© Springer International Publishing Switzerland 2015Neelam A. Vashi (ed.)Beauty and Body Dysmorphic Disorder10.1007/978-3-319-17867-7_14
14. Approach and Resources
Department of Dermatology, Cosmetic and Laser Center, Boston University, 609 Albany Street, J602, 02118 Boston, MA, USA
Department of Dermatology, Boston University School of Medicine, Boston Medical Center, 609 Albany St, J602, 02118 Boston, MA, USA
General Tips for Caring for Those with Suspected BDD
Empathize with the patient.
Act in a nonjudgmental way.
Do not comment on the perceived defect.
Do not offer cosmetic treatments.
Ask about suicidal thoughts.
Familiarize yourself with resources and offer patients information regarding the disorder.
Refer the patient to an appropriate mental health expert.
Recognize that patients may not accept the referral.
Decide your comfort level with starting treatment.
Empathize with the patient. Statements such as “sorry for the suffering,” “I understand that you are experiencing much anxiety,” or “I think that there is a way for you to feel better” may be helpful, while also not acknowledging the actual appearance complaint.
Approach the patient in a calm and nonjudgmental way. Many are ashamed and feel misunderstood. Do not compare those with body dysmorphic disorder (BDD) to other people in terms of appearance or functioning as this may make them feel worse.
Do not argue with patients about how they look, discuss appearance at length, or try to talk persons out of their faulty beliefs . Comments such as “you look fine,” “did not notice it,” and “not that bad” do not work. Although certain individuals, typically those with some insight, may benefit from the occasional reminder that their view is wrong and due to a mental disorder, the majority will not believe your comments to be true. Even if a response does temporarily improve symptoms, this short-lived relief fuels more attempts to again obtain this reassurance. Therefore, the main objective is to not comment on the appearance.
Do not offer cosmetic treatments. If you have already provided treatment, be willing to stop and avoid being defensive. If a patient is suspected but unknown to have BDD, avoid all invasive procedures; however, it may be acceptable to provide a minimally invasive procedure that is relatively inexpensive and not permanent, and reevaluate on follow-up. Although the vast majority should be excluded from surgery, a group of authors describe a subset of patients with the “Thersites complex,” who may be candidates for cosmetic correction after careful selection . The authors describe those with this complex as having excessive preoccupation with an actual but minor bodily defect or anomaly. Relative indications include a minimal real deformity (Thersites complex) with excessive concern, realistic expectations, acceptable surgical risks, and operative feasibility. Of note, many contraindications are discussed including multiple previous surgical operations, aggressive behavior, unacceptable surgical risk, and psychoses.
Always ask about suicidal ideation. Immediate treatment is needed for any patient with suicidal thought. Rates of attempted and completed suicide are surprisingly very high in those with BDD, possibly higher than any other mental illness [3–6].
Familiarize yourself with those in your community who can offer help, support, and treatment for your patients. See the below list of national and international resources.
Refer the patient to a mental health expert in your area. Once suspected, it is imperative that a patient receive appropriate psychiatric treatment from a mental health expert familiar with BDD. When making the referral, remain calm, nonjudgmental, matter-of-fact, and empathetic. If a patient is hesitant or refuses to get mental health treatment, try changing the focus on the suffering he or she is experiencing and the effect of this on his or her quality of life and everyday functioning. Focus on the time spent on every day worry, the stress on his or her mind and body because of intrusive thoughts, and the inability to live a normal life. Discuss his or her lack of control and how the thoughts and obsessions are, in fact, controlling his or her life . Encourage a trial of treatment, and discuss that he or she does not necessarily have to be on it for his or her entire life. If mild and with some insight, refer the patient to a mental health expert with experience in cognitive-behavioral therapy (CBT) and BDD. If moderate, the patient can be started on a selective serotonin reuptake inhibitor (SSRI) or referred to a CBT specialist, or both. If severe, the patient needs to be on an SSRI and referred to a mental health expert. BDD can be life-threatening so always inquire into suicidal thoughts.
Recognize that patients may not accept the referral. If a patient is insistent upon cosmetic care and has poor to absent insight, one can try referral to psychiatry as a standard protocol.
Decide your comfort level with starting SSRIs. If patients are delusional, suggest trying an SSRI to help other symptoms that have become associated, that is, depressed mood. Alternatively, suggest trying an SSRI as an experiment to see how it will affect mood and symptoms. After patients’ symptoms improve, they may be more amenable to referral to a trained expert.
Approach to Diagnosis
Be willing to ask simple screening questions.
Are you very worried about your appearance or certain features?
Do you think about your appearance a lot and wish you could think about it less?
Does your appearance upset you a lot?
Has it caused you any problems with work, school, or relationships?
Are there things you avoid because of your appearance?
Familiarize yourself with screening questionnaires.
Look for red flags.
The initial consultation is the first means in establishing a physician–patient relationship. This consultation can incorporate simple screening questions for the practitioner to better understand patient motivations and concerns. If suspected, simple screening questionnaires can be administered. The Body Dysmorphic Disorder Questionnaire and Body Dysmorphic Disorder Questionnaire—Dermatology Version are both simple, short questionnaires that can be administered in the waiting room as an effective way to identify those who may have symptoms of BDD. See Chap. 11.
Look for red flags that may be indicators of underlying pathology. Red flags include doctor shopping with dissatisfaction of results; checking appearance in mirrors excessively; seeking reassurance; using makeup and clothing to cover up defects; making statements indicating impairment in work, school, or social realms; and spending substantial amounts of time thinking about or trying to camouflage the defect.
Approach to Therapy
Obtain a medication history as SSRIs should not be given with some medications, such as monoamine oxidase inhibitors.
Calm the patient about misconceptions and concerns regarding the medication.
Start with a low dose.
Increase the dose gradually while monitoring for side effects.
Make sure the medication is dosed appropriately at a high enough dose for at least 12–16 weeks.
After improvement for several months, a slow and gradual lowering of dose can be attempted to see if a lower dose works equally as well.
Switch to a different SSRI if the medication is not efficacious after an appropriate trial.
Add a medication if the medication partially works.
Do not stop the SSRI abruptly. It should be gradually tapered.
SSRIs are generally safe and well tolerated. No pretreatment labs are required. Side effects are typically infrequent and mild-moderate in nature. They are more likely to occur early in treatment and/or when the dose is raised. They may improve or disappear on their own with time. In addition, a slower up titration or lowering the dose can give the body time to adjust and diminish side effects. Reported side effects include fatigue, nausea, sexual dysfunction, insomnia, decreased appetite, jittery sensations, and sweating. These will resolve upon discontinuation of the medication.
Prior to starting an SSRI, make sure to address patient concerns and misconceptions. SSRIs are not addictive or habit forming. Although occasionally patient may experience fatigue or agitation, they act normal and not “drugged” or “high.” They are overall well-tolerated with minimal side effects. A patient may state that a particular SSRI did not work in the past; however, discuss that it may not have worked because it was not given at a high-enough dose for a long-enough period of time. SSRIs need to be taken every day, at the highest dose tolerated for 3–4 months to indicate an appropriate treatment trial . If an appropriate trial was made, another can be tried as patients can respond differently to different SSRIs. Alternatively, if a patient had a partial response to an appropriate trial, another medication can be added to the regimen.
Start with a low dose, and gradually increase the dose, while monitoring for side effects. For example, a dose can typically be increased after 2 weeks. A reasonable goal is to the reach the maximum dose based on package insert within 4–9 weeks of starting the medication . Make sure the medication is dosed appropriately as BDD often needs higher than typical dosages. An appropriate medication trial involves the patient taking the medication for at least 12–16 weeks. The dosage should be at the highest tolerated or maximum recommended for 3 of these weeks before concluding that the medication is ineffective . Once improvement is seen for several months, a slow and gradual lowering of dose can be attempted to see if a lower dose works equally well. If the medication is not efficacious after an appropriate trial, try switching to a different SSRI. If the medication works partially, another medication can be added to improve efficacy. At this point, a psychiatrist and/or other trained medical experts should be involved. Make sure to never stop SSRIs abruptly. They should be gradually tapered.
Behavior Tactics that Can Be Offered
Patients who are motivated and accept their diagnosis will likely benefit from CBT. CBT should be administered by a trained professional with BDD experience; however, some behavioral tactics can be offered. Habit reversal can be suggested prior to official CBT initiation. Habit reversal begins with awareness training in that the patient first writes down detailed information about the behaviors. Then alternative behaviors are offered to compulsive behaviors (e.g., skin picking), such as clenching one’s fists or knitting. Activity scheduling involves the act of actually scheduling activities throughout the day in an appointment book. This is an attempt to minimize idle time so as to leave less time for BDD obsessions and compulsive behaviors. Vocational rehabilitation may be helpful for those who have been unemployed for a lengthy amount of time. The first step may be a volunteer job, which also decreases idle time .