another selective SRI, fluoxetine, was studied in a randomized, placebo-controlled manner.42 In patients studied, 20% had complete remission and 40% had partial remission. No adjunctive therapy was given (e.g. psychotherapy). Dosing was twice daily starting at 20 mg/day, increasing by 20 mg every 10 days. The maximum dose used was 80 mg and the mean was 50 mg/day. In an open-label trial of the selective SRI citalopram, 80% of participants had complete or partial remission.43 Addition-ally, the average time to onset of remission was shorter (4 to 6 weeks) than other SRIs (6 to 9 weeks), but no studies directly comparing different SRIs have been done. Citalopram was started at 20 mg/day and increased by 20 mg every 14 days to a maximum of 60 mg/day (once daily dosing). The mean dose was 50 mg/day. In general, BDD often requires higher doses than those needed for depression, and it is recommended the maximum, or highest tolerated, dose should be prescribed. An adequate trial is considered 12 to 16 weeks once the maximum dose is achieved. The antidepressant effects occur sooner than the anti-obsessive effects. In treatment-resistant cases combination therapy has been suggested although trials have not evaluated their effectiveness. Adding pimozide to SRIs in delusional patients was thought to improve insight (not with clomipramine since both drugs cause QT prolongation), but a recent study showed no benefit from adding pimozide.44 Adding buspirone or clomipramine to SRIs has been beneficial in some cases, but monitor clomipramine blood concentrations because they are augmented by SRIs.45 Avoiding Treating BDD Patients Established BDD is a contraindication to cosmetic medical and surgical treatments. BDD patients may never be satisfied with treatment outcomes, which leads to patient and physician frustration. Even if a skin condition (i.e. acne) improves with treatment, the BDD symptoms (i.e. picking) are not likely to remit without psychiatric intervention. If possible, incorporate the BDDQ into a medical history form or interview. In an atmosphere where cosmetic procedures are becoming very commonplace, it is imperative to remember these patients exist. If BDD, is suspected, keep in mind the likely co-morbidities, especially depression, and recognize the continuum of insight that exists and treat accordingly. If insight is good, referral to a psychotherapist trained in cognitive behavioral therapy may be possible early. If insight is poor and patients refuse referral, they may be amenable to treatment with SRIs to help them feel less distressed about their appearance, and if insight improves, then referral may be possible at a later date. It is important to censor our comments about patients’ features lest they be misinterpreted as overly critical. Many more controlled studies are necessary assessing the cognitive and behavioral approaches with SRIs on patients with BDD, as well as trials comparing different SRIs. Until then, it is important to keep the patients’ best interests in mind and avoid cosmetic procedures in this population.
CME #124: Recognizing Body Dysmorphic Disorder
CME #124 October 2005 Skin & Aging is proud to bring you this latest installment in its CME series. This series consists of regular CME activities that qualify you for two category 1 physician credit hours. As a reader of Skin & Aging, this course is brought to you free of charge — you aren’t required to pay a processing fee. This CME article focuses on body dysmorphic disorder and how it affects many patients. As the number of elective cosmetic procedures continues to grow, it’s important to be aware of this disorder and know how to recognize it. Lucinda S. Buescher, M.D., offers tips for how to screen cosmetic patients for this disorder and also discusses possible treatment options. At the end of this article, you’ll find a PDF of the exam and evaluation. Mark your responses in the designated area, and fax to HMP Communications at (610) 560-0501. Amy McMichael, M.D., CME Editor Amy McMichael, M.D., is Associate Professor in the Department of Dermatology, Director of the Hair Disorders Clinic and Residency Program Director at Wake Forest University Medical Center in Winston-Salem, NC. Principal Faculty: Lucinda Buescher, M.D. Method of Participation: Physicians may receive two category 1 credits by reading the article on pp. 89-94 and successfully answering the questions found on pp. 94-95. A score of 70% is required for passing. Submit your answers and evaluation via fax or log on to our Web site at www.skinandaging.com. Estimated Time to Complete Activity: 2 hours Date of Original Release: October 2005 Expiration Date: October 2006 Accreditation Statement: This activity is sponsored by the North American Center for Continuing Medical Education (NACCME). NACCME is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Designation Statement: NACCME designates this continuing medical education activity for a maximum of two category 1 credit(s) toward the AMA Physician’s Recognition Award. Each physician should claim only those credits that he/she actually spent in the educational activity. This activity has been planned and produced in accordance with the ACCME Essential Areas and Policies. Off-Label Disclosures: This educational activity contains discussion of published and/or investigational uses of agents that are not indicated by the FDA. Neither the North American Center for Continuing Medical Education, nor Mylan, Lilly, or Forest recommends the use of any agent outside of the labeled indications. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications and warnings. Disclosure Policy: All faculty participating in Continuing Medical Education programs sponsored by The North American Center for Continuing Medical Education are expected to disclose to the audience any real or apparent conflict(s) of interest related to the content of their presentation. Faculty Disclosures: Dr. Buescher has disclosed that she has no significant financial relationship with any organization that could be perceived as a real or apparent conflict of interest in the contexts of the subject of her presentation. Learning Objectives: 1. Raise physicians’ awareness of body dysmorphic disorder. 2. Learn simple screening questions to detect body dysmorphic disorder. 3. Learn appropriate treatment options for body dysmorphic disorder. Target Audience: Dermatologists, Plastic Surgeons, Internists Commercial Support: None Sponsor: NACCME Recognizing Body Dysmorphic Disorder T here is no doubt that we live in a culture that emphasizes physical beauty. You only need to look at images on television, magazine covers and billboards to realize that we are barraged with images of beauty perfection on a daily, and sometimes hourly, basis. Intellectually, we know that media photographs today are digitally modified, but in our quest for perfection it is easy to forget. Even children’s cartoons, publications and toys reflect the physical perfection that adults seek. We certainly can’t hold Barbie responsible for our unachievable physical expectations, but the doll is often used as an example of our tendency to portray humanly impossible (or at least improbable) physical beauty. There are many references to Barbie’s measurements if she were her real life size of 5’9” tall. On this scale she would measure 38-18-28.1 Compare that to the measurements of an “average” woman, 37-29-40, and the chance that a real woman would have Barbie’s measurements (without the assistance of a cosmetic surgeon) is less than 1 in 100,000.2 Girls are not alone in the subliminal exposure to superhuman physiques; boys have grown up with G. I. Joe as his muscularity has increased beyond average human proportion over the years. Still, nearly 90% of all cosmetic procedures are performed on women. Thompson et al comments on the cultural impact on body image satisfaction in their text “Exacting Beauty”: “Although thinness is at least partially under an individual’s control, many other socioculturally endorsed aspects of appearance, such as youth, height, and Caucasoid features, are less amenable to alteration. Thus, it has been hypothesized that although some changes may be possible through cosmetics or plastic surgery, sociohistorical changes favoring an aging population and expanding numbers of women of color will inevitably result in increasingly fewer women who are able to achieve the society’s ideal. Perhaps, as a result, increasing numbers of women have reported significant body image discontent. This places culture and physiology in conflict3; judging from the normative degree of dissatisfaction with one’s body among women4, culture appears to be winning.”5 Cosmetic Procedures on the Rise Is it any wonder that the number of cosmetic procedures performed in the last 7 years has increased nearly 400%?6 The cosmetic surgery data have been compiled annually by the American Society for Aesthetic Plastic Surgery (ASAPS) since 1997. In 2004, this organization surveyed cosmetic surgeons in the United States, including plastic surgeons, otolaryngologists and dermatologists. The non-surgical procedures far outnumber the surgical procedures performed (Figure 1). In fact, more botulinum toxin injections are performed than all other surgical procedures combined (Figure 2). Among the millions of patients seeking physical beautification through cosmetic procedures, approximately 10% suffer from body dysmorphic disorder (BDD). Treating these patients with cosmetic procedures can be unrewarding for you and for your patient because the expectations of these patients are unrealistic. This article will raise raise your awareness of this disorder, discuss some simple screening questions and review alternative strategies for managing this challenging disease. What is Body Dysmorphic Disorder? In 1891, dysmorphophobia7 was published in the medical literature and since then BDD has had many names including beauty hypochondria,8 dermatologic hypochondriasis9 and more recent publications refer to patients as “polysurgery addicts”10 and “insatiable.”11 Finally, in 1987, body dysmorphic disorder was given separate diagnostic status in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM III).12 One of the leading researchers of BDD, Dr. Katharine Phillips, was largely responsible for bringing this disease into public awareness with the publication of her text, “The Broken Mirror; Understanding and Treating Body Dysmorphic Disorder.”13 She also provided the most succinct, but descriptive, definition of this disorder: “the distress of imagined ugliness.”14 The most recent edition of the Diagnostic and Statistical Manual of Mental Disorders defines BDD as a preoccupation with an imagined defect in appearance; “if a slight physical anomaly is present; the individual’s concern is markedly excessive.”15 This is only the first criterion. Additionally, the preoccupation must cause significant distress or impairment in social, occupational or other important areas of functioning. This helps guard against overdiagnosis since researchers suggest that some degree of body image concern may be beneficial. A normal level of concern leads to regular grooming and hygiene which facilitate our interactions in society and maintain health. A final requirement for the diagnosis of BDD is that other mental disorders are ruled out, especially anorexia nervosa. Clinical Features of Body Dysmorphic Disorder The major feature of this disorder is a preoccupation with appearance. Usually the perceived flaw is located on the face or head, but any visible body part may be the focus of concern. Most frequently the preoccupation centers on the skin, hair or nose. Often there is more than one problematic area and there is a perception of disturbing asymmetry. The thoughts are difficult to resist and lead to low self-esteem. Most patients report feelings of unworthiness, embarrassment and shame, which results in avoidance of social and occupational activities in 97% of those studied.16 The degree of insight a patient has is highly variable and exists on a continuum in every individual. It’s estimated that at least 40% are delusional for a period of time during their illness and during this time they are less likely to accept appropriate therapeutic intervention.17,18 Insight may also lessen with stress and social exposure. Fortunately, treatment often improves insight and patients may sympathize with their medical professionals and family for tolerating their sometimes difficult behavior. Repetitive behaviors are a major component of the behavior of BDD patients. Mirror gazing is the most common of these behaviors. Nearly 80% will pathologically gaze at their reflection; others may avoid reflective surfaces in an exaggerated way. The majority who mirror gaze are secretive about it and fear they will be perceived as vain or narcissistic. They are uniformly disgusted by their reflection. The drive to mirror gaze is so great that they will use any reflective surface available to gaze into, even a poorly reflective surface such as a spoon. A study in 2001 quantitated differences in mirror use between BDD patients (n=52) and controls (n=55).19 The mean duration of the longest session in front of the mirror was 73 minutes in the BDD patients and 21 minutes in the controls; while the maximum time spent was 174 minutes vs. 36 minutes, respectively. Participants rated the amount of distress they felt before starting their session on a scale of 1 to 10 (10 being the most distress). The BDD patients felt significantly more distress before beginning than controls (6.4 vs. 1.6). Motivation for using a mirror was different between patients with BDD and controls. Control subjects said they used the mirror for functional purposes, such as shaving or combing. On the other hand, patients with BDD used mirrors to constantly compare three different images; what they saw in the mirror, what they perceived to be the ideal image of themselves and the distorted image of themselves. This type of behavior led to uncertainty about how they really looked and started the vicious cycle of more mirror gazing to rectify the images. In general, BDD patients gaze in the mirror each time with a hope that they will finally look ideal and feel more comfortable. They also feel worse if they resist the impulse to look and need excessive amounts of time to perform another characteristic behavior: camouflaging. Camouflaging, comparing, and reassurance-seeking are all behaviors that become characteristically repetitive in BDD. Camouflaging is necessary for most of these patients to endure social situations and may involve wigs, makeup, body positioning, sunglasses, hats or clothing. They also constantly compare themselves with others, usually celebrities or models. Reassurance-seeking can frustrate family, friends and medical professionals when the patient requires reassurance that the defect is sufficiently camouflaged. This reassurance may reduce their stress for a short time, but then further reassurance is sought. Another form of reassurance is persuading others that the perceived flaw is real and it is, indeed, unattractive. Compulsive skin picking may be a sign of BDD (Figure 3). About 27% of people with the disorder pick at their skin to improve its appearance.20 Patients with BDD report that the urge to pick is difficult to resist and some may do it for hours each day. Patients may use various implements, such as needles, razors or knives. In one case report, a woman picked at her neck until she exposed her carotid artery.21 These patients are also more likely to report suicidal ideation and attempts. It is important to be aware that psychiatric co-morbidities are prevalent in BDD patients — 60% of BDD patients have concurrent depression and there is an 80% lifetime risk of depression. The BDD usually precedes the onset of depression, which may be secondary to BDD. One-third of patients will have social phobia, substance abuse or obsessive compulsive disorder. More that 50% will have avoidant personality disorder, which may explain why up to 20% of school-aged patients will drop out because of BDD.22 What Causes Body Dysmorphic Disorder? The pathophysiology of this disorder is still obscure but research in epidemiology, neurobiology, pharmacology and sociology are all contributing to a greater understanding of the condition. Although this condition is multifactorial, there appears to be a familial contribution to developing the disorder because a patient is four times more likely to have a first-degree relative with BDD than an individual without the diagnosis.23 It is therefore most likely that a nature and a nurture component to the familial predisposition exists. The neurobiological literature is extensive and gathered from imaging studies from patients with known BDD and other body image disorders, sometimes following neurologic trauma. It is well known that the temporal and occipital lobes of the brain process facial images. These areas, along with the parietal lobes, are involved in disorders with disturbed body image. Indirectly, treatment data support a neurochemical basis for the disorder. Antagonism of the serotonin system is known to exacerbate BDD symptoms. Based on this knowledge, it was presumed that under functioning, or lack of, serotonin contributed to the symptoms in BDD. Fortunately, treatment with serotonin reuptake inhibitors has proved beneficial to many patients and provides further evidence for the neurochemical imbalance.23 Epidemiology of Body Dysmorphic Disorder Few studies have focused on the epidemiology of BDD and the prevalence, and clinical features of the disorder vary depending on the population studied. The best evidence of lifetime prevalence in the general population is 1%.24 When a group of German college students was studied, 5.3% fit the criteria for BDD,25 whereas 13% of a cohort of American psychology students qualified.26 When patients in cosmetic surgery practices were screened in two studies, 6% to 15% fit the criteria for BDD.27,28 In 2001, 23% of patients seeking treatment with botulinum toxin type A (Botox) at a dermatology clinic matched the BDD profile.29 It is thought that many of the patients in these clinical settings would benefit more from psychotherapy than from the cosmetic procedures they desire. Even though the average age at which a BDD patient presents to a dermatologist is about 34 years old,30 the disorder usually begins in adolescence and affects an estimated 2.2% of 14 to 19 year olds.31 Most published clinical studies involve patients in their mid thirties, but those who have evaluated adolescents have found some troubling statistics. Two-thirds of adolescents with BDD report suicidal ideation, 21% have attempted suicide, 38% have engaged in violent behavior and 39% have been psychiatrically hospitalized.32 As a comparison, the suicide rate in the general population in 1999 was 11 per 100,000 and estimated attempts were just under 1%. In 1998, a study reported a 5% to 7% rate of suicidal ideation in patients with psoriasis and acne.34 This disorder affects men and women equally, but there are some interesting gender-related differences in the clinical features of BDD. Women are more frequently focused on breasts, hips, thighs and weight; whereas men are concerned more with body build, genitalia, hair and height. Women perform more repetitive behaviors such as mirror checking, camouflaging and skin picking. Men are more likely to abuse alcohol and have bi-polar affective disorder, while women suffer from bulimia, panic disorder and generalized anxiety disorder.30 A new subtype of BDD, muscle dysmorphia, has developed primarily in men.35 In these cases, men are fixated on muscle size and shape, and they perform repetitive behaviors such as camouflaging with clothing, mirror checking and reassurance-seeking. They may also exercise and take food supplements in excess. What are the Implications for Dermatologists? In a cohort of patients undergoing psychiatric treatment for BDD, nearly half had sought treatment from a dermatologist and one-third had requested cosmetic surgery. Approximately 20% had cosmetic surgery and two-thirds of these patients reported “no change” in or worsening of their appearance.30 Surgery may change their physical appearance but it does not alter their internal body image or mental state. When patients in general dermatology practices were screened in 2000, 10% to 14% had BDD, and their most frequent concerns were skin elasticity, skin coloring and perceived imperfections such as acne, scars, moles and cellulite.36 Physicians may underestimate the prevalence of this condition in their practices. In 2001, a survey by the American Society for Aesthetic Plastic Surgery showed that their physician members who responded estimated that only 2% of the patients in their practices had symptoms of BDD.6 How Do We Make the Diagnosis? Katharine Phillips devised a brief screening questionnaire called the Body Dysmorphic Disorder Questionnaire (BDDQ) (Figure 4).37 The questions reflect the DSM-IV criteria, but are only intended as a screening tool, not a diagnostic one. The first question establishes whether there is a preoccupation present. Many individuals might admit to being worried about how they look, but because we live in a society that places an extraordinarily high level of importance on the way we look, an affirmative answer to this question only hints at the possible presence of BDD. The second question addresses the issue of an eating disorder. The third question establishes whether the preoccupation causes significant distress or impairment. This is the most important factor in determining if clear BDD symptoms are present. Finally, quantifying the amount of time spent thinking about how they look is addressed. On average, people spend less than 1 hour per day thinking about their appearance; more than that is considered pathological. If this simple questionnaire is offered to patients waiting for a cosmetic consultation, the results can be discussed with them in an objective manner. They are likely to have BDD (or an “altered body image”) if: they are very worried about how they look; they think about their appearance more than 1 hour per day and wish they could think about it less; and their appearance has gotten in the way of work, school or interpersonal relationships. Treating Body Dysmorphic Disorder Psychotherapy. The treatment of choice for patients with BDD is psychotherapy, specifically cognitive behavioral therapy, which has been likened to “cosmetic surgery for the mind.” There are two components to cognitive behavioral therapy. Cognitive restructuring involves identifying and modifying automatic thoughts of the perceived physical defects. Then, behavioral techniques are prescribed to break the repetitive and self-destructive habits that characterize this disorder. When the patient starts substituting “healthier” behaviors for the problematic ones, they may feel more distressed, but this lessens with time. An example would be the therapeutic strategies often recommended for mirror gazing: only look into mirrors at a distance; do not use magnifying mirrors; limit the amount of time spent in front of the mirror; do not look into ambiguous reflective surfaces; focus on the whole area not one specific part; delay the urge to look in the mirror until the urge diminishes. An excellent tool to diminish skin picking using a cognitive behavioral approach was developed for the Internet by licensed psychologists Suzanne Mouton-Odom, Ph.D., and Nancy Keuthen, Ph.D., and dermatologist Allison Jones Stocker, M.D. The interactive Web site, www.stoppicking.com, encourages participants to record in a journal details about time spent picking at their skin.38 The journal is then used to illustrate patterns in their picking behavior and recommend alternate behaviors and coping strategies based on their picking patterns. Details are all plotted in graphs so patients can monitor their progress as they implement recommendations. The design is similar to many successful weight loss programs. Pharmacotherapy. Although early trials with antipsychotics, tricyclic antidepressants and electroconvulsive therapy were unsuccessful, the serotonin reuptake inhibitors (SRIs) showed promise. Nearly 60% of patients achieved partial remission or better, meaning decreased distress and depression, less time spent on obsessional thoughts, decreased ritualistic behavior, improved social function and improved insight. The improved insight is interesting because delusional symptoms in other disorders do not usually respond to SRIs.39 The first controlled pharmacologic study of BDD assessed clomipramine, a potent but non-selective SRI, and desipramine, a selective norepinephrine reuptake inhibitor.40 Desipramine had no effect on BDD symptoms but clomipramine was significantly better. Patients were started on 25 mg/day and increased slowly to a maximum of 250 mg/day or the highest tolerated dose. The mean dosage was 150 mg/day. An open-label trial of fluvoxamine, a selective SRI, demonstrated 70% of patients had “much” or “very much” improvement on the Clinical Global Impressions Scale (validated by the NIH).41 Uniquely, patients reported less anger and hostility while on treatment. The initial dose was 50 mg qhs, and it was increased by 50 mg every 4 to 7 days; doses of more than 100 mg were divided. The maximum dosage patients received during the trial was as high as 300 mg, but the mean was 260 mg/day. Another selective SRI, fluoxetine, was studied in a randomized, placebo-controlled manner.42 In patients studied, 20% had complete remission and 40% had partial remission. No adjunctive therapy was given (e.g. psychotherapy). Dosing was twice daily starting at 20 mg/day, increasing by 20 mg every 10 days. The maximum dose used was 80 mg and the mean was 50 mg/day. In an open-label trial of the selective SRI citalopram, 80% of participants had complete or partial remission.43 Addition-ally, the average time to onset of remission was shorter (4 to 6 weeks) than other SRIs (6 to 9 weeks), but no studies directly comparing different SRIs have been done. Citalopram was started at 20 mg/day and increased by 20 mg every 14 days to a maximum of 60 mg/day (once daily dosing). The mean dose was 50 mg/day. In general, BDD often requires higher doses than those needed for depression, and it is recommended the maximum, or highest tolerated, dose should be prescribed. An adequate trial is considered 12 to 16 weeks once the maximum dose is achieved. The antidepressant effects occur sooner than the anti-obsessive effects. In treatment-resistant cases combination therapy has been suggested although trials have not evaluated their effectiveness. Adding pimozide to SRIs in delusional patients was thought to improve insight (not with clomipramine since both drugs cause QT prolongation), but a recent study showed no benefit from adding pimozide.44 Adding buspirone or clomipramine to SRIs has been beneficial in some cases, but monitor clomipramine blood concentrations because they are augmented by SRIs.45 Avoiding Treating BDD Patients Established BDD is a contraindication to cosmetic medical and surgical treatments. BDD patients may never be satisfied with treatment outcomes, which leads to patient and physician frustration. Even if a skin condition (i.e. acne) improves with treatment, the BDD symptoms (i.e. picking) are not likely to remit without psychiatric intervention. If possible, incorporate the BDDQ into a medical history form or interview. In an atmosphere where cosmetic procedures are becoming very commonplace, it is imperative to remember these patients exist. If BDD, is suspected, keep in mind the likely co-morbidities, especially depression, and recognize the continuum of insight that exists and treat accordingly. If insight is good, referral to a psychotherapist trained in cognitive behavioral therapy may be possible early. If insight is poor and patients refuse referral, they may be amenable to treatment with SRIs to help them feel less distressed about their appearance, and if insight improves, then referral may be possible at a later date. It is important to censor our comments about patients’ features lest they be misinterpreted as overly critical. Many more controlled studies are necessary assessing the cognitive and behavioral approaches with SRIs on patients with BDD, as well as trials comparing different SRIs. Until then, it is important to keep the patients’ best interests in mind and avoid cosmetic procedures in this population.
CME #124 October 2005 Skin & Aging is proud to bring you this latest installment in its CME series. This series consists of regular CME activities that qualify you for two category 1 physician credit hours. As a reader of Skin & Aging, this course is brought to you free of charge — you aren’t required to pay a processing fee. This CME article focuses on body dysmorphic disorder and how it affects many patients. As the number of elective cosmetic procedures continues to grow, it’s important to be aware of this disorder and know how to recognize it. Lucinda S. Buescher, M.D., offers tips for how to screen cosmetic patients for this disorder and also discusses possible treatment options. At the end of this article, you’ll find a PDF of the exam and evaluation. Mark your responses in the designated area, and fax to HMP Communications at (610) 560-0501. Amy McMichael, M.D., CME Editor Amy McMichael, M.D., is Associate Professor in the Department of Dermatology, Director of the Hair Disorders Clinic and Residency Program Director at Wake Forest University Medical Center in Winston-Salem, NC. Principal Faculty: Lucinda Buescher, M.D. Method of Participation: Physicians may receive two category 1 credits by reading the article on pp. 89-94 and successfully answering the questions found on pp. 94-95. A score of 70% is required for passing. Submit your answers and evaluation via fax or log on to our Web site at www.skinandaging.com. Estimated Time to Complete Activity: 2 hours Date of Original Release: October 2005 Expiration Date: October 2006 Accreditation Statement: This activity is sponsored by the North American Center for Continuing Medical Education (NACCME). NACCME is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Designation Statement: NACCME designates this continuing medical education activity for a maximum of two category 1 credit(s) toward the AMA Physician’s Recognition Award. Each physician should claim only those credits that he/she actually spent in the educational activity. This activity has been planned and produced in accordance with the ACCME Essential Areas and Policies. Off-Label Disclosures: This educational activity contains discussion of published and/or investigational uses of agents that are not indicated by the FDA. Neither the North American Center for Continuing Medical Education, nor Mylan, Lilly, or Forest recommends the use of any agent outside of the labeled indications. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications and warnings. Disclosure Policy: All faculty participating in Continuing Medical Education programs sponsored by The North American Center for Continuing Medical Education are expected to disclose to the audience any real or apparent conflict(s) of interest related to the content of their presentation. Faculty Disclosures: Dr. Buescher has disclosed that she has no significant financial relationship with any organization that could be perceived as a real or apparent conflict of interest in the contexts of the subject of her presentation. Learning Objectives: 1. Raise physicians’ awareness of body dysmorphic disorder. 2. Learn simple screening questions to detect body dysmorphic disorder. 3. Learn appropriate treatment options for body dysmorphic disorder. Target Audience: Dermatologists, Plastic Surgeons, Internists Commercial Support: None Sponsor: NACCME Recognizing Body Dysmorphic Disorder T here is no doubt that we live in a culture that emphasizes physical beauty. You only need to look at images on television, magazine covers and billboards to realize that we are barraged with images of beauty perfection on a daily, and sometimes hourly, basis. Intellectually, we know that media photographs today are digitally modified, but in our quest for perfection it is easy to forget. Even children’s cartoons, publications and toys reflect the physical perfection that adults seek. We certainly can’t hold Barbie responsible for our unachievable physical expectations, but the doll is often used as an example of our tendency to portray humanly impossible (or at least improbable) physical beauty. There are many references to Barbie’s measurements if she were her real life size of 5’9” tall. On this scale she would measure 38-18-28.1 Compare that to the measurements of an “average” woman, 37-29-40, and the chance that a real woman would have Barbie’s measurements (without the assistance of a cosmetic surgeon) is less than 1 in 100,000.2 Girls are not alone in the subliminal exposure to superhuman physiques; boys have grown up with G. I. Joe as his muscularity has increased beyond average human proportion over the years. Still, nearly 90% of all cosmetic procedures are performed on women. Thompson et al comments on the cultural impact on body image satisfaction in their text “Exacting Beauty”: “Although thinness is at least partially under an individual’s control, many other socioculturally endorsed aspects of appearance, such as youth, height, and Caucasoid features, are less amenable to alteration. Thus, it has been hypothesized that although some changes may be possible through cosmetics or plastic surgery, sociohistorical changes favoring an aging population and expanding numbers of women of color will inevitably result in increasingly fewer women who are able to achieve the society’s ideal. Perhaps, as a result, increasing numbers of women have reported significant body image discontent. This places culture and physiology in conflict3; judging from the normative degree of dissatisfaction with one’s body among women4, culture appears to be winning.”5 Cosmetic Procedures on the Rise Is it any wonder that the number of cosmetic procedures performed in the last 7 years has increased nearly 400%?6 The cosmetic surgery data have been compiled annually by the American Society for Aesthetic Plastic Surgery (ASAPS) since 1997. In 2004, this organization surveyed cosmetic surgeons in the United States, including plastic surgeons, otolaryngologists and dermatologists. The non-surgical procedures far outnumber the surgical procedures performed (Figure 1). In fact, more botulinum toxin injections are performed than all other surgical procedures combined (Figure 2). Among the millions of patients seeking physical beautification through cosmetic procedures, approximately 10% suffer from body dysmorphic disorder (BDD). Treating these patients with cosmetic procedures can be unrewarding for you and for your patient because the expectations of these patients are unrealistic. This article will raise raise your awareness of this disorder, discuss some simple screening questions and review alternative strategies for managing this challenging disease. What is Body Dysmorphic Disorder? In 1891, dysmorphophobia7 was published in the medical literature and since then BDD has had many names including beauty hypochondria,8 dermatologic hypochondriasis9 and more recent publications refer to patients as “polysurgery addicts”10 and “insatiable.”11 Finally, in 1987, body dysmorphic disorder was given separate diagnostic status in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM III).12 One of the leading researchers of BDD, Dr. Katharine Phillips, was largely responsible for bringing this disease into public awareness with the publication of her text, “The Broken Mirror; Understanding and Treating Body Dysmorphic Disorder.”13 She also provided the most succinct, but descriptive, definition of this disorder: “the distress of imagined ugliness.”14 The most recent edition of the Diagnostic and Statistical Manual of Mental Disorders defines BDD as a preoccupation with an imagined defect in appearance; “if a slight physical anomaly is present; the individual’s concern is markedly excessive.”15 This is only the first criterion. Additionally, the preoccupation must cause significant distress or impairment in social, occupational or other important areas of functioning. This helps guard against overdiagnosis since researchers suggest that some degree of body image concern may be beneficial. A normal level of concern leads to regular grooming and hygiene which facilitate our interactions in society and maintain health. A final requirement for the diagnosis of BDD is that other mental disorders are ruled out, especially anorexia nervosa. Clinical Features of Body Dysmorphic Disorder The major feature of this disorder is a preoccupation with appearance. Usually the perceived flaw is located on the face or head, but any visible body part may be the focus of concern. Most frequently the preoccupation centers on the skin, hair or nose. Often there is more than one problematic area and there is a perception of disturbing asymmetry. The thoughts are difficult to resist and lead to low self-esteem. Most patients report feelings of unworthiness, embarrassment and shame, which results in avoidance of social and occupational activities in 97% of those studied.16 The degree of insight a patient has is highly variable and exists on a continuum in every individual. It’s estimated that at least 40% are delusional for a period of time during their illness and during this time they are less likely to accept appropriate therapeutic intervention.17,18 Insight may also lessen with stress and social exposure. Fortunately, treatment often improves insight and patients may sympathize with their medical professionals and family for tolerating their sometimes difficult behavior. Repetitive behaviors are a major component of the behavior of BDD patients. Mirror gazing is the most common of these behaviors. Nearly 80% will pathologically gaze at their reflection; others may avoid reflective surfaces in an exaggerated way. The majority who mirror gaze are secretive about it and fear they will be perceived as vain or narcissistic. They are uniformly disgusted by their reflection. The drive to mirror gaze is so great that they will use any reflective surface available to gaze into, even a poorly reflective surface such as a spoon. A study in 2001 quantitated differences in mirror use between BDD patients (n=52) and controls (n=55).19 The mean duration of the longest session in front of the mirror was 73 minutes in the BDD patients and 21 minutes in the controls; while the maximum time spent was 174 minutes vs. 36 minutes, respectively. Participants rated the amount of distress they felt before starting their session on a scale of 1 to 10 (10 being the most distress). The BDD patients felt significantly more distress before beginning than controls (6.4 vs. 1.6). Motivation for using a mirror was different between patients with BDD and controls. Control subjects said they used the mirror for functional purposes, such as shaving or combing. On the other hand, patients with BDD used mirrors to constantly compare three different images; what they saw in the mirror, what they perceived to be the ideal image of themselves and the distorted image of themselves. This type of behavior led to uncertainty about how they really looked and started the vicious cycle of more mirror gazing to rectify the images. In general, BDD patients gaze in the mirror each time with a hope that they will finally look ideal and feel more comfortable. They also feel worse if they resist the impulse to look and need excessive amounts of time to perform another characteristic behavior: camouflaging. Camouflaging, comparing, and reassurance-seeking are all behaviors that become characteristically repetitive in BDD. Camouflaging is necessary for most of these patients to endure social situations and may involve wigs, makeup, body positioning, sunglasses, hats or clothing. They also constantly compare themselves with others, usually celebrities or models. Reassurance-seeking can frustrate family, friends and medical professionals when the patient requires reassurance that the defect is sufficiently camouflaged. This reassurance may reduce their stress for a short time, but then further reassurance is sought. Another form of reassurance is persuading others that the perceived flaw is real and it is, indeed, unattractive. Compulsive skin picking may be a sign of BDD (Figure 3). About 27% of people with the disorder pick at their skin to improve its appearance.20 Patients with BDD report that the urge to pick is difficult to resist and some may do it for hours each day. Patients may use various implements, such as needles, razors or knives. In one case report, a woman picked at her neck until she exposed her carotid artery.21 These patients are also more likely to report suicidal ideation and attempts. It is important to be aware that psychiatric co-morbidities are prevalent in BDD patients — 60% of BDD patients have concurrent depression and there is an 80% lifetime risk of depression. The BDD usually precedes the onset of depression, which may be secondary to BDD. One-third of patients will have social phobia, substance abuse or obsessive compulsive disorder. More that 50% will have avoidant personality disorder, which may explain why up to 20% of school-aged patients will drop out because of BDD.22 What Causes Body Dysmorphic Disorder? The pathophysiology of this disorder is still obscure but research in epidemiology, neurobiology, pharmacology and sociology are all contributing to a greater understanding of the condition. Although this condition is multifactorial, there appears to be a familial contribution to developing the disorder because a patient is four times more likely to have a first-degree relative with BDD than an individual without the diagnosis.23 It is therefore most likely that a nature and a nurture component to the familial predisposition exists. The neurobiological literature is extensive and gathered from imaging studies from patients with known BDD and other body image disorders, sometimes following neurologic trauma. It is well known that the temporal and occipital lobes of the brain process facial images. These areas, along with the parietal lobes, are involved in disorders with disturbed body image. Indirectly, treatment data support a neurochemical basis for the disorder. Antagonism of the serotonin system is known to exacerbate BDD symptoms. Based on this knowledge, it was presumed that under functioning, or lack of, serotonin contributed to the symptoms in BDD. Fortunately, treatment with serotonin reuptake inhibitors has proved beneficial to many patients and provides further evidence for the neurochemical imbalance.23 Epidemiology of Body Dysmorphic Disorder Few studies have focused on the epidemiology of BDD and the prevalence, and clinical features of the disorder vary depending on the population studied. The best evidence of lifetime prevalence in the general population is 1%.24 When a group of German college students was studied, 5.3% fit the criteria for BDD,25 whereas 13% of a cohort of American psychology students qualified.26 When patients in cosmetic surgery practices were screened in two studies, 6% to 15% fit the criteria for BDD.27,28 In 2001, 23% of patients seeking treatment with botulinum toxin type A (Botox) at a dermatology clinic matched the BDD profile.29 It is thought that many of the patients in these clinical settings would benefit more from psychotherapy than from the cosmetic procedures they desire. Even though the average age at which a BDD patient presents to a dermatologist is about 34 years old,30 the disorder usually begins in adolescence and affects an estimated 2.2% of 14 to 19 year olds.31 Most published clinical studies involve patients in their mid thirties, but those who have evaluated adolescents have found some troubling statistics. Two-thirds of adolescents with BDD report suicidal ideation, 21% have attempted suicide, 38% have engaged in violent behavior and 39% have been psychiatrically hospitalized.32 As a comparison, the suicide rate in the general population in 1999 was 11 per 100,000 and estimated attempts were just under 1%. In 1998, a study reported a 5% to 7% rate of suicidal ideation in patients with psoriasis and acne.34 This disorder affects men and women equally, but there are some interesting gender-related differences in the clinical features of BDD. Women are more frequently focused on breasts, hips, thighs and weight; whereas men are concerned more with body build, genitalia, hair and height. Women perform more repetitive behaviors such as mirror checking, camouflaging and skin picking. Men are more likely to abuse alcohol and have bi-polar affective disorder, while women suffer from bulimia, panic disorder and generalized anxiety disorder.30 A new subtype of BDD, muscle dysmorphia, has developed primarily in men.35 In these cases, men are fixated on muscle size and shape, and they perform repetitive behaviors such as camouflaging with clothing, mirror checking and reassurance-seeking. They may also exercise and take food supplements in excess. What are the Implications for Dermatologists? In a cohort of patients undergoing psychiatric treatment for BDD, nearly half had sought treatment from a dermatologist and one-third had requested cosmetic surgery. Approximately 20% had cosmetic surgery and two-thirds of these patients reported “no change” in or worsening of their appearance.30 Surgery may change their physical appearance but it does not alter their internal body image or mental state. When patients in general dermatology practices were screened in 2000, 10% to 14% had BDD, and their most frequent concerns were skin elasticity, skin coloring and perceived imperfections such as acne, scars, moles and cellulite.36 Physicians may underestimate the prevalence of this condition in their practices. In 2001, a survey by the American Society for Aesthetic Plastic Surgery showed that their physician members who responded estimated that only 2% of the patients in their practices had symptoms of BDD.6 How Do We Make the Diagnosis? Katharine Phillips devised a brief screening questionnaire called the Body Dysmorphic Disorder Questionnaire (BDDQ) (Figure 4).37 The questions reflect the DSM-IV criteria, but are only intended as a screening tool, not a diagnostic one. The first question establishes whether there is a preoccupation present. Many individuals might admit to being worried about how they look, but because we live in a society that places an extraordinarily high level of importance on the way we look, an affirmative answer to this question only hints at the possible presence of BDD. The second question addresses the issue of an eating disorder. The third question establishes whether the preoccupation causes significant distress or impairment. This is the most important factor in determining if clear BDD symptoms are present. Finally, quantifying the amount of time spent thinking about how they look is addressed. On average, people spend less than 1 hour per day thinking about their appearance; more than that is considered pathological. If this simple questionnaire is offered to patients waiting for a cosmetic consultation, the results can be discussed with them in an objective manner. They are likely to have BDD (or an “altered body image”) if: they are very worried about how they look; they think about their appearance more than 1 hour per day and wish they could think about it less; and their appearance has gotten in the way of work, school or interpersonal relationships. Treating Body Dysmorphic Disorder Psychotherapy. The treatment of choice for patients with BDD is psychotherapy, specifically cognitive behavioral therapy, which has been likened to “cosmetic surgery for the mind.” There are two components to cognitive behavioral therapy. Cognitive restructuring involves identifying and modifying automatic thoughts of the perceived physical defects. Then, behavioral techniques are prescribed to break the repetitive and self-destructive habits that characterize this disorder. When the patient starts substituting “healthier” behaviors for the problematic ones, they may feel more distressed, but this lessens with time. An example would be the therapeutic strategies often recommended for mirror gazing: only look into mirrors at a distance; do not use magnifying mirrors; limit the amount of time spent in front of the mirror; do not look into ambiguous reflective surfaces; focus on the whole area not one specific part; delay the urge to look in the mirror until the urge diminishes. An excellent tool to diminish skin picking using a cognitive behavioral approach was developed for the Internet by licensed psychologists Suzanne Mouton-Odom, Ph.D., and Nancy Keuthen, Ph.D., and dermatologist Allison Jones Stocker, M.D. The interactive Web site, www.stoppicking.com, encourages participants to record in a journal details about time spent picking at their skin.38 The journal is then used to illustrate patterns in their picking behavior and recommend alternate behaviors and coping strategies based on their picking patterns. Details are all plotted in graphs so patients can monitor their progress as they implement recommendations. The design is similar to many successful weight loss programs. Pharmacotherapy. Although early trials with antipsychotics, tricyclic antidepressants and electroconvulsive therapy were unsuccessful, the serotonin reuptake inhibitors (SRIs) showed promise. Nearly 60% of patients achieved partial remission or better, meaning decreased distress and depression, less time spent on obsessional thoughts, decreased ritualistic behavior, improved social function and improved insight. The improved insight is interesting because delusional symptoms in other disorders do not usually respond to SRIs.39 The first controlled pharmacologic study of BDD assessed clomipramine, a potent but non-selective SRI, and desipramine, a selective norepinephrine reuptake inhibitor.40 Desipramine had no effect on BDD symptoms but clomipramine was significantly better. Patients were started on 25 mg/day and increased slowly to a maximum of 250 mg/day or the highest tolerated dose. The mean dosage was 150 mg/day. An open-label trial of fluvoxamine, a selective SRI, demonstrated 70% of patients had “much” or “very much” improvement on the Clinical Global Impressions Scale (validated by the NIH).41 Uniquely, patients reported less anger and hostility while on treatment. The initial dose was 50 mg qhs, and it was increased by 50 mg every 4 to 7 days; doses of more than 100 mg were divided. The maximum dosage patients received during the trial was as high as 300 mg, but the mean was 260 mg/day. Another selective SRI, fluoxetine, was studied in a randomized, placebo-controlled manner.42 In patients studied, 20% had complete remission and 40% had partial remission. No adjunctive therapy was given (e.g. psychotherapy). Dosing was twice daily starting at 20 mg/day, increasing by 20 mg every 10 days. The maximum dose used was 80 mg and the mean was 50 mg/day. In an open-label trial of the selective SRI citalopram, 80% of participants had complete or partial remission.43 Addition-ally, the average time to onset of remission was shorter (4 to 6 weeks) than other SRIs (6 to 9 weeks), but no studies directly comparing different SRIs have been done. Citalopram was started at 20 mg/day and increased by 20 mg every 14 days to a maximum of 60 mg/day (once daily dosing). The mean dose was 50 mg/day. In general, BDD often requires higher doses than those needed for depression, and it is recommended the maximum, or highest tolerated, dose should be prescribed. An adequate trial is considered 12 to 16 weeks once the maximum dose is achieved. The antidepressant effects occur sooner than the anti-obsessive effects. In treatment-resistant cases combination therapy has been suggested although trials have not evaluated their effectiveness. Adding pimozide to SRIs in delusional patients was thought to improve insight (not with clomipramine since both drugs cause QT prolongation), but a recent study showed no benefit from adding pimozide.44 Adding buspirone or clomipramine to SRIs has been beneficial in some cases, but monitor clomipramine blood concentrations because they are augmented by SRIs.45 Avoiding Treating BDD Patients Established BDD is a contraindication to cosmetic medical and surgical treatments. BDD patients may never be satisfied with treatment outcomes, which leads to patient and physician frustration. Even if a skin condition (i.e. acne) improves with treatment, the BDD symptoms (i.e. picking) are not likely to remit without psychiatric intervention. If possible, incorporate the BDDQ into a medical history form or interview. In an atmosphere where cosmetic procedures are becoming very commonplace, it is imperative to remember these patients exist. If BDD, is suspected, keep in mind the likely co-morbidities, especially depression, and recognize the continuum of insight that exists and treat accordingly. If insight is good, referral to a psychotherapist trained in cognitive behavioral therapy may be possible early. If insight is poor and patients refuse referral, they may be amenable to treatment with SRIs to help them feel less distressed about their appearance, and if insight improves, then referral may be possible at a later date. It is important to censor our comments about patients’ features lest they be misinterpreted as overly critical. Many more controlled studies are necessary assessing the cognitive and behavioral approaches with SRIs on patients with BDD, as well as trials comparing different SRIs. Until then, it is important to keep the patients’ best interests in mind and avoid cosmetic procedures in this population.
