CLINICAL SYNTHESIS

Body Dysmorphic Disorder: Clinical Aspects and Relationship to Obsessive-Compulsive Disorder Katharine A. Phillips, M.D.

Body dysmorphic disorder (BDD)osan obsessive-compulsive and related disorder that is common and usually causes sub­stantial distress and impairment in psychosocial functioning. BDD is associated with markedly poor quality of lifeand highrates of suicidal ideation and behavior. The first-linepharmacologic approach is a serotonin reuptake inhibitor, often at relatively high doses; serotonin reuptake inhibitors are also recommended for patients with delusional BDDbeliefs The first­lme psychosocial treatment is manualized cognitive-behavioral therapy that is tailoredto BDD's unique clinical features; it is not recommended that therapists simply apply cognitive-behavioral approaches for other disorders, such as obsessive-compulsive disorder (OCD)Because insight is so often absent or poor in BDDmotivational interviewing techniques are often needed to engage and retain patients in treatment. Cosmetic treatment (e.g~ surgery or dermatologic treatment) is not recommended because It appears to only rarely improve BOD symptoms and can even make them worse. BOD has many similarities to OCD and 1s probably closely relat~d to OCD, but the two disorders also have some important differences. From a clinical perspective, the most important differences are that BOD is characterized by poorer insight, more frequent comorbid major depressive disorder and substance use disorders, and more frequent suicidality. Although treatment approaches have similarities to those for OCD. effective cognitive-behavioral therapy for BOD meaningfully differs from that forOCD

Body dysmorphic disorder (BOD) is about as common as obsessive-compulsive disorder (OCD). BDD typically causes substantial impairment in psychosocial functioning-on par with, or perhaps even more severe than, that typically seen in OCD. BDD is associated with high rates of suicidality, which is of particular importance to clinicians.

Despite its prevalence and severity, BDD usually goes unrecognized in clinical settings; sometimes it is misdi­agnosed as OCD, yet BOD is not simply OCD. Although BDD has much in common with OCD and is newly catego­rized in DSM-5 as one of the obsessive-compulsive and re­lated disorders, BDD and OCD have a number of important differences. For example, BDD appears to be characterized by more frequent suicidality, comorbid major depressive disorder and substance use disorders, and poorer insight, which can make it difficult to engage and retain patients in treatment.

Although research on BDD lags far behind that of most other severe psychiatric disorders, understanding of BDD has increased dramatically in recent decades. Treatment research is still limited, yet findings are con­sistent in indicating that serotonin reuptake inhibitors (SRis) (often at relatively high doses) are often effica­cious, as is cognitive-behavioral therapy (CBT) that is specifically tailored to BDD's unique clinical features. Table 1 provides a summary of some key clinical aspects of BDD.

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DEFINITION AND CORE CLINICAL FEATURES OFBDD

Diagnostic Criteria for BDD in DSM-5 Criterion A . Individuals with BDD are preoccupied with one or more perceived defects or flaws in their appearance; the perceived defects, however, are not observable or appear only slight to other people (criterion A) (1). Patients typically describe disliked areas as looking"ugly," "unattractive," or "deformed," although they actually look normal (2). The appearance pre­occupations usually occur for :a:: l hour a day; the average is 3- 8 hours a day (3). They are intrusive, distressing, unwanted, and usually difficult to resist and control (3, 4).

The skin (usually facial skin) is the most frequently disliked body area (e.g., perceived acne, scarring, color, or wrinkles), fol­lowed by the hair (usually head hair; e.g., thinning hair or ex­cessive facial hair) and nose (often size or shape). However, any body area may be the focus of preoccupation, such as teeth, eyes, mouth, jaw, ears, head size or shape, breasts, thighs, stomach, legs, hands, genitals, or body build (5, 6). The number of areas of excessive concern ranges from one to virtually the entire body, with an average of five to seven areas over the course of the disorder (5, 6). More than 25% of patients have at least one concern involving asymmetry (e.g., uneven hair or asymmetrical nostrils), which should be diagnosed as BOD rather than OCD (7).

Criterion B. The appearance preoccupations trigger excessive repetitive behaviors that focus on checking, fixing, hiding, or

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TABLE L Some Key Facts About Body Dysmorphlc Disorder

The core features or BOD are distressing or impairing preoccupation with nonexistent or slight defects or flaws in appearance; the preoccupation triggers excessive repetitive behaviors that attempt to check. fix. hide, or obtain reassurance about the perceived bodily deformities le.g . mirror checking. comparing with others. excessive grooming. reassurance seeking. and skin picking).

BOD is about as common as OCD. with a current prevalence or approximately 2% or the population.

BOD affects nearly as many men as women.

Many patients with BOO express suicidal ideation. and the rates of suicide attempts and completed suicide appear markedly elevated.

Individuals with BOD may be reluctant to spontaneously reveal their appearance concerns to psychiatrists and other mental health clinicians; thus. BOD may be misdiagnosed as major depressive disorder, social anxiety disorder, OCD. agoraphobia. and other disorders. Patients should be specifically asked about BOD symptoms.

The recommended first-line medication for BOD is an SRI, even if appearance beliefs are delusional 1n nature.

SRI doses and trial durations are similar to those used for OCD; higher doses and a longer treatment trial than those typically used tor depression and most other disorders are recommended.

Antipsychotics may be helpful in addition to an SRI but are not recommended as monotherapy tor patients with any level of insight (including delusional BOD).

Cognitive-behavioral therapy that 1s specifically tailored to BDD 1s the psychosocial treatment of choice. Simply treating BOD as if it were OCD 1s not recommended. Because the treatment can be complex and challenging. use of a BOD-specific treatment manual is recommended.

BOO. body dysmorphtc disorder; OCO. obsessive-compulsive disorder; SRI, serotonin reuptake inhibitor

obt:iining reassurance about the perceived flaws (1, 4). These behaviors intend to {but often do not) alleviate emotional dis­tress caused by the appearance preoccupations (4). Virtually all patients perform one or more of these repetitive behaviors at some point during the course of the disorder, as reflected in criterion B, a new criterion in DSM-5 (3). BDO repetitive be­haviors have many similarities to OCD compulsions (8); they are commonly referred to as compulsions or rituals. Like OCD rit­uals, BOD repetitive behaviors are typically difficult to resist or control, are distressing, and usually occur for ~I hour a day (most often, for 3-8 hours a day) (3, 8).

Table 2 lists common repetitive BOD behaviors (5, 6). This list is not exhaustive; patients may engage in other re­petitive behaviors, such as compulsive shopping for hair products, videotaping their "receding" hairline, or searching for information about surgery onlinc. Most of these behav­iors are observable, hut some- most notably, comparing with others- arc mental acts.

More than 90% of patients camouflage their perceived defects, hiding them with a hat, their hair, makeup, clothes, or body position (5, 6). The goal of camouflaging is to avoid or escape unpleasant feelings or prevent a feared event, such

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Pl-llll IPS

TABLE 2. Common Repetitive Behaviors (Compulsions) in Body Dysmorphic Disorde,.a

Behavior Percentage

Comparing disliked body parts with the same areas BB on others (e.g .• in person. online. on television)

Checking disliked body areas in mirrors or other B7 reflecting surfaces

Grooming (e.g .. applying makeup: cutting, styling, shaving. or removing head hair. facial hair, o r body hair)

Seeking reassurance about the perceived defects or questioning others about how they look (e.g., ·can't you see this on my face?'I

Touching the disliked areas to check their appearance

Changing clothes (e.g .. to camouflage disl~ked

areas or find an outfit that distracts others from the ·defects-)

Dieting (e.g .• to make a ·wide. face narrower)

Skin picking to improve perceived skin flaws

Tanning (e.g .• to darken ·pate· skin)

Excessive exercising

Excessive weight lifting

• Lifetime rates.

59

54

52

46

39

3B

25

21

lB

as being ridiculed. In this sense, it is a safety behavior; how­ever, camouflaging can be done repeatedly (e.g., repeatedly rearranging one's bongs to hide a supposedly high forehead) and thus may fulfill DSM-5 criterion B.

Criteria C and D. The appearance preoccupations and re­sulting repetitive behaviors must cause clinically significant distress or impairment in social, occupational, or other im­portant areas of functioning (criterion C) (1). Appearance pre­occupations that focus on excessive body fat or weight and qunlify for an eating disorder diagnosis should be diagnosed as an eating disorder rather than BOD (criterion D) (1).

BDD Specifiers in DSM-5: Muscle Dysmorphin, Insight, nnd Panic Attacks DSM-5 added two new specifiers to BOD's definition, which identify important subgroups of individuals \vith BDD as follows.

Muscle dysmorphia. The "with muscle dysmorphia" speci­fier identifies normal-looking individuals (usually men) who are preoccupied with the inaccurate belief that their body build is too small or insufficiently muscular (1, 3, 9). Some men with the muscle dysmorphia form ofBDD are unusually muscular because they abuse anabolic steroids or exces~ sively lift weights (9). This specifier is used if patients also have nonmuscle-focused appearance preoccupations.

Insight. The "insight" specifier indicates level of insight re­garding BOD beliefs (a typicnl belief is "I look ugly."). DSM-5 provides the following three levels of insight (1): "with good

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BODY OYSMORPH C DISORDER ANO RELATIONSHIP TO OCD

FIGURE 1. Level of lnsight/DelusionaUty in Body Dysmorphic Disorder Versus Obsessive-Compulsive Oisorde,.a

45

40

35 "' u Cl> 30 D' :> 25 Vl

0 20 c

Cl> l:! 25 Cl>

CL 10

5

0 Delusional Poor Fair

aoco ln~2991 •BOD (nz327l

Good Excellent

aTotal score on the Brown Assessment of Beliefs Scale BOD, body dysmorph1c disorder; OCD, obsessive-compulsive disorder.

or fair insight": the person recognizes that a belief about his or her appearance is definitely or probably not true, or that it may or may not be true; "with poor insight": the person thinks the BDD belief probably is true; and "with absent insight/ delusionnl beliefs": the person is completely convinced that the BDD belief is true.

These levels are identical to DSM-S insight levels for OCD and hoarding disorder, and the definition of the different levels of insight is similar to that for OCD (degree of con­viction that the BDD or OCD belief is accurate).

The new insight specifier conveys several clinically relevant points (10). First, individuals who are completely convinced that their BDD belief is true-that they truly are ugly, defonned, or abnonnnl looking-should be diagnosed with "BDD \vith absent insight/delusional beliefs" rather thnn a psychotic dis­order (this point was unclear in prior editions of DSM). Second, because delusional BDD and nondelusionnl BOD appear to be the same disorder, varying only in degree ofinsight, they should be treated similarly. Finally, specifying level of insight allows identification of patients with absent or poor insight who may be reluctant to accept a psychiatric diagnosis and treatment (instead believing that they actually look dcfonned and need cosmetic treatment). Psychiatrists may need to put greater emphasis on motivational interviewing and development of a good therapeutic alliance in order to successfully eng:ige and retain such patients in treatment

Figure 1 shows level of insight in BOD versus OCD (11). In both disorders, insight spans a full range, from excellent to absent (i.e., delusional beliefs). However, in BDD, insight reg:irding the perceived appearance defects (e.g., "I look ugly") is usually ~bsent or poor. By contrast, about 85% of individuals with OCD have excellent, good, or fair insight into the beliefs that underlie their obsessions (e.g., whether the house realty will burn down if they do not check the stove 30 times). Individuals with BDD arc also less likely than those with OCD to recognize that their disorder-related beliefs have a psychiatric/psychological cause, rather than actually being true (Figure 2). Thus, patients with BDD may

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FIGURE 2. Does Body Dysmorphic Disorder/Obsessive­Compulslve Disorder Belief Have a Psychiatric/ Psychological Cause?•

70

60

"' 50 ~ :g- 40 Vl

c 30 CV l:! 8!. 20

OOCO (n•299} • BDD(n•320I

Dehnitely Probably Possibly Probably Definitely does not does not does does does

~ Item 6 on the Brown Assessment of Beliefs Scale. Phillips et al. (11). BOD. body dysmorphic disorder; OCO. obsessive compulsive disorder

be more difficult to engage nnd retain in treatment than those with OCD.

Panic attacks. The "with panic attacks" specifier may be used for any disorder characterized by disordeHriggered panic attacks (as opposed to panic attacks that "come out of the blue," as in panic disorder) (1). Nearly 30% of patients with BDD experience panic attacks that are triggered by BDD symptoms (e.g., when looking at perceived defects in the mirror, when feeling that others are scrutinizing them, or when in a place with bright lights) (12).

Although not designated by a specifier in DSM-5, BDD by proxy is a form of BDD in which an individual has distressing or impairing preoccupations with perceived defect-; in another person's appearance (4). For example, a parent may be pre­occupied with her toddler's "pushed in" nose and not let the child leave the house or attend family g:itherings because it would be too embarrassing for others to see his nose.

KEY ASSOCIATED FEATURES

Many patients feel embarrassed and ashamed by their supposed physical deformities (4). A majority experience BOD-related ideas or delusions of reference, falsely believing that others take special notice of them in a neg:itive way because of their "defects" (e.g., stare at, talk about, or mock them) (6, 11). BDD is also associated with high levels of rejection sensitivity, social anxiety and avoidance, anxiety, depressed mood, neuroticism, and hostility, as well as low levels of self-esteem, extravcrsion, and assertiveness (4).

EPIDEMIOLOGY

In nationwide epidemiologic studies in adults, BOD is about as common as OCD, with a point (current) prevalence of 2.4% in the United States and l.7"/o- 1.8% in Germany (13-15). In epidemiologic samples, individuals with BDD arc less likely to

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be living with a partner or employed and are more likely to report suicidal ideation and suicide attempts due to appear­ance concerns (13, 14).

BDD also appears common in clinicaJ settings, with a prev­alence of 13%-16% among general psychiatric adult inpa­tients in the United States {16, 17). An inpatient study found that BDD was more common than OCD, schizophrenia, post­traumatic stress disorder, eating disorders, and a number of other disorders; patients with BOD had significantly lower scores on the Global Assessment of Functioning scale and twice the rate of suicide attempts as those without BDD (17). Among adolescent psychiatric inpatients, 7%-14% had current BOD (17, 18). BDD also appears fairly common in dermatology (9%-15%), cosmetic surgery (7%-15% in most studies), and orthodontia settings (8%), and among patients presenting for oral or maxillofacial surgery (10%-13%) (4, 19).

BDD is slightly more common in females than in males in epidemiologic samples (13-15); the largest clinical studies have similarly found a slight preponderance of females or an equal proportion of males and females (5, 6).

AGE AT ONSET AND COURSE OF ILLNESS

Two-thirds of persons with BDD experience BDD onset in childhood or adolescence, most often at age 12-13 years (20). BOD virtually never onsets after age ~40 years (20). Those with onset before age 18 years are more likely to have at­tempted suicide and been psychiatrically hospitalized, and they have more comorbidity (20).

In the only prospective observational study of BDD's course of illness, BOD tended to he chronic (21). In up to 4 years of follow-up, the cumulative probability of full remission was only 0.20, and the cumulative probability of full or partial remission was only 0.55. A lower likelihood of remission was predicted by being an adult., greater BOD severity at intake into the study, and longer lifetime duration of BDD. Subjects who partially or fully remitted during the follow-up period had a cumulative probability of subsequent full relapse of 0.42. The probability of subsequent full or partial relapse was 0.63, which was predicted by more severe BDD at study in­take and earlier age at BDD onset. Most subjects received treatment in the community, but few received treatment currently considered adequate for BDD.

BOD IN YOUTH

BDD is particularly concerning in youth. Youth have poorer insight regarding their perceived appearance defects and are more likely than adults to attempt suicide (44% versus 24%) (22). At a trend level, youth have more severe BDD than adults with BDD and are more likely to be psychiatrically hospitalized (43% versus 24%) (22). An inpatient study found that youth with BDD had more severe anxiety and depression, as well as significantly higher scores on a standardized mea­sure of suicide risk, than youth without significant body image concerns (18).

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PHILLiPS

A substantia1 proportion of youth with BDD refuse to attend school because they reel too ugly to be seen, and 18%- 22% drop out of school primarily because of BDD symptoms (22, 23). Because BOD often persists unless appropriately treated, it is important to identify and treat youth with BDD, especially those who attempt suicide or refuse to attend school. Untreated BOD in youth often impedes accomplishment of developmentaJ tasks and transitions such as completing school, dating, and de­veloping social competence. These deficits not uncommonly persist well into adulthood and may even be lifelong.

IMPAIRMENT IN PSYCHOSOCIAL FUNCTIONING

BDD is associated with markedly impaired psychosocial func­tioning and very poor mental health- and physical health­related quality oflife (24, 25). Scores on measures such as the Medical Outcomes Study 36-item Short-Form Health Survey are typically severaJ standard deviation units below commu­nity norms and 0.4-0.7 SD units below norms for depression (24, 25). A prospective observational study found that the cumulative probability of attaining functional remission on the Global Assessment of Functioning (score > 70 for at least 2 consecutive months) during the follow-up period (mean follow-up period of 2.7 ± 0.9 years) was only 5.7% (26). More severe BOD symptoms predict poorer functioning and quality of life (24-26).

More severely impaired individuals are completely socially isolated, quit their job or drop out of school, and are house­bound (sometimes for many years) to avoid being seen ( 4, 6). Nearly 40% of individuals with BOD have been psychiatri­cally hospitalized, and more than one-quarter attribute at least one hospitalization primarily to BDD (5).

SUICIDALITY

A high proportion of individuals with BOD-higher than in OCD-experience suicidal ideation (about 80% lifetime) and attempt suicide (24%-28% lifetime) (27, 28). In a nationwide epidemiologic study, 31% of subjects with BDD reported thoughts about committing suicide specifically because of appearance concerns, and 22% had actually attempted suicide due to appearance concerns {14). Among psychiatric inpatients, those with BDD had double the suicide attempt rate as those without BOD (17). In a study of inpatients with anorexia nervosa, those with comorbid BOD had triple the number of suicide attempts as those without BDD (29). Suicide attempts often have high potential lethality and intent, and thus they must be taken seriously (27).

Suicidal ideation and suicide attempts are both in­dependently predicted by greater BOD severity (27). In ad­dition, suicidal ideation is associated with lifetime comorbid major depressive disorder, and suicide attempts are associated with lifetime comorbid posttraumatic stress disorder and a substance use disorder (27).

Completed suicide in BOD has been only minimally studied, but the rate appears markedly elevated; it may be

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BODY DVSMORPHIC DISORDER AND RELATIONSHIP TO OCD

even higher than in bipolar disorder and major depressive disorder (30). In a retrospective 20-ycar study, most patients in two dermatology practices who committed suicide had acne or BDD (31).

Patients with BDD may feel suicidal because they feel hopeless about being "deformed," feel they cannot improve how they look, feel rejected by others because they are "ugly,'' feel socially isolated and mocked by others because of how they look (referential thinking), and believe they are unlovable and worthless. In addition, many have comorbid major depressive disorder (5, 32).

GENDER-RELATED ASPECTS OF BOD

BDD's clinical features (e.g., demographics, body areas of concern, comorbidity, suicidality) have more similarities than differences in females and males (5, 33, 34). However, females appear more likely to be preoccupied with weight (being overweight), breasts, hips, legs, and "excessive" body hair; to check mirrors, pick their skin, and camouflage their bodies to hide disliked areas; and to have a comorbid eating disorder. Men appear more likely to be single; to be pre­occupied with "small" body build (muscle dysmorphia), "thinning" hair, and genitals (often penis size); and to have a comorbid substance use disorder. Men also appear some­what more impaired in terms of psychosocial functioning (e.g., to be unemployed and receiving disability payments).

COMORBIDITY

The largest samples of subjects assessed with the Structured Clinical Interview for DSM-I\' indicate that about three­quarters of individuals with BDD have past or current major depressive disorder, the most common comorbid disorder (6, 32). BDD usually onsets first, and many patients attribute depressive symptoms to the suffering caused by BDD (32). A past or current substance use disorder occurs in 30% 50% of individuals with BDD, nearly 70% of whom attribute their substance use problem at least in part to the distress caused by BDD (32, 35). About 20% of men with muscle dysmorphia abuse anabolic androgenic steroids to build muscle (9). These drugs may cause abuse or dependence and may have adverse physical and psychiatric effects, such as depressive symptoms when discontinuing use and aggressive behavior ("roid rage"). Nearly 40% of patients with BDD have past or current social anxiety disorder, and about one-third have past or current OCD (6, 32).

A PATIENT WITH BOD

Aaron, a 26-year-old single unemployed white man who lived with his parents, was brought by his parents for a di­agnostic evaluation. His parents believed that he had BDD, but Aaron did not, and he was reluctant to come to the evaluation. He believed that a diagnosis ofBDD did not apply to him because he truly was ugly, and he was scheduled for

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a cranioplasty to widen his skull, after having consulted 12 surgeons across the country. Aaron believed that his skull was too narrow (although measurementc; confirmed that it was within the normal range); he also believed that his nose was misshapen and too large, and he planned to have a rhinoplasty in the near future. Although these body areas looked normal, Aaron was convinced that he looked "de­formed." He obsessed about these perceived defects for 8-10 hours a day and spent 6-8 hours a day checking the disliked areas in mirrors, comparing his appearance with others (often celebrities), asking his parents to confirm that he looked ugly, and searching online for information about cosmetic surgery. He could not work and avoided virtually all social situations and relationships because he felt too ugly to be seen. He often felt suicidal because "life isn't worth living if I look like a freak."

EMERGING CLUES ABOUT BOD'S ETIOLOGY AND PATHOPHYSIOLOGY

Genetic Factors Family studies indicate that BDD is more common in first­de!,rree relatives of OCD probands than control probands, suggesting shared etiology (genetic and/or environmental) with OCD (36-38). Similarly, a twin study, which can tease apart genetic versus environmental influences, found that "dysmorphic concern" (a concept with similarities to BDD) has shared genetic vulnerability \vith other obsessive-compulsive and related disorders, including OCD; in addition, the study found BOD-specific genetic influences (heritability of 43%) (39).

Neurobiological Fnctors Visual processing studies (e.g., using functional magnetic resonance imaging) suggest that individuals with BDD ac­tually see things differently than those without BDD; they appear to exhibit a bias for encoding and analyzing details of faces and nonface objects such as houses (40-42). Holistic visual processing, which emphasizes a global and more in­tegrated view of objects, appears disrupted, with local details of the face and body seeming to override the gestalt view of the whole. Small eye-tracking studies similarly suggested a hyperfocus on features or details instead of wholes ( 43, 44). Preliminary data also suggest abnormalities in executive functioning (45, 46). In addition, persons with BDD, com­pared with healthy controls, show relative hyperactivity in the left orbitofrontal cortex and bilateral head of the caudate when viewing their own face versus a familiar face, which may reflect the occurrence of obsessional preoccupation while viewing their own face (47). Although this study did not directly compare BDD to OCD, this activation pattern is characteristic of OCD.

A small structural MRI study found no volumetric dif­ferences between subjects with BDD and healthy controls, whereas two studies found greater total white matter vol­ume in subjects with BDD (38). One study additionally found a leftward shift in caudate asymmetry, and the other addi­tionally found a smaller orbitofrontal cortex and anterior

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cingulate and larger thalamic volumes (38). BDD may also be characterized by compromised white matter fibers (re· duced organization) and inefficient connections (48). Another study did not find this (although statistical power was limited) but did find a relationship between fiber disorganization and impaired insight in white matter tracts that connect visual with emotion/memory processing systems ( 49). A number of studies suggest involvement of frontostriatal dysfunction in BDD (47).

Information Processing Biases Individuals with BDD appear to have a bias toward interpreting neutral faces as contemptuous and angry, and ambiguous sce­narios as threatening (50, 51), consistent with the occurrence of ideas/ delusions of reference in BOD.

Psychological and Social/Environmental Factors The above-noted twin study found that "dysmorphic concern" had unique disorder-specific environmental risk factors that were not shared by other obsessive-compulsive and related disorders (39). A history of teasing is one possible risk factor (52). Studies also suggest high rates of childhood neglect and/or abuse (53, 54). It is likely that sociocultural influences regarding the importance of appearance also play a role (4, 55).

Evolutionary Perspective An evolutionary perspective may be relevant to BDD (e.g., a desire to attract mates or avoid social rejection) (3, 56). In animals, greater symmetry of body parts or the absence of facial defects (e.g., skin lesions) may signal reproductive health and fitness or absence of disease. Compulsive groom­ing in BOD has notable similarities to compulsive grooming behaviors in animals, such as acral lick syndrome in dogs and compulsive feather plucking in birds.

BOD'S RELATIONSHIP TO OCD: SIMILARITIES AND DIFFERENCES

BOD has received far less investigation than OCD; nonetheless, data nre emerging on their similarities and differences, and a number of studies have directly compared them across var­ious domains. (Replication studies and additional direct com­parison studies are needed.) This section and Table 3 briefly summarize key findings; more detailed discussions are avnil· able elsewhere (38).

BDD is widely considered one of the disorders most closely related to OCD, based on similarities in a variety of domains (38). Examples are similar phenomenologic features, similarly chronic course, familiality, and other domains shown in Table 3. Psychosocial impairment is usually very poor in both disorders and perhaps even somewhat poorer in BDD (57). An important similarity is the apparent need for similarly high doses of SRis as n first-line treatment Although anti­psychotic augmentation of SRis appears less promising than in OCD, this approach has been only minimally studied in BDD, and a possible explanation is the low prevalence of

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TABLE 3. Some Similarities and Differences Between Body Dysmorphic: Disorder and Obsessive-Compulsive Dlsorde~

Similarities

Unwanted, distressing obsessions/preoccupations

Distressing repetitive behav.ors (compulsions) that aim to reduce anxiety or distress and are functionally linked to obsessions/preoccupations

Similar BDD-YBOCS/Y-BOCS scores for individual items

Most demographic features

Often severe functional impairment and markedly poor quality of life (even poorer in BOD?)

High levels of perfectionism; high neuroticism, low extraversion

Course of illness (often chronic)

Familiality

Overlapping genetic vulnerability?

Abnormalities in frontostnatal systems. including hyperactivity on fMRI in the orbitofrontal cortex and head of the caudate

Relatively high doses of SRfs as first-line pharmacotherapy

Difrerences

Different focus of obsessions. core beliefs, and compulslons

Poorer insight and more referential thinking in BOD {and more frequent paranoid personahty disorder)

More frequent comorbid major depressive disorder and comorbid substance use disorders in BOD

More frequent suicldahty 1n BOD

More childhood emotional and sexual abuse in BOD?

Differences in translational studies (e.g .• different structural MRI findings; greater frequency of threatening interpretations of ambiguous social and appearance-related information in BOD)

Differences in CBT: In BOD. more complex and often longer treatment, with greater focus on cognitive techniques. and behavioral experiments; inclusion of perceptual retraining, habit reversal for skin picking and hair pluck1ngfpulling. approaches for cosmetic surgery; greater need to address depressive symptoms

More intensive strategies {e.g., motivational interviewing) needed to engage and retain patients with BOD m treatment

•Replication studies and larger studies are needed; some, but not all. results are from studies that directly compared BOD and OCD; some findings are not specific to BOD and OCD (e.g .. chronic course of illness. high levels of perfectionism). BOD. body dysmorphic disorder; CBT. cognitive-behavioral therapy; fMRI, functional magnetic resonance imaging. SRI, serotonin reuptake 1nhib1tor; Y- BOCS, Yale- Brown Ob· sess1ve Compulsive Scale.

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BODY DYS/.IORPHIC DISORDER AND RELATIONSHIP TO OCD

comorbid tic disorders in BDD (which is 3ssociated with treatment response in OCD).

However, studies that h3ve directly comp3red BDD and OCD suggest that they 3lso have some not3ble differences and are not identical disorders (Table 3) (3). Clinically im­port3nt differences include the following: poorer insight in BDD (Figures 1 3nd 2 and discussion above) (IO, 11, 58), gre3ter suicidality in BDD (persons with BDD appear more likely to h3ve lifetime suicidal ideation and attempt suicide bec3use of their disorder) (8, 59), and a different CBT ap­proach. In the author's experience, treating BOD with ex­posure and response prevention alone, and as if BDD were OCD, is unlikely to be successful. CBT for BDD is more complex and often lengthier than CDT for OCD. It usually requires a greater focus on motivational interviewing, cog­nitive approaches (because of poorer insight and referential thinking in BDD), and incorpor:ition of behavioral experi­ments into exposure exercises (60). CBT for BOD also includes elements that are not relevant to CBT for OCD, such as mindfulness/perceptual retraining that targets visual pro­cessing abnormalities, habit reversal for BOD-related skin picking and hair plucking/pulling, and interventions that target problematic behaviors that arc characteristic of BDD but not OCD, such as surgery seeking (Table 3) (60).

In a prospective longitudinal study, BOD symptoms per­sisted in a sizable proportion of participants who remitted from comorbid OCO (61). This finding suggests that BDD is not simply a symptom of OCD.

BOD also has similarities with other disorders, such as social anxiety disorder, with which BDD shares prominent shame, fear of being embarrassed and humiliated, rejection sensitivity, and social anxiety and avoidance (4, 62, 63). BOD shares distorted body image and appearance preoccupations with eating disorders. BOD also has features in common with depressive disorders and psychotic disorders. However, BOD differs in important ways from these other disorders (4). For example, direct comparison studies found that compared with anorexia nervosa and bulimia nervosa, BDD is characterized by poorer insight, more negative self-evaluation and self-worth, poorer functioning and quality of life due to appearance con­cerns, and more avoidance of activities (64-66).

HOW TO ASSESS PATIENTS FOR BOD

BOD is common but is usually undiagnosed in mental health settings (2, 4, 16, 17). Patients typically do not spontaneously reveal their appearance concerns because they arc too embar­rassed, tltel' fear the clinician will negatively judge them (e.g., consider them vain) or not understand their concerns, or they do not know that psychiatric treatment may be helpful (16, 17). Furthermore, because insight is usually absent or poor, many patients believe that the BDD diagnosis does not apply to them (Figures 1 and 2). To detect BDD, clinicians usually need to ask patients about BDD symptoms (Table 4). Screening, diagnostic, severity, and insight measures for clinical and research purposes are freely available online (www.bodyimageprogram.com).

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In most cases, diagnosing BOD is straightforward, espe­cially when using questions such as those in Table 4 as a guide. The most complex differential is with eating disorders when patients present with concern that they weigh too much or that parts of their body are too fat (see below). Ad­ditional differential diagnosis issues arc discussed below.

HOW TO DIFFERENTIATE BOD FROM DISORDERS WITH WHICH IT IS OFTEN CONFUSED

Treatment of BDD differs from that of other disorders, and thus it is important to differentiate BOD from them.

OCD Obsessions that focus on perceived defects in one's physical appearance, including symmetry concerns, should be di­agnosed as BDD, not OCD. (See discussion above and Table 3 for key similarities and differences between BDD and OCD.)

Excoriation (Skin-Picking) Disorder When skin picking is done in response to concerns about perceived skin blemishes or other skin flaws, and picking intends to improve the skin's appearance, BDD should be diagnosed rather than excoriation (skin-picking) disorder.

Trichotillomania (Hair-Pulling Disorder) When hair plucking or pulling is trim~ered by concerns that one's hair is ugly or looks abnormal (e.g., "excessive" facial hair or "asymmetrical" eyebrows), and the plucking intends to improve one's appearance, BOD should be diagnosed rather than trichotillomania (hair-pulling disorder).

Major Depressive Disorder Depressive symptoms are common in BDD; they appear to often be secondary to the distress and impairment that BDD causes. BDD should be diabrnosed in depressed individuals if diagnostic criteria for BDD are met.

Social Anxiety Disorder (Social Phobin) Many patients with BDD fear being rejected and humiliated because they look abnormal; thus, social anxiety and social avoidance are very common in BDD (62, 63). When these symptoms are attributable to concerns about one's physical appearance, BDD should be diabrnosed rather than social anxiety disorder.

Agoraphobia Some people with BOD avoid public places or are housebound because they feel too ugly to be seen or fear that others will stare at them or mock them because of how they look. Such avoidance should be diagnosed as BOD, not abroraphobia.

Generalized Anxiety Disorder Patients with BDD have excessive anxiety and worry about their appearance. Such anxiety and worry should not be attributed to generalized anxiety disorder.

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PHILLIPS

Eating Disorders TABLE 4. Diagnostic Questions for Body Dysmorphlc Disorder As specified by DSM-5 criterion D, preoccupation with ex­cessive weight or body fat that qualifies for an enting disorder diagnosis should not be diagnosed as BDD. When enting disorder symptoms do not meet full criteria for an eating disorder, it may be difficult to determine whether BDD or "other specified feeding and enting disorder" is the more ac­curate diagnosis; careful questioning nnd clinical judgment arc needed to make the correct diagnosis.

Psychotic Disorders Appearance beliefs in BOD are often delusional in nature, which should be diagnosed as BDO, with the absent insight specifier. Occnsionally, a psychotic disorder diagnosis may be more appropriate (e.g., if a patient fears being persecuted by white supremacists for looking "ethnic" and has other perse­cutory delusions). BOD may be characterized by appenrance­rclatcd delusions of reference but not by other psychotic symptoms, disorganized speech or behavior, or negative symptoms.

Gender Dysphoria BDD should not be diaI,rnosed if diagnostic criteria for gen­der dysphoria arc met and appearance preoccupations focus only on genitals and secondary sex characteristics.

Olfactory reference syndrome. (preoccupation with emitting a foul body odor when no odor is clearly present) should be diagnosed as "other specified obsessive-compulsive and re­lated disorder" rather than BDO.

Clearly noticeable physical defects. (e.g., due to an accident or congenital anomnly) that cause distressing or impairing pre­occupntions should be diagnosed as "other specified obsessive­compulsive and related disorder." If skin picking due to BDD concerns cnuses noticeable skin lesions or scarring, BOD should be diagnosed nonetheless.

TREATING BDD

Treatment Challenges and How to Address Them

DSM-5 Criterion

A: Preoccupation with per~eived defects or flaws in appearance that are not observable or appear only slight to others

B: Repetitive behaviors in response to appearance concerns

C: Clinically significant · distress or impairment in functioning

D: Concerns not better explained by an eating disorder

Muscle dysmorphia specifier

Because poor or absent insight is so common in BDD, it can Insight specifier be difficult to engage and retain individuals with this dis-order in psychintric treatment. Before proceeding with im-plementation of medication or CBT, it is important to do the following: 1) Strive to build rapport, trust, nnd n strong therapeutic alliance by being nonjudgn1ental and express-ing empathy for the patient's suffering. 2) Provide psycho-education about BOD. Patients may benefit from reading nbout BOD (e.g., reference 4). 3) For patients who nre con-sidering cosmetic trentment, discuss the likelihood thnt the outcome will be poor. Cosmetic treatment can mnke BOD symptoms worse and may trigger legal nction or even violent behavior toward clinicians who provide such treatment (67-69). 4) Convey that psychiatric treatment is likely to be helpful and encourage the patient to try it. 5) Address

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Questions

"Are you very worried about your appearance in any way?" or "Are you unhappy with how you look?"

·can you tell me about your concern?" or "What don't you like about how you look?"

"How much time would you estimate that you spend each day thinking about your appearance. if you add up all the time you spend?" or "Do these concerns preoccupy you?"

"Is there anything you feel an urge lo do over and over again in response to your appearance concerns?" Give examples of repetitive behaviors

"How much distress do these concerns cause you?" Ask about anxiety. social anxiety, depression. feelings of panic. and suicidal thinking

·oo these concerns interfere with your life or cause problems for you in any way?" Ask about effects on work, school, other aspects of role functioning {e.g .. caring for children}, relationships, intimacy. family and social activities. household tasks. and other types of interference

Ask diagnostic questions for anorexia nervosa. bulimia nervosa. and binge eating disorder

·Are you preoccupied with the idea that your body build is too small or that you·re not muscular enough?"

Elicit a global belief about all of the perceived defect{s}: "Whal word would you use lo describe how bad your (till in disliked areas) look?" Optional: "Some people use words like unattractive, ugly. deformed, or hideous: The global belief must be inaccurate. Do not use beliefs that are true, such as ·1 don't look perfect" or "I want to look better:

"How convinced are you that these body areas look (fill in patient's global descriptor}?"

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BODY DVSMORPHIC DISORDER AND RELATIONSHIP TO OCD

misconceptions about recommended treatment (e.g., that SRis will be poorly tolerated or CBT exposures will be too difficult). 6) When patients resist treatment, focus on their suffering and poor functioning and on the potential for rec­ommended treatments to alleviate their dysfunction and distress. 7) When patients are reluctant to try medication or CBT, try using motivational interviewing techniques that are tailored to BDD (60). 8) Do not try to talk patients, especially those with delusional beliefs, out of their appearnnce con­cerns. Rather, the clinician can note that people with BDD have a distorted and negative view of how they look, which differs markedly from the view that others h:l\'e of them. Reasons for this mismatch in perception are not well un­derstood, although overfocusing on tiny details and staring at themselves in the mirror at close range for long periods of time may possibly contribute to their distorted view. 9) As­sess and monitor suicidal ideation. Treat more highly sui­cidal patients with an SRI, and encourage participation in CBT. For more highly suicidal patients, consider incor­porating cognitive-behavioral approaches for suicidality into treatment (70). 10) Consider partial hospital or inpatient care for more severely ill or suicidal patients while keeping in mind that patients may resist such care because they feel too anx­ious being seen by other people. 11) Involve supportive family members if clinically appropriate. At the very least it can be helpful for them to understand the diagnosis, recommended treatment, and treatment rationale and to support recom­mended treatment

Surgical, Dermatologic, Dental, and Other Cosmetic Treabnent A majority of individuals with BDD seek and receive cos­metic surgery (most often rhinoplasty, followed by breast aubrmentation), dermatologic treatment (e.g., topical acne agents and isotretinoin [AccutaneJ), dental treatment, and other types of cosmetic treatment for BDD concerns (67, 68).

Most patients are dissatisfied with cosmetic treatment and find that it does not improve BDD symptoms; symptoms may worsen (28, 67, 68, 71). In a survey of cosmetic surgeons, 43% of respondents reported that after surgery, 43% of patients with BDD were even more preoccupied with the treated "defects," and only 1% were free of their preoccu­pation (69). The concern switched to another body part in 39% of cases (69). Forty percent reported that a dissatisfied patient with BDD had threatened the surgeon legally and/ or physically (69). Although such events are rare, dissatisfied patients have kiJled their physician or themselves ( 4, 72).

Pharmncotherapy SRI efficacy. No medications are approved by the Food and Drug Administration for BDD, because no pharmaceutical companies have sought this indication. However, SRis, at adequately high doses, are considered the first-line somatic treatment for BDD (4, 73-75). A placebo-controlled trial with fluoxetine, a blinded crossover trial of clomipramine versus desipramine, and four methodologically rigorous open-label

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SRI trials (two with fluvoxamine, one with citalopram, and one with escitalopram [N"'l5-30]) found that an adequately dosed SRI usually improves BOD-related preoccupations, repetitive behaviors, distress, and impairment in functioning, as well as associated features such as depression, anxiety, anger/hostility, and quality oflife (75-77). SRis also decrease suicidal ideation and protect against suicidality worsening in patients with BDD (78, 79). No studies have directly com­pared the efficacy of different SRls for BDD, but a prospective series from a clinical practice (N=90) found similar response rates for each type of SRI (80).

SRis appear more efficacious than non-SRI antidepressants or other psychotropic medications, although data are limited. SRI monotherapy appears as efficacious for patients with de­lusional BDD beliefs as for those with nondelusional beliefs; thus, an SRI, rather than antipsychotic monotherapy, is rec­ommended for patients with the absent insight/delusional beliefs specifier (4, 75-77).

SRI dosing. A critical consideration is that it appears that SRI doses often need to be in the range used for OCD and arc substantially higher than those typically used for many other disorders, such as depression ( 4, 80). Patients often improve, or further improve, when the dose of an ineffective SRI is raised. Further improvement may also occur when the maximum SRI dose recommended by the pharmaceutical company is exceeded (4, 75). However, 250 mg/ day should not be exceeded for clomipramine, and the recent dosing limit for citalopram makes it a much less appealing option for treating BDD. Mean daily doses, and typical maximum doses, that the author has used are as follows: escitalopram, 29:!:12 mg (60 mg); fluoxctine, 67::!:24 mg (120 mg); fluvoxamine, 308:!:49 mg (450 mg); sertraline, 202::!:46 mg (400 mg); parox­etine, 55± 13 mg (90 mg); clomipramine, 203±53 mg (250 mg); and citalopram, 66::!:36 mg ( 40 mg/ day is the current dosing limit for patients aged <60 years) ( 4, 80). It may be wise to obtain an electrocardiogram for patients receiving a high dose of escitalopram.

SRI trial duration. To determine whether an SRI is effective, patients should receive a trial of 12-16 weeks, while reaching a high dose (if needed and tolerated) for at least 3-4 of those weeks (4, 75). The mean time for SRI response is 4-9 weeks ( 4, 75). After 12- 16 weeks, if the highest dose that is tolerated or recommended by the pharmaceutical company has been tried for at least 3-4 of those 12-16 weeks, clinicians should consider switching to another SRl or augmenting the SRI.

SRI switching and augmentation. One study found that 43% of patient'> who did not respond to nn initial adequate SRI trial did respond to at least one subsequent adequate SRI trial (80). For patient'> who have partially improved with an SRI, it is often desirable to continue the SRI and augment it with another medication, such as buspirone. In n chart­review study, buspirone (57±15 mg/day) effectively aug­mented SRis in 33% of trials, with a large effect size (80). In

Focus Vol. 13, No. 2. Spring 2015

the only controlled augmentation study, pimozide was not more efficacious than placebo in augmenting fluoxetine (81). However, clinical experience suggests that adding an atypical antipsychotic such as ziprasidone or aripiprazole to an SRI is sometimes helpful. Chart-review studies and clinical experi­ence suggest that occasionally patients may improve when an SRI is augmented with bupropion, lithium, methylphenidate, or venlafaxine (80). If clomipramine is combined with a se­lective serotonin reuptake inhibitor, clomipramine and me­tabolite levels, pulse, and blood pressure should be monitored, and an electrocardiogram should be obtained.

Non-SRI monotherapy. Venlafaxine and levetiracetam im­proved BDD symptoms in small open-label trials; placebo­controlled trials are needed (82, 83). Given the limited evidence base, serotonin-norepinephrine reuptake inhibitors and other non-SRis are not generally recommended as first-line treat­ments for BDD ( 4, 75).

Electroconvulsive therapy (ECT) studies in BDD arc lacking. Case series data suggest that ECT is usually not effective, although ECT can be considered for highly suicidal patients or those with severe comorbid major depressive disorder (especially those who have been refractory to SRis) ( 4). No studies have reported on the efficacy of deep brain stimulation or transcranial magnetic stimulation for BDD.

Cognitive-Behavioral Therapy CBT that is tailored to BDD's unique clinical features is the best-studied psychotherapy for BDD and has been shown to be effective for a majority of patients ( 4, 73, 74). CBT that is specific for BOD, rather than CBT for other disorders, should be used. As discussed above, CBT for BDD has some similarities to CBT for OCD as well as important differences.

The only CBT study that used an adequate control group found that 12 weeks of BOD-focused CBT was more effica­cious than 12 weeks of anxiety management for BDD (84). Outcomes further improved after four additional CBT ses­sions; gains were maintained at I-month follow-up. CBT was as efficacious for delusional BDD as for nondelusional BOD.

Three studies that used a wait-list control group found that BDD-focused CBT (an additional study used mctacognitivc therapy) was often efficacious and more effective than no treatment (85-88). However, BDD can be difficult to treat with CBT, especially when patients are more severely ill and func­tionally impaired. Thus, it is recommended that therapists use a BOD-specific CBT treannent manual, which provides detniled guidance for the therapist Two CBT treatment manuals for adults arc available that have some published evidence to sup­port their efficacy (60, 89). (No empirically based treatment manual is available for children and adolescents.)

Components of CBT for BDD The treatment manuals noted above, and CBT approaches used in other studies, contain some overlapping techniques, such as cognitive restructuring. exposure, and response pre­vention; however, they also contain some distinct approaches.

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The treatment developed by the author and her colleagues has the following components (60).

Foundation for treatment. Because BDD is often difficult to treat and insight is often poor, more extensive initial groundwork is often needed than when treating other dis­orders with CBT. The first three or four sessions should be devoted to developing a good understanding of the patient's symptoms, providing psychoeducation, and building an in­dividualized cognitive-behavioral model of the patient's ill­ness to help the patient understnnd the rationale for CBT techniques. Meaningful treatment gonls should be set Moti­vational intervie\ving techniques are often needed during initial sessions and later in treatment to enhance motivation for treatment.

Cognitive restructuring. Patients learn to identify and eval­uate their negative appearance-related thoughts and beliefs and to identify cognitive errors, such as fortune-telling, mind reading, and all-or-nothing thinking. They learn to develop more accurate and helpful appearance-related beliefs.

Exposure helps patients gradually face avoided situations, which are usually social situations. Behavioral experiments, in which patients design and carry out experiments to test the accuracy of their beliefs, are done during exposures.

Ritual (response) prevention helps patients cut down on repetitive behaviors, such as mirror checking, excessive grooming, and comparing.

Perceptual retraining, which includes mindfulness skills, helps patients develop a more holistic, rather than a detail­oriented, view of their appearance. Patients look in the mirror and, from head to toe, describe each part of their body (not just disliked areas) with neutral (not negative) language. This exercise takes only 5- 10 minutes a day. It does not involve staring at disliked areas.

Advanced cognitive strategies address negative core beliefs; beliefs thnt one is worthless, unlovable, or inadequate are common in BOD.

Habit reversal (optional module) is used for BOD-related skin picking or hair picking/plucking.

Depression treatment (optional module), which focuses on activity scheduling and scheduling pleasant or meaning­ful activities, can be used for inactive patients or those with more severe depression.

Cosmetic treatment (optional module) is used for patients who desire, are seeking, or are receiving cosmetic treatment for BDD.

Body shape/weight concerns (optional module) addresses muscle dysmorphia and concerns with being overweight or fat

Relapse prevention. At the end of treatment, patients prepare to terminate formal treatment and to continue to implement learned strategies.

Approaches that are not recommended include staring in mirrors (which reinforces the ritual of mirror checking), listening to audiotapes that say the patient is ugly, or creating

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BODY OYSMORPHIC DISORDER ANO RELATIONSHIP TO OCD

obvious "flaws" such as messing up one's hair or painting bright red spots on one's face before going out in public.

The duration of CBT should be tailored to each patient. Twelve to 16 weeks of weekly hour-long treatment is often inadequate; longer treatment, such as 24 weeks, is usually recommended (60, 87). More severely ill patients may need considerably longer treatment (e.g., 90 hours) (90). Comple­tion of daily structured homework assignments is essential. After formal treatment ends, patients should continue to practice CBT skills on their own; booster sessions with the therapist should be done as needed. Patients who have not met developmemal milestones or have been unemployed or socially isolated because of BDD may need vocational or social skills training after CBT.

Combined Pharmacotherapy and CBT The efficacy of combined treatment versus monotherapy has not been studied; however, combined treatment is especially recommended for more severely ill patients. For those who are too ill or depressed to participate in CBT, initial im­provement with medication may make CBT feasible.

Approaches for Treatment-Refractory BDD M:my, if not most. patients who appear treatment refractory have not received adequate treatment for BDD. Common problems include inadequate SIU doses, too brief an SIU trial, use of non-SRJs as monothcrapy, or poor medication compli­ance. Most patients have not received CBT from a CDT-trained therapist using an evidence-based treatment manual with good homework compliance (these manuals were only re­cently developed) (60, 89). More treatment-refractory patients should receive both medication and CBT, and partial hospital or residential treatment that focuses on BDD can be considered.

FUTURE DIRECTIONS

Because BDD has received relatively little investigation, vir­tually all aspects of this disorder need to be studied. Treatment research is especially needed, including studies in children and adolescentc;, CBT studies with control groups that receive treatments commonly used in the community (e.g., supportive psychotherapy), studies of CBT augmentation ofSRis and vice versa, and studies of other psychotherapies, non-SRI medi­cations, and other somatic treatments. Further investigation of the relationship between BDD and OCD is also needed. The need for this work is pressing, given the substantial morbidity and mortality associated with BDD.

AUTHOR AND ARTICLE INFORMATION

Katharine A. Phillips. M.D .. Body Oysmorphic Disorder Program. Rhode 151and Hospital. and Alpert Medical School o f Brown Unrvernty, Provi­dence. Rhode lsiland

Address correspondence to Katharine A Phillips. M.D. Body Dysmorphic Disorder Program. Rhode ISiand Hospital Coro Center West, Suite 2 030. 1 Hoppin Street. Pro111dence. RI 02903. e-mail: l<atharine_Phillips@brown.edu

The author thanks R chard Meza-Lopez for assistance w ith manuscript preparation

172 focus.psychiatryonlme.org

Dr. Phillips has received research/salary support from the National In­stitute of Mental Health (salary and research funding), Norman Prince Neurosciences Institute/Brown Institute for Brain Science (research funding). Brown University Division of Biology and Medicine (research funding). and the National Institute of General Medical Sciences (salary support); honoraria. royalties. and/or travel reimbursement from Oxford University Press. American Psychiatric Publishing. Abbott Laboratories (presentation unrelated to company products). AstraZeneca (presentation ' unrelated to company products}. Merck Manual. and UpToDate (luture); and po tential future royalties from the Free Press. Guilford Press. and American Psychiatric Publishing.

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7. Hart AS, Phillips KA: Symmetry concem~ ;is a symptom of body dys­morphic dLo;order. J Obsessive Compuls Refot DLo;ord 2013; 2:292-29K

8. Phillips KA, Gunderson CG, Mollya G, et al: A comparison sn1dy of body dysmorphic disorder and obscssive-compulsh·c disorder. J Clin Psychiatry 1998; 59:568r575

9. Pope CG, Pope HG, Menard W, et al: Clinical features of muscle dysmorphia among males with body dysmorphic disorder. Body Image 2005; 2:395-400

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31. Cotterill JA, Cunliffe WJ: Suicide in dcrmatoloi,oical patients. Br J Dcrmatol 1997; 137:246-250

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47. Fcusncr JD, Moody T, Hemhacher E. et :il: Abnormalities or visu:il processing and frontostriatal systems in body dysmorphic disorder. Arch Gen Psychiatry 2010; 67:197- 205

4R. Buchanan BG, Rossell SL, Maller JJ, ct al: Brain connectivity in body dysmorphic disorder compnred with controls: a diffusion tensor imaging study. Psycho! Med 2013; 43:2513-2521

49. Fcusner JD, Aricnzo D, Li W, ct al: White matter microstructurc in body dysmorphic disorder and iL~ clinic:il correl:ites. Psychintrv Res 2013; 211:132-140

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51. Buhlmann U, Wilhelm S, McNally RJ, et al: Interpretive bi:iscs for ambiguous information in body dysmorphic disorder. CNS Spectr 2002; 7:435-436, 441-443

52. Buhlm:inn U, Cook LM, Fama JM, et al: Perceived teru;ing expe­riences in bod)• dysmorphic disorder. Body lmai,'t! 2007; 4:381- 385

53. Didic ER, Tortolani CC, Pope CG, et al: Childhood abuse and neglect in body dysmorphic disorder. Child Abuse Ncgl 2006; 30: 1105-lll5

54. Neziroglu F, Kheml:ini-P:itcl S, Y:iryura-Tobias JA: Rates or abuse in body dysmorphic disorder and obsessive-compulsive disorder. Body Image 2006; 3:189 193

55. Pope HG Jr, Phillips KA, Oliv:irdia R: The Adonis Complex: The Secret Crisis of Male Body Obsession. New York, The Free Press, 2000

56. Fcusner JD, Hcmb:icher E, Phillips KA: The mouse who couldn't stop washing: pathologic i,rrooming in animals and humans. CNS Spectr 2009; 14:503-513

57. Didie ER, Walters MM, Pinto A, ct al: A comparison or quality of life :md psychosocial runctioning in obsessive-compulsive disorder and body dysmorphic disorder. Ann Clin Psychi:itry 2007; 19: 181-186

SR. Eisen JL, Phillips KA, Coles ME, ct al: Insight in obsessive com­pulsive disorder and body dysmorphic disorder. Compr Psychiatry 2004; 45:10-15

59. Phillips KA, Pinto A, Menard W, et al: Obsessive-compulsive dis­order versus body dysmorphic disorder: a comparison study of two possibly related disorders. Depress Anxiety 2007; 24:399-409

60. Wilhelm S, Phillips KA, Steketee G: Cngnitivc-Beh:iviornl Thcr:ipy for Body Oysmorphic Disorder: A Modular Treatment M:munl. New York, NY, Guilford Press, 2013

61. Phillips KA, Stout RL: Associations in the longitudinal course of body dysmorphic disorder with major depression, obsessivc­compulsivc disorder, and soci:il phobia. J Psychiatr Res 2006; 40: 360-369

62. Pinto A, Phillips KA: Social anxiety in body dysmorphic disorder. Body Image 2005; 2:401-405

63. Kelly MM, Walters C, Phillips KA: Social anxiety and its re­lationship IO runctional impairment in body dysmorphic disorder. Rehav Ther 2010; 41:143- 153

64. Hrahosky JI, Cash TF, Veale D. ct al: Multidimensional body im­nge comparisons among patients with eating disorders, hody dys­morphic disorder, and clinical controls: a multisitc study. Body lmoge 2009: 6:155-163

65. Rosen JC, Ramirez E: A comp:irison of eating disorders ond body drsmorphic disorder on body im:ige :ind psychological adjustmcnL J Psychosom Res 199R; 44:441-449

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BODY DYSMORPHIC DISORDER AND RELATIONSHIP TO OCD

66. l<ollei I, Brunhoeber S, Rnuh E, et nl: Body image, emotions and thought control strategics in body dysmorphic disorder compnrcd to eating disorders and hcnlthy controls. J Psychosom Res 2012; 72:321-327

67. Phillips KA, Grant J, Siniscalchi J, ct al: Surgical and non­psychintric medical treatment of patients with body dysmorphic disorder. Psychosomntics 2001; 42:504- 510

68. Crerand CE, Phillips KA, Mennrd W, et nl: Nonpsychintric mcdicnl treatment of body dysmorphic disorder. Psychosomntics 2005; 46: 549-555

69. Snrn·cr DB: Awareness and identification of body dysmorphic disorder by aesthetic surgeons: results of n survey of American Society for Aesthetic Plastic Surgery Members. Aesthet Surg J 2002; 22:531-535

70. Wenzel A, Brown GI<, Deck AT: Cognith•e therapy for suicidal patients: scientific and clinical applica1ions. W:ishinb-ton, DC, American Psychological Associntion, 200K

71. Tignol J, Birabcn-Gotzamanis L, Martin-Guehl C, et nl: Dody dysmorphic disorder and cosmetic surgery: evolution of 24 sub­jects with n minimal defect in appearance 5 years after their re­quest for cosmetic surgery. Eur Psychiatry 2007; 22:520-524

72. Phillips KA: Dody dysmorphic disorder: the distress of imagined ugliness. Am J Psychiatry 1991; 148:1138 1149

73. Ipsi:r JC, Sander C, Stein DJ: Phnrmncothi:rapy and psychothcr· apy for body dysmorphic disorder. Cochrane Database Syst Rev 2009; (l):CD005332

74. Natiom1I Collaborating Centre for Mental Health: Core intcr­vi:ntions in the trentmi:nt of obsessive compulsive disorder and body dysmorphic disorder (a guideline from the National Institute for Health and Clinical Excellence, National Health Service). www.nicc.org.uk/ page.aspx?o;;289817

75. Phillips KA, Hollander E! Treating body dysmorphic disorder with medication: evidence, misconceptions, and a suggested approach. llody Image 2008; 5:13-27

76. Phillips KA, Albertini RS, Rasmussen SA: A randomized placcbo­controlled trial of ftuoxctine in body dysmorphic disorder. Arch Gen Psychiatry 2002; 59:381-388

77. Hollander E, Allen A, Kwon J, ct al: Clomipraminc vs desipramini: crossover trial in body d~·smorphic disorder: selective efficacy of

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a serotonin reuptake inhibitor in imat,rincd uglini:ss. Arch Gen Psychiatry 1999; 56:1033-1039

7R. Phillips KA, Kelly MM: Suicidality in a placebo-controlled Ruox­ctine study of body dysmorphic disorder. Int Clin Psycho­pharmacol 2009; 24:26-28

79. Phillips KA: Suicidality in body dysmorphic disorder. Prim Psy­chiatry 2007; 14:58-66

80. Phillips KA, Albertini RS, Siniscalchi JM, ct al: Effectiveness of pharmacothcr:ipy for body dysmorphic disorder: a chart-review study. J Clin Psychiatry 2001; 62:721-727

81. Phillips KA: Placebo-controlled study of pimozide augmentation of ftuoxctine in body dysmorphic disorder. Am J Psychiatry 2005; 162:377 379

82. Phillips KA, Menard W: A prospective pilot study of le\•ctir:icctam for body dysmorphic disorder. CNS Spectr 2009; 14:252-260

83. Allen A, Hadley SJ, Kaplan A, et al: An open-label trial of ven­lafaxine in bod~· dysmorphic disorder. CNS Spcctr 2008; 13: 138-144

84. Veale D, Anson M, Miles S, ct al: Efficacy of cognitive behaviour therapy versus anxiety management for body dysmorphic disorder: a randomised controlled trial. Psychmher Psychosom 2014; 83: 341- 353

85. Veale D, Gournay K. Dryden W, ct al: Body dysmorphic disorder: n cognitive behavioural model and pilot randomised controlled trial. Dehav Res Ther 1996; 34:717-729

86. Rosen JC, Ri:itcr J, Orosan P: Cognitive-behavioral body image therapy for body dysmorphic disorder. J Consult Clin Psycho! 1995; 63:263- 269

87. Wilhelm S, Phillips KA, Didie E, et al: Modular cognitive­bchaviornl therapy for body dysmorphic disorder: o randomized controlled tri:il. Dehnv Thcr 2014; 45:314-327

88. Rabici M, Mulkcns S, Kalantari M, et al: Metacognitive therapy for body dysmorphic disorder patients in I rnn: acceptability and proof of concept. J Dehav Ther Exp Psychiatry 2012; 43:724-729

89. Veale D, Ncziroglu F: Body Dysmorphic Disorder: A Treatment Manuol. West Sussex, UK, Wiley-Blackwell, 2010

90. Neziroglu FA, Yaryura-Tobias JA: Exposure, response prevention, and cognitive therapy in the treatment of body dysmorphic dis­order. Dchav Ther 1993; 24:431-438

Focus Vol. 13. No. 2. Spring 2015