Psychosocial development
BDD therapy challenges the disorder’s core theme—that appearance is one’s only important attribute—and helps patients identify and develop qualities not related to appearance. Through social interactions, the BDD patient can:
- develop a multidimensional sense of self
- receive nonappearance-related positive feedback from the outside world.
Explore psychosocial development during the assessment phase and when a patient shows little progress in CBT. In some patients, for example, BDD onset in childhood or adolescence interferes with developmental transition to adulthood.
In our experience, some patients may resist treatment because of conscious and unconscious fears of adult responsibilities and relationships. We focus therapy on making them aware of these phenomena, exploring fears of development, and encouraging them to seek new relationships and responsibilities.
Because a BDD patient’s symptoms often create conflict and distress at home, offer the family support and education about the disorder. Occasionally, forces within the family seem to be working against the individual’s recovery and/or independence.
In some families, an individual with BDD may become the “identified patient,” diverting attention from other dysfunctional family members or relationships. During therapy, the BDD patient’s goal to develop a sense of self that is not appearance-based may run counter to the family’s need to keep him or her in the “sick” role.
If therapy is to succeed, talk to the patient about these dynamics. Consider family therapy if resistance to change is strong. When a patient is not progressing well with CBT, we find understanding the family system can be useful to comprehensive BDD treatment, although this observation remains to be validated.
Preventing and treating relapse
Educate patients that BDD is usually chronic, even when treated with psychotherapy and medication.31 Relapse often occurs, especially when patients discontinue medications on their own24 or drop out of therapy early. No guidelines exist, but based on our experience:
- we continue medication for at least 1 year after a patient improves
- psychotherapy is more variable but may need to last 6 to 12 months or more.
When therapy ends, we encourage patients to practice and reinforce everything they learned during treatment. Casting BDD resurgence as normal—and not as failure—will help patients who relapse to resist the downward spiral of low self-esteem, shame, and turning to the mirror for reassurance. Identifying BDD symptom triggers and developing plans to cope with them may also prevent relapse. CBT “booster sessions” scheduled monthly for 3 to 6 months may help patients who have completed therapy.
FOR CLINICIANS:
- Phillips KA. “I’m as ugly as the elephant man:” How to recognize and treat body dysmorphic disorder. Current Psychiatry. 2002;1(1):58-65.
- Cororve MB, Gleaves DH. Body dysmorphic disorder: a review of conceptualizations, assessment, and treatment strategies. Clin Psychol Rev. 2001;21(6):949-70.
FOR PATIENTS AND FAMILIES:
- Phillips KA. The broken mirror. New York: Oxford University Press; 2005.
- BDD and body image program, Butler Hospital, Providence, RI. BDD education and support. www.BDDcentral.com.
- Winograd A. Director, Accurate Reflections, Los Angeles, CA. Support group and information on BDD and obsessive compulsive spectrum disorders. www.AccurateReflections.com
Drug brand names
- Alprazolam • Xanax
- Aripiprazole • Abilify
- Buspirone • BuSpar
- Citalopram • Celexa
- Clomipramine • Anafranil
- Desipramine • Norpramin
- Escitalopram • Lexapro
- Fluoxetine • Prozac
- Fluvoxamine • Luvox
- Lithium • Lithobid, others
- Methylphenidate • Ritalin, Concerta
- Olanzapine • Zyprexa
- Paroxetine • Paxil
- Pimozide • Orap
- Quetiapine • Seroquel
- Risperidone • Risperdal
- Sertraline • Zoloft
Disclosures
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.