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AUTHOR AND EDITOR INFORMATION

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Author: Robert A Schwartz, MD, MPH, Professor and Head of Dermatology, Professor of Medicine, Professor of Pediatrics, Professor of Pathology, Professor of Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School

Robert A Schwartz is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi

Coauthor(s): Wanda M Patterson, MD, Department of Dermatology, UMDNJ-New Jersey Medical School; O Joseph Bienvenu III, MD, PhD, Assistant Professor, Department of Psychiatry, Johns Hopkins University School of Medicine; M Peter Chodynicki, MD, Staff Physician, Department of Psychiatry, Johns Hopkins University School of Medicine; Camila K Janniger, MD, Clinical Professor of Dermatology, Clinical Associate Professor of Pediatrics, Chief of Pediatric Dermatology, New Jersey Medical School

Editors: James J Nordlund, MD, Professor Emeritus, Department of Dermatology, University of Cincinnati College of Medicine; Richard P Vinson, MD, Assistant Clinical Professor, Department of Dermatology, Texas Tech University School of Medicine; Consulting Staff, Mountain View Dermatology, PA; Jeffrey Meffert, MD, Assistant Clinical Professor of Dermatology, University of Texas Health Science Center-San Antonio; Joel M Gelfand, MD, MSCE, Medical Director, Clinical Studies Unit, Assistant Professor, Department of Dermatology, Associate Scholar, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania; Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center

Author and Editor Disclosure

Synonyms and related keywords: dysmorphic syndrome, dermatological hypochondriasis, dermatological nondisease, body dysmorphic disorder, BDD, monosymptomatic hypochondriasis, delusions of dysmorphosis

INTRODUCTION

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Background

Dysmorphophobia has been described for more than a century.1 This psychiatric condition, also termed body dysmorphic disorder (BDD), is marked by a fixation on an imaginary flaw in the physical appearance. In cases in which a minor defect truly exists, the individual with BDD exhibits an inordinate amount of anguish. BDD often is encountered in dermatologic and cosmetic surgery settings. This disorder traditionally has been labeled dysmorphic syndrome. Dysmorphophobic symptoms in a dermatologic setting have been termed dermatological hypochondriasis, and in individuals without apparent cutaneous lesions, the condition is termed dermatologic nondisease.

BDD results in significant suffering, occupational dysfunction, and/or social malaise. Individuals with BDD have variable degrees of awareness concerning the psychiatric nature of the illness. Many people continue to agonize about an imagined defect although they are cognizant that their concerns are excessive. Other people with dysmorphophobia are regarded as delusional and have no insight into their unusual behavioral tendencies.

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Frequency

United States

As much as 1% of the population may have dysmorphophobia. A recent study demonstrated that the prevalence of BDD appears to be significantly higher among people receiving dermatologic care. Of people receiving dermatologic care, 11.9% were diagnosed with this condition.

Mortality/Morbidity

People with dysmorphophobia frequently develop major depressive episodes and are at risk for suicide.2 They also may exhibit violent behavior toward their treatment providers.

  • In many cases, individuals with BDD experience drastic social and occupational dysfunctions that may progress to the point of social isolation.
  • Embarrassment and fear of being scrutinized or mocked cause these individuals to avoid social situations and intimate relationships. Often victims of poor self-image, these individuals do not demonstrate sufficient social skills and frequently are single or divorced.
  • People with dysmorphophobia may believe firmly that a marked change in their perceived body defect is a prerequisite to their happiness and well-being.

Sex

Male-to-female ratio appears to be equal.

Age

Onset usually occurs in the teenage years; however, average age in people receiving dermatologic care is 33.7 years.


CLINICAL

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History

A typical case presentation of dysmorphophobia (illustrating a number of key features of BDD) is a 32-year-old male stockbroker who presents to the dermatologist because of concerns about excessive hair loss. The only evidence of this is a possibly receding hairline, which the dermatologist would not have noticed if the patient had not reported it. The patient spends hours each day checking his hair in the mirror and becomes upset when he finds fallen strands in his shower drain. He is self-conscious around others, has dated only occasionally, and currently is demoralized. He has seen numerous dermatologists and plastic surgeons and has undergone 2 cosmetic rhinoplasty operations. When discussing his plight, he bursts into tears and admits recent thoughts of suicide. He believes he is too hideous to attract a partner.

Typical presenting factors for the condition are as follows:

  • Dysmorphophobia usually takes a chronic course. A 12-month follow-up prospective study of its course indicated that in studies with similar methods, it tends to be chronic, with remission probabilities lower than reported for mood disorders, most anxiety disorders, and personality disorders in studies with similar methods.3
  • People with dysmorphophobia often have a history of multiple visits to dermatologists and cosmetic surgeons with resulting unsuccessful treatment.
  • Repeated visits may signify an attempt to gain reassurance concerning the individual's appearance; however, explaining that the physical defect is either nonexistent or minor is futile. Individuals with dysmorphophobia will continue to agonize over perceived flaws.
  • Many people with dysmorphophobia go to great lengths to conceal their defect using items such as wigs, hats, and makeup.
  • Individuals with BDD often develop compulsive habits (eg, frequent mirror checking, exorbitant grooming, skin picking).
  • Recognizing the symptoms early is crucial, since repeated investigations can result in needless use of resources, time, and money.
  • The presence of BDD in obsessive-compulsive disorder patients is associated with poor insight into obsessional beliefs and higher morbidity, reflected by a higher number of psychiatric comorbid disorders in general.4

Physical

  • Any body part can be a source of distress; however, the body areas noted most frequently are the skin, hair, and nose.
  • Complaints vary widely, including preoccupation with wrinkles, spots, acne, and large pores.
  • Vascular markings, greasiness, scars, paleness, redness, excessive hairiness, and thinning of hair also are encountered commonly as complaints.
  • Folliculitis and scarring may be a product of skin picking and plucking of nonexistent hairs; these often result in exacerbation of distress.

Causes

Heredity may contribute to development of the illness. The prevalence of dysmorphophobia is 4 times higher in first-degree relatives of people with dysmorphophobia than in relatives of probands without the condition. This condition appears to be related to obsessive-compulsive disorder, since it occurs frequently in people with obsessive-compulsive disorder and their relatives, and it responds to the same medications.5, 6, 7, 8


DIFFERENTIALS

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Other Problems to be Considered

Obsessive-compulsive disorder
Depression
Bipolar disease
Schizophrenia


TREATMENT

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Medical Care

Individuals with BDD often refuse psychiatric referral because of poor insight into the underlying psychiatric illness. Dermatologic or plastic surgery treatment frequently fails to improve dysmorphophobic symptoms. If provided routine treatment, most people with dysmorphophobia are displeased with therapy and may attest to increased preoccupation with the flaw.

  • Serotonin reuptake inhibitors (SRIs) have proven to be the most effective medications in the treatment of dysmorphophobia. The most widely used SRIs include clomipramine9 (average dose approximately 175 mg/d), fluoxetine (approximately 50 mg/d), and fluvoxamine (approximately 260 mg/d). These drugs often require high doses and lengthy treatment periods before symptoms improve; drug trials should continue for several months after the target dose is reached. Increase the dose gradually to prevent possible adverse effects. Almost 58% of patients with dysmorphophobia achieve either partial improvement or complete resolution of symptoms with an SRI regimen.
  • Efficacy of clomipramine (SRI) versus desipramine (selective norepinephrine reuptake inhibitor) was compared in a study of BDD. Superior results were noted with clomipramine treatment. Increased improvement occurred in obsessive characteristics, depression, insight, social performance, and general severity of the disorder.10
  • Selective serotonin reuptake inhibitors (SSRIs) also are used in the treatment of dysmorphophobia. Fluoxetine is used most frequently.
  • People with delusional symptoms may benefit from a therapeutic regimen including pimozide (antipsychotic) in addition to an SSRI.
  • Patient insight may improve using pimozide alone. A pimozide/clomipramine combination may lengthen the QT interval on ECG; therefore, close monitoring of the cardiogram is required.
  • Buspirone (30-60 mg/d) in addition to an SRI proves helpful to one third of patients who do not respond to SRI treatment alone.
  • In some situations, patients who show resistance to normal treatment may have positive results when treated with SSRIs in combination with clomipramine. In this case, monitor clomipramine levels because SSRIs increase clomipramine concentration in the blood.
  • If all else fails, monoamine oxidase inhibitors (MAOIs) may be used, although dietary and other restrictions are necessary (ie, avoiding foods containing tyramine, use of certain medications). These drugs probably should be prescribed only by experienced specialists.

Consultations

Nonpharmacologic psychiatric treatment may prove effective in the treatment of people with BDD; however, the patients are most likely to avoid psychiatric therapy.

  • An on-site psychiatric liaison may be used to bridge the gap between dermatologic and psychological treatments.
  • Therapy using behavioral modification includes encouraging people with BDD to discontinue or decrease compulsive behaviors such as skin picking. Gradual desensitization to social situations that cause anxiety also is helpful.
  • Cognitive behavioral therapy, including encouragement of self-esteem, modification of distorted thoughts, and formulation of coping strategies, may be most effective when used in conjunction with SRIs.
  • Therapy within a group setting and supportive psychotherapy may be adequate for people who are not truly delusional.


MEDICATION

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SRIs are the medications of choice in this illness. Clomipramine is a tricyclic antidepressant (TCA) and has adverse effects similar to other TCAs, in particular, sedation, anticholinergic effects, orthostatic hypotension, sexual dysfunction, weight gain, cardiac conduction slowing, and a potential for fatal overdose. Fluoxetine and fluvoxamine are SSRIs and usually have a milder adverse effect profile than clomipramine; however, adverse effects of SSRIs include initial anxiety or agitation, nausea or other GI disturbance, headache, sexual dysfunction (ie, delayed orgasm, loss of libido), and occasional apathy. Pimozide has adverse effects common to other typical high-potency antipsychotic medications (ie, extrapyramidal symptoms such as dystonia, parkinsonism, akathisia, neuroleptic malignant syndrome, tardive dyskinesia). Pimozide also can slow cardiac conduction and cause hyperprolactinemia.

SSRIs are widely used antidepressants and are often safer than alternatives, but they may be associated with a variety of cutaneous reactions that can be disturbing to these patients.11 SSRIs may produce spontaneous bruising, pruritus, urticaria, angioedema, erythema multiforme, Stevens-Johnson syndrome, toxic epidermal necrolysis, erythema nodosum, alopecia, hypertrichosis, leukocytoclastic vasculitis, and an acneiform eruption. Because cross-reactions may occur between SSRIs, even though they have different chemical structures, using another family of antidepressants may be advisable if an SSRI is linked to a serious skin eruption.

An open-label trial of venlafaxine showed that it may be an effective treatment for BDD.12 Controlled research on it was recommended.

Drug Category: Tricyclic antidepressants

Have central and peripheral anticholinergic effects and sedative effects and block the active reuptake of norepinephrine and serotonin.

Drug NameClomipramine (Anafranil)
DescriptionAffects serotonin uptake while it affects norepinephrine uptake when converted into its metabolite desmethylclomipramine. Nighttime dosing is recommended because of sedative properties. Initiate therapy at a low dose to minimize adverse effects. Available in 25-, 50-, and 75-mg caps.
Adult Dose25 mg PO qhs; increase as tolerated and indicated; average dose is 175 mg/d
Pediatric DoseNot established
ContraindicationsDocumented hypersensitivity; recent myocardial infarction; do not use within 14 d of MAOIs
InteractionsBarbiturates, phenytoin, and carbamazepine decrease effects of clomipramine; clomipramine increases effects of anticholinergics, sympathomimetics, alcohol, and CNS depressants; toxicity of MAOIs increases with clomipramine
PregnancyC - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
PrecautionsTherapeutic blood level monitoring of clomipramine and active metabolite is helpful in assessing whether patient is slow metabolizer; because of TCAs' slow cardiac conduction, avoid in patients with bifascicular block, left bundle-branch block, or prolonged QT interval; caution in severe cardiopulmonary or renal impairment, inability to metabolize sorbitol, and patients at high risk for suicide

Drug Category: Selective serotonin reuptake inhibitors

Inhibit presynaptic serotonin reuptake.

Drug NameFluoxetine (Prozac)
DescriptionSelectively inhibits presynaptic serotonin reuptake with minimal or no effect in the reuptake of norepinephrine or dopamine. Available in 10- and 20-mg caps and in 20 mg/5 mL liquid form.
Because of fluoxetine's stimulating properties, initiate dosing in the morning. If nausea is a problem, it may be helpful to take the medication with food.
Adult Dose10 mg PO qam; increase dose as tolerated; average dose is 50 mg/d
Pediatric DoseNot established
ContraindicationsDocumented hypersensitivity; concurrent or recent (within last 2 wk) administration of MAOIs
InteractionsIncreases toxicity of diazepam and trazodone by decreasing clearance; increases toxicity of MAOIs and highly protein-bound drugs
PregnancyC - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
PrecautionsCaution in hepatic impairment and history of seizures; discontinue MAOIs at least 14 d before initiating fluoxetine therapy

Drug NameFluvoxamine (Luvox)
DescriptionPotent selective inhibitor of neuronal serotonin reuptake. Does not bind significantly to alpha-adrenergic, histamine, or cholinergic receptors; therefore, it has fewer adverse effects than TCAs. Available in 50- and 100-mg tabs. If nausea is a problem, it may be helpful to take the medication with food.
Adult Dose50 mg PO qd for substantial anxiety symptoms; average dose is 260 mg/d
Pediatric DoseNot established
ContraindicationsDocumented hypersensitivity; current or recent (within last 2 wk) administration of MAOIs
InteractionsRisk of hypertensive crisis increases in coadministration with MAOIs; fluvoxamine potentiates effects of triazolam and alprazolam; therefore, when administering concurrently, reduce dose by at least 50%; also reduce dose of theophylline by one third, and monitor plasma levels if administered concurrently with fluvoxamine; alcohol, cimetidine, sertraline, phenothiazines, and warfarin increase toxicity of fluvoxamine
PregnancyC - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
PrecautionsCaution in liver dysfunction, cardiovascular disease, history of seizures, or suicidal tendencies

Drug Category: Neuroleptic agents

Reduce psychotic symptoms (hallucinations, delusions).

Drug NamePimozide (Orap)
DescriptionCentrally acting dopamine-receptor antagonist. Pimozide is available in 2-mg scored tablets in the United States; 2-, 4-, and 10-mg tabs are available in Canada.
Adult Dose1-2 mg PO qd initial; increase by 2-4 mg qwk; not to exceed 10 mg/d or 200 mcg/kg/d (0.2 mg/kg/d)
Pediatric DoseNot established
ContraindicationsDocumented hypersensitivity; history of cardiac arrhythmias or long QT syndrome; coadministration with macrolide antibiotics
InteractionsIncreases toxicity of MAOIs, alfentanil, CNS depressants, and guanabenz
PregnancyC - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
PrecautionsECG recommended at initiation of therapy and regular intervals thereafter; careful observation for extrapyramidal symptoms, especially in geriatric patients


FOLLOW-UP

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Complications

  • People with dysmorphophobia frequently develop major depressive episodes and are at risk for suicide. They also may exhibit violent behavior toward treatment providers.
  • In many cases, individuals with BDD experience drastic social and occupational dysfunctions that may progress to the point of social isolation.
  • Embarrassment and fear of being scrutinized or mocked cause individuals with BDD to avoid social situations and intimate relationships.
  • Often victims of poor self-image, individuals with BDD do not demonstrate sufficient social skills and frequently are single or divorced.
  • People with dysmorphophobia may believe firmly that a marked change in the perceived body defect is a prerequisite to their happiness and well-being.

Prognosis

  • BDD results in significant suffering, occupational dysfunction, and/or social malaise.
  • Individuals with BDD have variable degrees of awareness concerning the psychiatric nature of the illness. Many continue to agonize about an imagined defect although they are cognizant that their concerns are excessive.
  • Other people with dysmorphophobia are regarded as delusional and have no insight into their unusual behavioral tendencies.
  • People with dysmorphophobia frequently develop major depressive episodes and are at risk for suicide.
  • Psychosocial functioning tends to remain poor over time, with few attaining functional remission.13


MISCELLANEOUS

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Medical/Legal Pitfalls

  • Failure to recognize that people with dysmorphophobia frequently desire a cosmetic medical or cosmetic surgical approach but demonstrate unrealistic expectations
  • Failure to recognize the disorder, since people with dysmorphophobia may blame the physician for producing what is perceived as an unacceptable outcome
  • Failure to combine surgical treatment with psychiatric therapy when treating a person with dysmorphophobia


REFERENCES

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Dysmorphophobia excerpt

Article Last Updated: May 9, 2008