Detect and treat body dysmorphic disorder

Neelam Ajit Vashi, M.DDermatologists may consider referring patients who present with body dysmorphic disorder (BDD) for mental health care and/or may consider prescribing selective serotonin reuptake inhibitors (SSRIs) for these patients, according to Neelam Ajit Vashi, M.D., speaking at the American Academy of Dermatology meeting earlier this year.

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“Body image dissatisfaction is very common in modern society,” says Dr. Vashi. “Some degree of it is normal, but BDD is a chronic disorder of self-perception that occurs when there is a pre-occupation with imagined defects that cause impairment in social life or in one’s occupation. The defect may be non-existent or it may be a minimal flaw.” Dr. Vashi is Assistant Professor of Dermatology, Director, Boston University Center for Ethnic Skin, Cosmetic and Laser Center, Boston University School of Medicine, Boston Medical Center in Boston, Mass.

Classification and degree

In the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), the disorder has been classified under the newly formed obsessive-compulsive spectrum category.

READ: Dermatologists should recognize BDD

“There are degrees of BDD, and when the disease is mild, it is challenging for dermatologists to detect it,” according to Dr. Vashi. “BDD can be very difficult to diagnose. Patients may not talk about their distress. It is a question of deciding whether the patient’s pre-occupation is disproportionate. Patients may not be forthright with their distress because they have already been refused a procedure. They may have a new strategy by the time they see you and not provide all the information.”

When a patient reports that he or she has been to a dozen physicians, that should be a red flag that the patient has BDD and that other physicians have not complied with dermatological or cosmetic requests, says Dr. Vashi.

Ninety percent of patients with BDD who undergo a procedure to correct a perceived defect report that their symptoms remain unchanged or are worse following the procedure.

The preoccupation for patients who have BDD often involves features of the face such as the nose or the skin, notes Dr. Vashi. “These patients may ask for a hair transplant when they have had no hair loss, deeming the procedure not necessary,” says Dr. Vashi. “They may ask for laser treatment to treat a scar that does not exist.”

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In terms of presentation, the average age at which patients with BDD are diagnosed is 34, but the mean age of onset is 16 to 17, suggesting that there is a delay in diagnosis, explains Dr. Vashi. And while the disorder presents in 0.7% to 2.4% of individuals in the general population, it is more common in dermatology practices, with 9% to 14% of dermatology patients presenting with BDD. In particular, it has a higher incidence in cosmetic dermatology practices compared to general dermatology practices. Epidemiologically, the ratio of males to females who present with BDD is equal, adds Dr. Vashi.

NEXT: Risk factors and screening

Risk factors and screening

Several factors increase the risk of patients developing BDD such as having a first-degree relative who has the disorder. “A total of 8% have a first-degree relative who has the disorder,” notes Dr. Vashi.

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Another risk factor is experiencing childhood adversity, such as being bullied or teased, explains Dr. Vashi. “Recent studies suggest those who were bullied more or teased more had a greater incidence of BDD.”

There are several screening tools that can be employed to detect BDD, such as the Yale-Brown Obsessive Compulsive Scale modified for BDD (BDD-Y-BOCS), the Body Dysmorphic Disorder Questionnaire (BDDQ), the BDDQ-Dermatology Version, the Dysmorphic Concern Questionnaire, and the Body Image Concern Inventory. Some of the screening tools are more time-intensive to use than others, notes Dr. Vashi, suggesting the BDDQ-Dermatology Version is effective and efficient for busy dermatological practices.

Apart from using screening tools, dermatologists can ask some basic questions that provide them with an idea of the severity of BDD with which the patient presents, says Dr. Vashi.

“Ask the patient why he or she is interested in the procedure, how much stress it is causing the patient, and how often the patient is thinking about the defect. This will provide insight” into the severity of the disorder.

NEXT: Treatment options

Treatment options

Treatment options for BDD can include referring patients with BDD to mental health specialists. “If the patient is housebound and has suicidal thoughts, the patient needs immediate care,” says Dr. Vashi.

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Cognitive-behavioral therapy (CBT) can prove effective. Patients who have some insight into their disorder are better suited to participating in CBT compared to patients who have no insight and may be delusional.

It is estimated that up to 39% of patients are delusional, notes Dr. Vashi, adding that “patients have to be motivated to participate in CBT. Patients who aren’t delusional and have insight into the idea that they may be wrong are easier to treat. These patients are good candidates for CBT. Delusional patients will say they don’t believe you and will resist referral. For these patients, one may consider introducing a selective serotonin reuptake inhibitor (SSRI) to help with their distress.”

Because there is a relationship between BDD and serotonin levels and 5HT activity, SSRIs, which are used in the treatment of depression, are appropriate in the treatment of BDD, says Dr. Vashi, adding that physicians should obtain the history of medication use from the patient before prescribing the patient an SSRI.

“It has clearly been shown that BDD responds to neurotransmitter changes, specifically the SSRIs,” says Dr. Vashi. “Higher doses (of SSRI’s), however, are needed to treat BDD than for the treatment of MDD (major depressive disorder). It is best to start with a lower dose and gradually increase to a higher dose.”

In particular, research points to escitalopram and citalopram as effective pharmacotherapies in the treatment of patients with BDD. “Patients given these particular SSRIs showed earlier response rates and higher improvement scores," according to Dr. Vashi.

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Patients with BDD may need to take an SSRI for an extended period of time, says Dr. Vashi. “There is a high relapse rate. Chances are patients will be on one (SSRI) for a long time.”

BDD patients can also experience comorbid illness, with 75% having a lifetime prevalence of comorbid depression, says Dr. Vashi.

Dermatologists have not expressed comfort with prescribing psychopharmacological treatment such as SSRIs. Indeed, only 11% expressed that they would be comfortable with prescribing an SSRI to a patient with BDD, and 72% stating that had never prescribed an SSRI.

The consequences of not effectively treating BDD can be grave: the completed suicide rate of patients with BDD is 37 times higher than the general population. Nearly one in four patients with BDD (22% to 24%) has a history of suicide attempts.    

If a dermatologist does opt to refer a patient with BDD to a mental-health professional for CBT, it is wise for the dermatologist to follow up with that patient to evaluate that the patient received treatment and symptoms were improved, says Dr. Vashi.

Disclosures: Dr. Vashi recently acted as lead author and editor of Beauty and Body Dysmorphic Disorder.

BDD stats at a glance:

90% of patients with BDD who undergo a procedure to correct a perceived defect report that their symptoms remain unchanged or are worse following the procedure.

The completed suicide rate of patients with BDD is 37 times higher than the general population.

22% of BDD patients has a history of suicide attempts.

The average age at which patients with BDD are diagnosed is 34, but the mean age of onset is 16 to 17, suggesting a pattern of delay in diagnosis.

While BDD presents in 0.7% to 2.4% of individuals in the general population, it is more common in dermatology practices, with 9% to 14% of dermatology patients presenting with BDD.

The ratio of males to females who present with BDD is equal.

8% have a first-degree relative who has the disorder.

Up to 39% of patients are delusional.

75% having a lifetime prevalence of comorbid depression.

Only 11% of dermatologists expressed that they would be comfortable with prescribing an SSRI to a patient with BDD.