Body Dysmorphic Disorder E-Book

Sony Khemlani-Patel

• Herausgeber: Hogrefe Publishing
• Kategorie: Fachliteratur
• Serie: Advances in Psychotherapy - Evidence-Based Practice
• Sprache: Englisch
• Veröffentlichungsjahr: 2022

Seitenzahl: 227

Beschreibung

Learn how to assess and treat Body Dysmorphic Disorder (BDD) - Presents the best treatment practices - Instructions for novel and advanced treatment strategies - Tips for improving client engagement - Illustrated with case studies - Printable tools for clinical useMore about the book This volume provides a user-friendly, evidence-based guide to the diagnosis, phenomenology, etiology, and treatment of Body Dysmorphic Disorder (BDD). New and seasoned clinicians can learn about the foundations of CBT for BDD as well as the rationale and instructions for modifying the approach to meet the differences in symptoms found in this client group. The book explores techniques for treatment engagement, including adjusting therapeutic style, appropriate utilization of behavioral and cognitive therapy, family involvement, and motivational interviewing techniques. Other issues associated with BDD are also highlighted: poor insight, comorbidity, concerning rates of suicidality, and ambivalence regarding treatment. The authors outline step-by-step instructions for numerous novel and advanced treatment strategies, including perceptual re-training, attentional training, acceptance and commitment approaches, and ways to manage ongoing desire for cosmetic surgery. Detailed case examples are presented with corresponding treatment guidelines to highlight the variety in clinical presentation and corresponding treatment approaches. Printable tools in the appendices can be used in daily practice. Watch a video interview with the authors

Leseprobe

Advances in Psychotherapy – Evidence-Based Practice, Volume 44

Body Dysmorphic Disorder

Sony Khemlani-Patel

Bio Behavioral Institute, Great Neck, NY

Fugen Neziroglu

Bio Behavioral Institute, Great Neck, NY, and Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY

About the Authors

Sony Khemlani-Patel, PhD, is a licensed psychologist with over 20 years of experience in the treatment of obsessive-compulsive related disorders. She is clinical director of the Bio Behavioral Institute in Great Neck, NY, on the scientific and clinical advisory board of the International Obsessive Compulsive Disorder Foundation, and vice president of OCD New York. She has presented and published extensively in the areas of body dysmorphic and obsessive-compulsive related disorders and has co-authored two self-help books.

Fugen Neziroglu, PhD, ABPP, ABBP, is a board-certified behavior and cognitive psychologist and leading researcher in obsessive-compulsive related disorders. She is the co-founder and executive director of the Bio Behavioral Institute in Great Neck, NY, as well as clinical assistant professor at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell. She has published and presented over 175 papers in scientific journals and is the author and co-author of fifteen books which have been translated into many languages. She is on the scientific and clinical advisory board of the International Obsessive Compulsive Disorder Foundation, on the scientific council of the Anxiety and Depression Association of America, and president of OCD New York.

Advances in Psychotherapy – Evidence-Based Practice

Series Editor

Danny Wedding, PhD, MPH, Saybrook University, Oakland, CA

Associate Editors

Jonathan S. Comer, PhD, Professor of Psychology and Psychiatry, Director of Mental Health Interventions and Technology (MINT) Program, Center for Children and Families, Florida International University, Miami, FL

J. Kim Penberthy, PhD, ABPP, Professor of Psychiatry & Neurobehavioral Sciences, University of Virginia, Charlottesville, VA

Kenneth E. Freedland, PhD, Professor of Psychiatry and Psychology, Washington University School of Medicine, St. Louis, MO

Linda C. Sobell, PhD, ABPP, Professor, Center for Psychological Studies, Nova Southeastern University, Ft. Lauderdale, FL

The basic objective of this series is to provide therapists with practical, evidence-based treatment guidance for the most common disorders seen in clinical practice – and to do so in a reader-friendly manner. Each book in the series is both a compact “how-to” reference on a particular disorder for use by professional clinicians in their daily work and an ideal educational resource for students as well as for practice-oriented continuing education.

The most important feature of the books is that they are practical and easy to use: All are structured similarly and all provide a compact and easy-to-follow guide to all aspects that are relevant in real-life practice. Tables, boxed clinical “pearls,” marginal notes, and summary boxes assist orientation, while checklists provide tools for use in daily practice.

Continuing Education Credits

Psychologists and other healthcare providers may earn five continuing education credits for reading the books in the Advances in Psychotherapy series and taking a multiple-choice exam. This continuing education program is a partnership of Hogrefe Publishing and the National Register of Health Service Psychologists. Details are available at https://www.hogrefe.com/us/cenatreg

The National Register of Health Service Psychologists is approved by the American Psychological Association to sponsor continuing education for psychologists. The National Register maintains responsibility for this program and its content.

Library of Congress of Congress Cataloging in Publication information for the print version of this book is available via the Library of Congress Marc Database under the Library of Congress Control Number 2021948128

Library and Archives Canada Cataloguing in Publication

Title: Body dysmorphic disorder / Sony Khemlani-Patel (Bio Behavioral Institute, Great Neck, NY),

Fugen Neziroglu (Bio Behavioral Institute, Great Neck, NY, and Zucker School of Medicine at

Hofstra/Northwell, Hempstead, NY)

Names: Khemlani-Patel, Sony, author. | Neziroglu, Fugen A., 1951- author.

Series: Advances in psychotherapy--evidence-based practice ; v. 4.

Description: Series statement: Advances in Psychotherapy--Evidence-Based Practice ; volume 44 |

Includes bibliographical references.

Identifiers: Canadiana (print) 20210339470 | Canadiana (ebook) 20210339519 | ISBN 9780889375000

(softcover) | ISBN 9781616765002 (PDF) | ISBN 9781613345009 (EPUB)

Subjects: LCSH: Body dysmorphic disorder. | LCSH: Body dysmorphic disorder—Treatment.

Classification: LCC RC569.5.B64 K54 2021 | DDC 616.85/2—dc23

© 2022 by Hogrefe Publishing

www.hogrefe.com

The authors and publisher have made every effort to ensure that the information contained in this text is in accord with the current state of scientific knowledge, recommendations, and practice at the time of publication. In spite of this diligence, errors cannot be completely excluded. Also, due to changing regulations and continuing research, information may become outdated at any point. The authors and publisher disclaim any responsibility for any consequences which may follow from the use of information presented in this book.

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ISBN 978-0-88937-500-0 (print) • ISBN 978-1-61676-500-2 (PDF) • ISBN 978-1-61334-500-9 (EPUB)

https://doi.org/10.1027/00500-000

Citability: This EPUB includes page numbering between two vertical lines (Example: |1|) that corresponds to the page numbering of the print and PDF ebook versions of the title.

Contents

1 Description

1.1 Terminology

1.2 History

1.3 Obsessive-Compulsive and Related Disorders

1.4 Definition

1.4.1 Specifiers

1.4.2 Insight

1.5 Normal Concerns Versus BDD

1.6 Symptomatology

1.7 Epidemiology

1.8 Gender Differences

1.9 Onset, Course, and Prognosis

1.10 Functional Impairment

1.11 Suicidality

1.12 Quality of Life

1.13 Comorbidity and Differential Diagnosis

1.13.1 Depression

1.13.2 Social Anxiety

1.13.3 Obsessive-Compulsive Disorder

1.13.4 Personality Disorders

1.13.5 Anorexia Nervosa

1.13.6 Excoriation Disorder (Skin Picking)

1.13.7 Olfactory Reference Syndrome

1.14 Teasing and Bullying

1.15 History of Abuse

1.16 Diagnostic Procedures and Documentation

1.16.1 Diagnostic Interviews

1.16.2 Symptom Severity Measures

1.16.3 Insight Measures

1.17 Summary

2 Theories and Models

2.1 Biological Theories

2.1.1 Neurochemical Theories

2.1.2 Neuroanatomical Theories

2.1.3 Neuropsychological Models

2.2 Psychological Theories

2.2.1 Evolutionary Theory

2.2.2 Learning Theory

2.2.3 Cognitive Behavior Model Based on Social Learning

2.2.4 The Self as an Aesthetic Object

2.3 Summary

3 Diagnosis and Treatment Indications

3.1 Therapist Variables in Initial Sessions

3.2 Diagnostic Assessment

3.2.1 Connection Between Preoccupation and Compulsive and Avoidance Behaviors

3.2.2 Typical Day

3.3 Factors That Influence Treatment

3.3.1 Overvalued Ideation

3.3.2 Demographic Variables

3.3.3 Comorbidity

3.3.4 Previous Treatment Experience

3.4 Addressing Need for Cosmetic Surgery

3.5 Establishing Treatment Goals

3.6 Identifying the Appropriate Treatment

3.6.1 Medication for BDD

3.6.2 Cognitive Behavior Therapy for BDD

3.7 Summary

4 Treatment

4.1 Methods of Treatment

4.1.1 Assessment

4.1.2 Psychoeducation

4.1.3 Treatment Orientation and Engagement

4.1.4 Cognitive Therapy

4.1.5 Exposure and Response Prevention

4.1.6 Perceptual Retraining

4.2 Mechanisms of Action

4.3 Efficacy and Prognosis

4.4 Variations and Combinations of Methods

4.4.1 Attentional Training Technique and Task Concentration

4.4.2 Cognitive Remediation

4.4.3 Third Wave Therapies

4.4.4 Addressing Trauma and Loss

4.4.5 Addressing Skin Picking and Hair Pulling

4.4.6 Self-Surgery

4.4.7 Addressing Poor Quality of Life

4.4.8 Maintenance and Relapse Prevention

4.5 Problems Carrying Out the Treatments

4.5.1 Addressing Desire for Cosmetic Surgery

4.5.2 Addressing Suicidality

4.5.3 Nonadherence to Treatment

4.5.4 Family Involvement and Accommodation

4.6 Multicultural Issues in Treatment

4.7 Summary

5 Case Vignettes

Baseline Assessment

Clinical Assessment

Etiological Variables

Treatment

Baseline Assessment

Clinical Assessment

Etiological Variables

Treatment

Baseline Assessment

Clinical Assessment

Etiological Variables

Treatment

6 Further Reading

7 References

8 Appendix: Tools and Resources

Description

Instructions

Overall Appearance

Specific Body Parts

My Core Values

Desired Values Versus Time Spent on Values

Training Exercise 1

Training Exercise 2

Short- and Long-Term Life Goals

|1|1Description

1.1 Terminology

Body dysmorphic disorder (BDD), previously considered a somatoform disorder, was incorporated into the newly established obsessive-compulsive and related disorders (OCRDs) in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013). This category consists of disorders characterized by intrusive thoughts (obsessions) or repetitive behaviors (compulsions) (see Section 1.3).

1.2 History

BDD (referred to then as “dysmorphophobia”) first appeared in the DSM in the 3rd edition (DSM-III; American Psychiatric Association, 1980) as an “atypical somatoform disorder.” Diagnostic criteria were not included, resulting in minimal attention in the psychiatric literature.

With the publication of the DSM-III-R (American Psychiatric Association, 1987), BDD was established with diagnostic criteria as a “somatoform disorder,” and the term was changed to “body dysmorphic disorder.” No changes occurred in the publication of DSM-IV and DSM-IV-TR. The current DSM-5 diagnostic criteria are more detailed, reflecting the increase in recognition and research. The criteria include specifiers including insight levels.

BDD first appeared in the psychiatric literature in 1891, with the publication of a paper by an Italian psychiatrist Enrico Morselli. He coined the term “dysmorphophobia,” noting the desperation and intensity of the fear and thoughts (Morselli, 1891). Other European psychiatrists, including Pierre Janet, Emil Kraepelin, and most famously Sigmund Freud, have published case histories of BDD patients. Freud’s Wolf Man was a Russian aristocrat who had a preoccupation with the shape of his nose, accompanied by frequent mirror checking. He carried a small mirror in his pocket, checked for pores, and powdered his nose multiple times a day. His nickname came from recurrent dreams of wolves staring at him. He was later treated by one of Freud’s protégées, Ruth Brunswick, who published a paper in 1928 describing his symptoms in detail (Brunswick, 1928).

The disorder was largely unknown until the OCD spectrum of related disorders became a model for conceptualization and treatment, leading to the official classification of obsessive-compulsive and related disorders in 2013.

|2|1.3 Obsessive-Compulsive and Related Disorders

The obsessive-compulsive and related disorders (OCRDs) category was established with the 2013 publication of the DSM-5. This category designates disorders characterized by obsessions and/or compulsions. Obsessions are defined as intrusive, repetitive, and persistent thoughts that cause distress. Compulsions are repetitive behaviors or mental acts that are excessive, ritualistic, and repetitive. In addition to obsessive-compulsive disorder (OCD), BDD, and trichotillomania, this category includes the newly established hoarding disorder and excoriation disorder (skin picking).

The existing literature had established overlapping features, referring to this cluster as the “obsessive-compulsive spectrum disorders.” Similarities in symptom profile, treatment response, and comorbidity supported the categorization (Hollander et al., 2007).

1.4 Definition

BDD is characterized by a preoccupation with one or more perceived defects or flaws in physical appearance that are not observable to others or may appear slight to others. At some point the individual with BDD has engaged in repetitive behaviors, such as mirror checking, excessive grooming, skin picking, or seeking reassurance from others, or mental acts such as comparing appearance to that of others.

1.4.1 Specifiers

DSM-5 describes muscle dysmorphia as a specifier for BDD. This form of BDD is a preoccupation with the idea that one’s “body build is too small or insufficiently muscular” (American Psychiatric Association, 2013, p. 243). Higher percentages of men than women are found to suffer from muscle dysmorphia. Common compulsions include excessive use of natural supplements and protein shakes to enhance exercise for muscle building, excessive exercising, use of steroids, seeking medical procedures to enhance body build, and specialized diets or food regimes. Clothing to either hide or enhance muscles is commonly seen.

1.4.2 Insight

Insight as a further BDD specifier includes three categories: good or fair, with poor insight, or absent insight/delusional beliefs. Much research supports the fact that individuals with BDD demonstrate poorer insight than those with OCD (de Leon et al., 1989; Eisen et al., 2004; McKenna, 1984; Phillips et al., 2012; Vitiello & de Leon, 1990). In fact, appearance-related beliefs appear delusional at times, with up to 75% of patients showing lifetime prevalence of delusions. Referential thinking is frequently observed – believing that others |3|are taking special notice of one’s appearance or, specifically, one’s “flaws” (Phillips, 2004; Phillips et al., 1994). Studies have found that BDD individuals misperceive others facial expressions in self-referent scenarios (Buhlmann et al., 2006). Poor to absent insight interferes with treatment engagement, necessitating the addition of therapeutic intervention, including motivational interviewing, clarifying treatment goals, and values-based exercises which will be discussed in Chapter 3 and 4.

1.5 Normal Concerns Versus BDD

Body image focus and discontent is common both in nonclinical and clinical populations, including in patients with depression and eating disorders. Worry, dissatisfaction, poor self-esteem, and depression are also evident in dermatological or medical populations, in which physical appearance is altered, such as in those with vitiligo, psoriasis, or scars.

Percentages of body image dissatisfaction in nonclinical samples are high, with more than half of the general population endorsing discontent with aspects of their appearance, and rates are continually on the rise (Garner, 1997). Body image is an issue that is by no means limited to women, with men experiencing poor body image at high rates as well (Adams et al., 2005; McCabe & Ricciardelli, 2004). Women tend to be slightly less anxious about appearance as they age, although body dissatisfaction stays surprisingly stable across the lifespan in adulthood until they are quite elderly (Tiggemann, 2004). Research across cultures suggests that while the definition of attractiveness may vary across countries, body image dissatisfaction and the desire for cosmetic surgery is found around the world, including China, India, Brazil, Italy, Greece, and South Korea.

Distinguishing BDD from normal concerns may at first seem daunting, but careful assessment of current functioning, daily behavioral patterns, psychosocial history, thought processes, and clinical history will ensure a proper diagnosis.

1.6 Symptomatology

Individuals with BDD can become preoccupied with any aspect of their physical appearance. Typically, one or two main body areas are the primary source of distress, but dissatisfaction with multiple areas is common (Neziroglu & Yaryura-Tobias, 1993; Phillips, 2005). Facial features are the most frequently cited area of concern, including skin, nose size, and hair (Phillips, 2005; Veale, Boocock et al., 1996). Often patients describe the flaw in great detail, such as size, texture, color, proportion to other body parts, and structural symmetry. At times, individuals describe dissatisfaction with their overall appearance, expressing a general disgust or feeling ugly and unattractive. This would still be considered BDD.

|4|The hallmark of BDD is the level of distressing appearance-related obsessions, typically consuming many hours in a day. Thought content may consist of a focus on finding ways to improve or camouflage appearance, concern with others’ perceptions, or hopelessness about their future if their appearance does not improve.

Repetitive and excessive behaviors aimed at scrutinizing, improving, or hiding the body part of concern are found in almost all individuals with BDD. One of the most common behaviors is mirror checking, consisting of either frequent brief checks or lengthy episodes of standing in front of a mirror. Any shiny or reflective surface is used to check their appearance; with individuals experiencing distress in brightly lit and mirrored public spaces. In some cases, avoidance of mirrors is common, and so is a vacillation between mirror checking and mirror avoidance.

Other behaviors very common to BDD include camouflaging and hiding the perceived defect, such as wearing hats to hide hair loss or excessive makeup application to cover acne. Comparing oneself with others has been found in up to 94% of individuals with BDD (Phillips, Menard et al., 2005). Social media images or magazine photos may be collected as sources of comparison. Some individuals will look at photographs of themselves at different time periods in their lives or use cellular phone cameras to evaluate appearance in different poses or lighting. Comparison with family members to assess similarities and differences can be driven by the desire to look alike or different from loved ones. Measuring one’s body parts to compare them with a self-imposed standard or as a comparison with others is common as well.

Attempts to improve the body part may include extreme measures such as cosmetic or dermatological procedures or more self-initiated procedures, such as skin peels, frequent haircuts, teeth whitening, and other beauty-enhancing products related to the body part of concern.

Seeking reassurance can become a source of conflict with family members as loved ones can alternate between providing reassurance and becoming frustrated and antagonistic. Family members can misattribute BDD behaviors to vainness or self-absorption. Seeking compliments via indirect methods is also common, such as discussing topics related to beauty or appearance.

Avoidance of social and public situations occurs in varying degrees in almost all individuals with BDD. Avoidance of crowded or brightly lit places is quite common, as are situations involving a focus on appearance, such as bars and formal social events. Many BDD individuals vacillate between the desire to be noticed and the desire to hide. Many may avoid medical appointments, exercising, and activities involving outdoor activities.

Skin picking prevalence rates are alarmingly high in BDD; lifetime rates are approximately 45% (Grant et al., 2006). The skin picking creates further distress due to the resulting scars and a spiral of attempts to fix the damage due to the picking. The desire to achieve perfectly smooth skin leads to visual inspection as well as repeatedly feeling for bumps on body parts. The tactile experience can increase mirror checking and vice versa. In our clinical experience, the function of picking behavior evolves from appearance-based, to serving multiple other purposes, such as emotion regulation, further strengthening the behavior.

|5|1.7 Epidemiology

To date, three large prevalence studies for BDD within the general population have been conducted – two in Germany and one in the US. Results were quite similar in all three, with reported prevalence rates of 1.7%, 1.8%, and 2.4% (Buhlmann et al., 2010; Koran et al., 2008; Rief et al, 2006). Gender distribution in these studies suggested a slightly higher prevalence for women than men. A general consensus in the field suggests a relatively equal gender distribution for BDD.

Rates vary, however, depending on the population studied. Within international and US college populations, rates appear to be higher, with a prevalence of 4.8% found in a Turkish college population (Cansever et al., 2003) and of 5.8% in Pakistani medical students (Taqui et al., 2008).

Within clinical populations, prevalence rates are higher than in the general population. In adult inpatient psychiatric settings, rates range from 13.1% to 16% (Conroy et al., 2008; Grant et al., 2001). BDD patients are unlikely to report their symptoms unless specifically asked to do so by mental health providers (Phillips, 2005). Rates in adolescent inpatient hospitals have been documented at 4.5% (Dyl et al., 2006).

Prevalence rates in dermatology and cosmetic surgery patients are high, as would be expected, with rates ranging from 7% to 15% (Castle et al., 2004; Conrado, 2009; Crerand et al., 2004; Kacar et al., 2014; Phillips et al., 2000).

Interestingly, one recent study found that prevalence rates of BDD in military personnel were significantly higher than in the general population, with rates of 13% in men and 21.7% in women (Campagna & Bowsher, 2016). The authors postulate that those with a preexisting emphasis on achieving an ideal body type may be influenced by that as a driving factor in enlisting. In addition, the significant attention toward physical fitness in the military may reinforce dysfunctional beliefs in those who are already predisposed.

1.8 Gender Differences

Research has shown that BDD is found relatively equally in both genders, with studies citing similar clinical characteristics, age of onset, clinical course, demographics, impairment, and symptom severity (Phillips & Diaz, 1997). Skin and facial concerns are similar in both genders (Perugi et al., 1997; Phillips & Diaz, 1997). There are minor expected differences. For example, although both genders display concerns with hair, men are more concerned with thinning or balding, while women become concerned with other features of hair (Phillips & Diaz, 1997). Women are likely to be more concerned with their hips and weight, while men are likely to be dissatisfied with body build and suffer from muscle dysmorphia at higher rates (Campagna & Bowsher, 2016). Genital concerns seem to be primarily associated with men (Perugi et al., 1997; Phillips & Diaz, 1997).

|6|1.9 Onset, Course, and Prognosis

BDD typically has a chronic course. BDD onset is most frequently reported in adolescence, with a mean age of 16 (Phillips, 2005; Phillips, Menard et al., 2005). Appearance dislike occurs at earlier ages, but full diagnostic criteria are more likely to be met in mid to late adolescence. Longer duration of symptoms, being an adult, and severity level may impact remission rates (Phillips et al., 2006; Phillips et al., 2013; Phillips, Pagano, Menard, Fay, & Stout, 2005). Appropriate interventions can lead to promising outcomes. Left untreated, BDD does not typically improve spontaneously.

1.10 Functional Impairment

Individuals with BDD exhibit significant impairment across many domains of functioning. Work impairment is quite common with 39–53% of individuals being unemployed (Didie et al., 2008; Frare et al., 2004; Perugi et al., 1997; Veale et al., 1996). Many of those who do work struggle with regular attendance or are unable to maintain full-time employment. Attendance is often compromised due to the symptoms, such as mirror checking, morning grooming routines, as well as significant anxiety and distress about being seen by others. High depression rates can further impact functioning (Phillips et al., 2007).

Other domains of functioning are also affected. Up to 30% of individuals with BDD report being housebound due to the disorder (Phillips, 2005; Phillips, Didie et al., 2006; Rief et al., 2006). Psychiatric hospitalization rates are also high, with BDD being a significant reason for admission (Conroy et al., 2008). Social impairment is found to varying degrees in almost all sufferers. Between 50% and 90% of BDD individuals are not married (Frontenelle et al., 2006; Phillips, Menard et al., 2005; Veale et al., 1996), further supporting the evidence for avoidance of social and dating functioning. The level of functional impairment likely negatively impacts social support, financial status, occupational success, and subsequently overall quality of life.

1.11 Suicidality

Lifetime suicidal ideation is found in almost all individuals with BDD (approximately 80%), and attempts are alarmingly high at 24–28% (Phillips & Menard, 2006; Phillips, Coles et al., 2005; Veale et al., 1996). Completed suicide rates in BDD are 45 times higher than in the general population (Phillips & Menard, 2006). Comorbid depression predicts suicidal ideation, while posttraumatic stress, substance use, and disordered eating may increase suicide attempts. Level of functional impairment also predicts ideation and attempts. Shame may be a risk factor for suicide and depression (Weingarden, Renshaw, Wilhelm, et al., 2016). Suicide is a significant risk factor in this population and requires ongoing assessment and management. Suicide protocols may need to be incorporated into treatment delivery.

|7|1.12 Quality of Life

Self-reported quality of life is lower for BDD than in many other clinical and medical populations, including those with depression, diabetes, and a history of myocardial infarction (Phillips, 2000). Given the high levels of functional impairment, overvalued ideation, and suicidality associated with BDD, it is understandable that quality of life is negatively impacted. Quality of life has been shown to improve with both cognitive behavior therapy (Khemlani-Patel et al., 2011) and medications (Phillips & Najjar, 2003; Phillips & Rasmussen, 2004). Treatment interventions for BDD may require a long-term plan beyond symptom reduction in order to develop life satisfaction. This may include career counseling, development of social and leisure activities, and strengthening of life skills.

1.13 Comorbidity and Differential Diagnosis

Comorbidities in BDD are the rule rather than the exception. The most commonly coexisting conditions are depression, social anxiety, and personality disorders.

1.13.1 Depression

Depression is the most commonly found coexisting disorder, with 53–81% of BDD patients presenting with comorbid major depressive disorder (Frare et al., 2004; Gunstad & Phillips, 2003; Phillips, Didie et al., 2006). Depression tends to develop after the emergence of BDD symptoms, underscoring the significant impact of the BDD diagnosis (Phillips, 2004). Clinicians often have to treat both conditions simultaneously, especially if the depressive symptoms interfere with ability to engage in treatment.

Many individuals with depression struggle with poor self-image, including low levels of appearance satisfaction. They may even endorse avoidance behaviors due to poor body image or engage in some mirror checking or avoidance. BDD should be considered as a separate diagnosis based on the level of primarily appearance-based thoughts and behaviors. In contrast, individuals with depression alone are likely to endorse dissatisfaction and general poor self-worth in multiple areas, with appearance being one area of discontent.

1.13.2 Social Anxiety

Approximately 30–40% of BDD individuals suffer from comorbid social anxiety disorder (Coles et al., 2006; Gunstad & Phillips, 2003), and 11% of social anxiety individuals suffer from BDD (Brawman-Mintzer et al., 1995). A dual diagnosis likely leads to more significant social avoidance than BDD alone.

|8|