© Springer International Publishing Switzerland 2015Neelam A. Vashi (ed.)Beauty and Body Dysmorphic Disorder10.1007/978-3-319-17867-7_12
12. Therapeutic Interventions for Body Dysmorphic Disorder
Department of Dermatology, University of California San Francisco, 515 Spruce Street, 94118 San Francisco, CA, USA
KeywordsTreatmentSelective-serotonin reuptake inhibitorsCognitive behavioral therapyInference-based therapy
Patients with body dysmorphic disorder (BDD) often seek nonpsychiatric treatment. Many will attempt to receive cosmetic treatments for appearance enhancement, the most common being dermatologic and surgical . If unable to find a cosmetic surgeon to perform the treatment, some may become so desperate that they perform surgery on themselves . BDD responds poorly to such treatments and can even become worse. The expeditious recognition of BDD and commencement of treatment can have a positive impact on BDD patients’ lives . With adequate treatment, patients may experience full or substantial remission of symptoms and have an improved quality of life . The most effective and validated treatment options will be discussed in this chapter, including psychotherapeutic and pharmacologic interventions.
Psychological and pharmacological treatments for BDD both have significant utility . No head-to-head studies exist comparing the efficacy of psychotherapy and pharmacotherapy directly. A meta-analysis suggests that psychotherapy may be the more impactful of the two ; however, the effect of psychotherapy may be overestimated in the literature due to lack of blinding in control groups. The utilization of both treatment options in conjunction may have synergistic effects. Medication can make it easier for patients to realize the positive effects of psychotherapy and should certainly be considered in patients with severe cases of BDD .
When evaluating BDD patients for treatment, it is important to evaluate for psychiatric comorbidities. There is overlap in the symptoms, response to treatments, and even a genetic link between obsessive–compulsive disorder (OCD) and BDD. Anxiety, major depressive disorder, and social phobias are very commonly comorbid with BDD as well . Furthermore, BDD patients may or may not be delusional (36 % of BDD patients were delusional in one study) . The consideration of comorbidities, classification, and severity should be incorporated in the decision-making process when making a treatment regimen for BDD.
There are many barriers to overcome when treating BDD, and successful treatment will be contingent upon the acceptance, cooperation, and motivation of the patient. While some patients may feel relieved with the diagnosis of BDD, most BDD patients will be reluctant to accept their diagnosis. In addition, mental illness can, unfortunately, be stigmatized, which may make some reluctant to seek treatment. The clinician should not attempt to convince the patient that his or her beliefs are incorrect but should also avoid validating them. It is important to establish an alliance with the patient, to be empathic for the patient’s suffering, and to focus on discussing the potential for improvement with proper psychotherapeutic and/or pharmacologic treatment.
Cognitive behavioral therapy (CBT) that specifically focuses on BDD symptoms is the first-line of psychotherapeutic treatment for BDD . Both individual and group sessions of CBT are effective in treating BDD [9, 10]. CBT has also been shown to be safe and effective in children and adolescents . The use of inference-based therapy (IBT), where the therapy revolves around the patient’s misguided inferences about their body image, may be a beneficial therapeutic approach as well . There is very limited evidence evaluating other forms of psychotherapy for the treatment of BDD .
Therapeutic techniques for BDD are developed around the understanding of thought processes prevalent in BDD. For patients with BDD, appearance is believed to be highly important, and individuals tend to see themselves as unattractive . Patients with BDD are thought to have enhanced aesthetic sensitivity . Compared to a control group, functional magnetic resonance imaging (fMRI) studies revealed that BDD patients are much more focused on recognizing facial details than on processing facial information holistically . Individuals with BDD tend to have high levels of perfectionism and compare themselves extensively with others. Perceived teasing may also have a significant role in BDD . Maladaptive appearance-related behaviors, values, and beliefs perpetuate the disorder .
CBT entails using cognitive and behavioral therapeutic strategies in conjunction over the course of treatment. In the treatment of BDD, cognitive methods have focused on recognizing maladaptive thoughts, helping the patient realize overvalued beliefs about physical appearance, and instituting cognitive restructuring regarding body dissatisfaction. Behavioral components of therapy for BDD have entailed methods such as exposure therapy, response prevention, and relapse prevention . These methods are detailed below.
Cognitive Behavioral Therapy
CBT is a practical treatment approach that teaches skills and includes cognitive restructuring, behavioral experiments, exposure, and response prevention. It focuses on changing and substituting, both, beliefs and thoughts (cognitive aspect) and behaviors (behavioral aspect) such as skin picking and mirror checking. CBT should be tailored to the individual person and performed by a trained therapist who is familiar in treating BDD. It is typically administered as weekly, hourly sessions. Wilhelm et al. developed a treatment manual for CBT for BDD. The CBT-BDD methods include the following facets as outlined below :
Psychoeducation and cognitive-behavioral case formulation begins the process of CBT-BDD by educating the patient about BDD and developing a cognitive-behavioral model for the patient’s specific symptoms.
Cognitive restructuring entails evaluating maladaptive thoughts with Socratic questioning and identifying cognitive errors with the goal of developing more accurate and helpful beliefs.
Exposure identification provides insight on situations that provoke anxiety. Patients should gradually practice confronting these situations with the goal of eventually no longer needing to avoid these stressors.
Ritual prevention identifies situations in which rituals are performed and strategies are developed to reform them to stop compulsive behaviors.
Mindfulness/perceptual retraining helps the patient’s mind focus on the body as a whole. Patients use objective, nonjudgmental language to describe the entire body in the mirror with avoidance of excessively focusing on details.
Advanced cognitive strategies identify and challenge deeply rooted negative beliefs to broaden the basis for self-worth.
Relapse prevention strategies may entail scheduling healthy activities to replace and distract from time spent on compulsive BDD-related repetitive behaviors.
Targeted modular interventions may focus on specific patients needs such as: (1) skin picking and hair plucking, (2) muscularity and weight, (3) cosmetic treatments, and (4) mood management.
A randomized waitlist-control study evaluated the efficacy of CBT-BDD . Efficacy was evaluated using the body dysmorphic disorder-Yale Brown Obsessive Compulsive Scale (BDD-YBOCS), the most frequently used scale for BDD treatment response. Responders were defined as having greater than 30 % improvement at the end of the treatment period. After 12 weeks of weekly 60-min sessions, 50 % (8 of 16) of participants in the treatment group were BDD-YBOCS responders compared to 12 % (2 of 17) in the waitlist control group (p = 0.026). After 12 weeks, all study participants were crossed over into the treatment group, and by the end of the 22-week study, 81 % (26 of 32) of all participants were responders. Patient satisfaction in this study also was high (client satisfaction inventory with score of 87.3 %), and treatment gains were maintained when evaluated at a 6-month follow-up.
Traditional CBT methods (not according to the BDD-CBT protocol) have also been efficacious in the treatment of BDD in a number of controlled trials and case series. A randomized waitlist-controlled study evaluated the efficacy of 12 weeks of CBT in BDD patients. They found that the treatment group had a mean 50 % reduction in symptoms on the BDD-YBOCS with a significant difference compared to the control group (treatment group 22.00 pre-, 10.75 posttreatment; waitlist group 21.18 pre-, 24.33 posttreatment, p < 0.01) . A higher score corresponds to more severe symptoms on the BDD-YBOCS. Evidence has repeatedly supported the efficacy of individual CBT in the treatment of BDD, and it is considered as the first-line psychotherapeutic technique. In fact, CBT was found to be the best-established treatment for a variety of somatoform disorders, including BDD, in a review of 34 randomized controlled trials involving 3922 patients .
Group CBT has also been studied and found to be useful in the treatment of BDD. One randomized waitlist-controlled study (n = 54) demonstrated significantly improved scores on the body dysmorphic disorder examination (BDDE) (treatment group 93.9 pre-, 41.4 posttreatment; waitlist group 89.9 pre-, 83.2 posttreatment, p < 0.001) . A higher score corresponded to more severe symptoms. Not only was the treatment effective, but also the patients reported a positive impression of the therapy. During the weekly 2-h sessions of 8 weeks, attendance was 100 %, and 80 % of the participants said they would recommend the program. Another case series demonstrated the efficacy of group CBT (BDD-YBOCS pretreatment 28.5, posttreatment 21.3); however, this study lacked a control group . The demonstrated efficacy of group CBT may have the added benefits of increased social support and decreased cost. Direct comparisons of efficacy and compliance between individual and group CBT for BDD are needed.
BDD is commonly seen in adolescents, but the treatment in this population has not been well studied. From the limited data available, CBT has been successful in the pediatric population. One case series found that 4 of 6 patients were responders by the BDD-YBOCS, and that all of these patients also experienced a concomitant decrease in depressive symptoms . CBT has been demonstrated to be effective in adults and data suggest this is true in pediatrics as well; however, more studies in this population are warranted. When working with a younger population, it is important to adjust the technique by using appropriate language and interaction approach for the age group. Emphasizing behavioral strategies over cognitive strategies may be beneficial for younger patients as well .
Inference-based therapy (IBT) is a technique that was originally developed for patients with OCD with particularly fixed beliefs or obsessions. BDD shares features with OCD including obsessions, fixed ideations, and repetitive behaviors. Many BDD patients have overvalued ideation (OVI), which is a very strong conviction in the objective reality of their belief without the level of certainty to qualify as a delusion. Patients with OVI may be less likely to respond to CBT .
In IBT, BDD obsessions are conceptualized as a two-step process where the establishment of a faulty inference is used as the basis for a secondary inference with negative anticipated consequences. For example, the belief that “I am not big enough to get noticed” (faulty inference) may be followed by the inference “if I never get noticed, I will never find a girlfriend” (negative consequence). In this case, the patient was 90 % convinced that if he did not perform his rituals (working out), he would suffer the negative consequence (never getting a girlfriend) . In IBT, the therapist first tries to explore the patient’s fear or believed negative consequence and then works backward to help identify the initially held obsessional belief . These faulty inferences are the primary target for therapeutic intervention with IBT. One case series demonstrated the efficacy of IBT for patients with BDD . IBT may be especially useful in patients with firmly held ideations contributing to their BDD. More studies are needed on the emerging topic of IBT for BDD.
Selective-serotonin reuptake inhibitors (SSRIs) are the first-line agents in the pharmacologic treatment of BDD [22, 23]. These are antidepressants that have also been shown to have efficacy in diminishing OCD-type symptoms. By inhibiting the reuptake of serotonin, SSRIs increase the availability of this neurotransmitter at cell–cell junctions. While there are currently no medications approved by the FDA for the treatment of BDD, SSRIs are the most studied and efficacious medications in the treatment of BDD. SSRIs have been shown to be more effective in treating BDD compared to non-SSRI medications [24, 25]. They also appear to help people with delusional BDD as much as those with non-delusional BDD . Modification of SSRI treatment by adding a non-SSRI psychotropic medication can be beneficial in recalcitrant cases. Some non-SSRI medications may be effective in the treatment of BDD as monotherapy as well.
Selective-Serotonin Reuptake Inhibitors (SSRIs)
SSRIs are useful for the medical management of many psychiatric conditions including: major depressive disorder, OCD, generalized anxiety disorder, panic disorder, phobias, bulimia, posttraumatic stress disorder, and a number of off-label uses, including BDD. They are generally well tolerated, but common mild–moderate side effects include: gastrointestinal disturbances, agitation, anxiety, insomnia, and sexual dysfunction. SSRI medications currently available include: fluvoxamine (Luvox®) 50–300 mg/day, fluoxetine (Prozac®) 20–80 mg/day, paroxetine (Paxil®) 20–50 mg/day, sertraline (Zoloft®) 50–200 mg/day, citalopram (Celexa®) 20–40 mg/day, and escitalopram (Lexapro®) 10–20 mg/day. Clomipramine (Anafranil®) 150–250 mg/day is a nonselective serotonin reuptake inhibitor (SRI) that has also been used as treatment for BDD. Clomipramine is generally not used first-line as it is more likely to cause side effects and can be toxic at very high doses.
Randomized controlled studies and open-label studies have been conducted on fluoxetine, fluvoxamine, citalopram, and escitalopram, all demonstrating clinically significant improvements in symptoms. In a randomized placebo-controlled trial, fluoxetine was shown to be effective in 53 % of patients compared to 18 % in the placebo group. The mean response time was 7.7 weeks in these patients, and the mean dose was 77.7 mg/day . The relative response to fluoxetine compared to the placebo group was 3.07 . Two open-label studies demonstrated the efficacy of fluvoxamine in the treatment of BDD [27, 28]. In one study, 10 of 12 patients were markedly improved after 10 weeks of fluvoxamine therapy . In the other study, 63.3 % (n = 30) of patients responded to fluvoxamine based on the BDD-YBOCS with a mean response time of 6.1 weeks and a mean dose of 238 mg/day . An open-label study evaluated the efficacy of citalopram for the treatment of BDD and found that 73.3 % (11 of 15 patients) were responders after 12 weeks . The mean endpoint dose for citalopram was 51.3 mg/day and mean time to response was 4.6 weeks. An open-label study of escitalopram demonstrated an efficacy of 73.3 % (11 of 15 patients) with a mean endpoint dose of 28.0 mg/day (starting at 10 mg/day, increasing dose by 10 mg every 2 weeks up to 30 mg/day) and a mean time to response of 4.7 weeks . Although no studies have compared one SSRI to another, one author has noted that escitalopram and citalopram had somewhat higher percentages of patient improvement, had higher percentages of “very much improved” compared to only “much improved,” and lastly, many patients in those studies responded earlier (within 2–6 weeks) . More research is needed; however, it may be that escitalopram and citalopram are most efficacious.