Body Dysmorphic Disorder — Advanced Management

Body dysmorphic disorder (BDD) is a DSM-5 obsessive-compulsive related disorder characterized by preoccupation with one or more perceived defects or flaws in physical appearance not observable or appearing slight to others, repetitive behaviors (mirror checking, excessive grooming, skin picking, reassurance seeking, comparing) or mental acts (comparing to others), and clinically significant distress or impairment.

BDD typically begins in adolescence with chronic course; common areas of preoccupation are skin, hair, nose, weight, muscle (muscle dysmorphia), face, breast or genitals. Insight ranges from good to absent or delusional. Suicidality is markedly elevated (20-40% lifetime suicide attempt). Comorbid major depression, social anxiety, OCD, eating disorders, and substance use are common. Many patients seek dermatologic or cosmetic surgical procedures with poor outcomes and worsening dysmorphic concerns.

Diagnosis is clinical with screening tools (BDDQ, BDD-YBOCS) and careful differentiation from normal appearance concerns, eating disorders (centered on weight/shape), schizophrenia (delusions broader than appearance), and OCD (broader obsessions). Management combines cognitive-behavioral therapy adapted for BDD with exposure to feared situations and response prevention, mirror retraining, perceptual retraining, and cognitive restructuring. Pharmacotherapy: SSRI at higher doses than for depression (fluoxetine up to 80 mg, sertraline 200 mg, escitalopram 20-30 mg, citalopram 40 mg, fluvoxamine 200-300 mg) with adequate trial 12-16 weeks; clomipramine alternative; antipsychotic augmentation for poor insight or delusional BDD or partial response. Cosmetic procedures generally discouraged; collaboration with dermatology and surgery to prevent unnecessary interventions. Suicide risk assessment is essential at each visit.