Body dysmorphic disorder: a treatment synthesis and consensus on behalf of the International College of Obsessive-Compulsive Spectrum Disorders and the Obsessive Compulsive and Related Disorders Network of the European College of Neuropsychopharmacology

Disturbed interoception in body dysmorphic disorder: A framework for future research

Body dysmorphic disorder is a severe psychiatric condition characterised by a preoccupation with a perceived appearance flaw or flaws that are typically not observable to others. Although significant advances in understanding the disorder have been made in the past decade, current explanations focus on cognitive, behavioural and visual perceptual disturbances that contribute to the disorder. Such a focus does not consider how perception of the internal body or interoception may be involved, despite (1) clinical observations of disturbed perception of the body in body dysmorphic disorder and (2) disturbed interoception being increasingly recognised as a transdiagnostic factor underlying a wide range of psychopathologies. In this paper, we use an existing model of hierarchical brain function and neural (predictive) processing to propose that body dysmorphic disorder involves defective interoception, with perceived appearance flaws being the result of 'interoceptive prediction errors' that cause body parts to be experienced as 'not just right'. We aim to provide a framework for interoceptive research into body dysmorphic disorder, and outline areas for future research.

The Body Dysmorphic Disorder Questionnaire-Aesthetic Surgery: Are We Screening the Troublesome Patients?

This study aims to clarify the current concept of performing rhinoplasty in patients with possible body dysmorphic disorder (BDD). The primary objective was to investigate the validity and evolution over time of the Body Dysmorphic Disorder Questionnaire-Aesthetic Surgery (BDDQ-AS) before and after surgery. Together with the BDDQ-AS, also the Nasal Obstruction Symptom Evaluation scale, FACE-Q nose and nostrils, and Utrecht questionnaire (UQ) were used for convergent validation. In this prospective study, 187 patients completed these patient-reported outcome measures at four time points: at the preoperative consultation and postoperatively at 3, 6 and 12 months. The preoperative BDDQ-AS positivity rate was as high as 55.1%. Postoperatively, there was a highly significant decrease in the odds of scoring positive on the BDDQ-AS. At the preoperative consultation, positively screened patients were less satisfied with the esthetics of their noses with worse scores on UQ, FACE-Q nose, and visual analog scale. The preoperative differences in outcome measure ratings disappeared postoperatively, except for the FACE-Q nostrils, which surprisingly showed better values in BDDQ-AS positive patients. Younger age and absence of nasal trauma were statistically significant covariates associated with positive BDDQ-AS screening. Due to the overwhelming decrease in positive BDDQ-AS outcomes after surgery, a positive screening result on the BDDQ-AS should not be interpreted as a formal contraindication for surgery. Collaboration with psychologists or psychiatrists remains crucial to diagnose BDD conclusively.

Clinical specificity profile for novel rapid acting antidepressant drugs

Mood disorders are recurrent/chronic diseases with variable clinical remission rates. Available antidepressants are not effective in all patients and often show a relevant response latency, with a range of adverse events, including weight gain and sexual dysfunction. Novel rapid agents were developed with the aim of overcoming at least in part these issues. Novel drugs target glutamate, gamma-aminobutyric acid, orexin, and other receptors, providing a broader range of pharmacodynamic mechanisms, that is, expected to increase the possibility of personalizing treatments on the individual clinical profile. These new drugs were developed with the aim of combining a rapid action, a tolerable profile, and higher effectiveness on specific symptoms, which were relatively poorly targeted by standard antidepressants, such as anhedonia and response to reward, suicidal ideation/behaviours, insomnia, cognitive deficits, and irritability. This review discusses the clinical specificity profile of new antidepressants, namely 4-chlorokynurenine (AV-101), dextromethorphan-bupropion, pregn-4-en-20-yn-3-one (PH-10), pimavanserin, PRAX-114, psilocybin, esmethadone (REL-1017/dextromethadone), seltorexant (JNJ-42847922/MIN-202), and zuranolone (SAGE-217). The main aim is to provide an overview of the efficacy/tolerability of these compounds in patients with mood disorders having different symptom/comorbidity patterns, to help clinicians in the optimization of the risk/benefit ratio when prescribing these drugs.

Body Dysmorphic Disorder in Women

Body dysmorphic disorder (BDD) consists of distressing or impairing preoccupation with perceived defects in physical appearance that are actually nonexistent or only slight. This common and often-severe disorder, which affects more women than men, frequently goes unrecognized. BDD is associated with marked impairment in functioning, poor quality of life, and high rates of suicidality. Most patients seek cosmetic treatment, which virtually never improves BDD symptoms. In contrast, serotonin-reuptake inhibitors, often at high doses, and cognitive behavioral therapy that is tailored to BDD's unique clinical features are often effective. This article provides a clinical overview of BDD, including BDD in women.

Pilot study of single-dose psilocybin for serotonin reuptake inhibitor-resistant body dysmorphic disorder

OBJECTIVE

Body dysmorphic disorder (BDD) is an often-severe condition in which individuals are preoccupied by misperceptions of their appearance as defective or ugly. Only serotonin reuptake inhibitors and cognitive-behavioral therapy have been demonstrated efficacious in randomized controlled trials. Psilocybin is a psychedelic drug with growing evidence for safety and efficacy in treatment of depression. This study aimed to pilot test the feasibility, tolerability, safety, and efficacy of psilocybin treatment of adults with BDD.

METHODS

In this open-label trial, 12 adults (8 women, 4 men) with moderate-to-severe non-delusional BDD that had been unresponsive to at least one serotonin reuptake inhibitor trial received a single oral dose of psilocybin 25 mg. There was no control group. Psychological support was provided before, during, and after the dosing session. The primary outcome measure for efficacy was the Yale-Brown Obsessive Compulsive Disorder Scale Modified for BDD (BDD-YBOCS) score during 12 weeks of assessments after dosing.

RESULTS

All participants completed dosing and all follow-up assessments. BDD-YBOCS scores decreased significantly over 12 weeks of follow-up (p < .001) with a large effect size (partial eta squared = 0.54), and significant changes from baseline were present at week 1 and persisted through week 12. Secondary efficacy measures of BDD symptoms, conviction of belief, negative affect, and disability also improved significantly, and no serious adverse events occurred. At week 12, seven participants (58%) were rated responders, based on ≥30% decrease in BDD-YBOCS.

CONCLUSION

This study provides promising preliminary support for psilocybin as a treatment of BDD, warranting future controlled studies.

Mapping the future of interventional psychiatry for the obsessive-compulsive related disorders: A scoping review

Body dysmorphic disorder (BDD), hoarding disorder (HD), skin-picking disorder (SPD), and hair-pulling disorder (HPD) are characterized by compulsive behaviours leading to distress and impairment. Current treatments attain only partial or non-response. Interventional psychiatric approaches may target specific regions of the brain for treatment. This scoping review maps the current literature and synthesizes key findings. Databases were searched up to June 27, 2022 for studies examining interventional psychiatric treatments for BDD, HD, SPD, and HPD, producing 910 results. Twenty were included; 16 were case reports, two were case series, and two were randomized controlled trials. Studies reported on electroconvulsive therapy (ECT) (n=7), deep brain stimulation (DBS) (n=1), and intermittent theta-burst stimulation repetitive transcranial magnetic stimulation (rTMS) (n=1) for BDD; rTMS (n=1) and transcranial direct current stimulation (n=1) for HD; gamma knife capsulotomy (n=1) and rTMS (n=1) for SPD; and rTMS (n=2) and ECT (n=1) for HPD. Four studies reported on DBS for other indications complicated by SPD or HPD. The current literature consists mainly of case reports. Future studies should be randomized, controlled, adequately powered and blinded, examining rTMS localized to the anatomical targets for each disorder. Presently, the mainstay of treatment remains disorder-specific psychotherapy with limited evidence for medications.

Understanding and treating body dysmorphic disorder

Body dysmorphic disorder (BDD) is a mental disorder that involves a distressing preoccupation with a perceived defect in physical appearance, associated with excessive or repetitive behaviours or mental acts aimed at camouflaging, checking or 'improving' the perceived area of concern. BDD is relatively common, affecting at least 2% of the population world-wide, yet is poorly understood. Professor Susan Rossell has produced a substantial body of influential research, which has improved our understanding of BDD. This includes a more comprehensive understanding of the phenomenology, neurocognition and neurobiology, as well as significant treatment advances. This work will be reviewed in this commentary.

Editorial Perspective: Medical body modification in youth with gender dysphoria or body dysmorphic disorder - is current practice coherent and evidence-based?

In recent decades, there has been a steady increase in the number of people, including adolescents, undergoing medical body modification (MBM) to alter their physically healthy bodies in invasive and nearly irreversible ways through medical treatment (e.g. surgery). While MBM is often recommended for youth with persisting gender dysphoria (GD), in body dysmorphic disorder (BDD) it has been considered contraindicated. Here, we outline the current controversies surrounding MBM practice and recommendations in adolescents with GD versus those with BDD in order to better understand under what circumstances we may or may not support adolescents who want to change their bodies medically and often irreversibly. We compare the two disorders in terms of the overlap and uniqueness of their behavioural and psychological features. In doing so, we discuss limitations of the existing (often low-quality) evidence for and against MBM in young patients. We conclude that the currently available evidence is too preliminary and far from conclusive to make any robust recommendations in terms of benefits and harms of MBM in youth with persisting GD or BDD. However, we strongly recommend further urgent scientific discussions and systematic research efforts into more robust evaluations and the identification of more precise psychological characteristics that may serve as decision criteria for or against MBM - particularly in those adolescents who did not respond to non-MBM, that is, psychiatric/psychological treatment and psychosocial support, if available at all. This will greatly benefit youth healthcare professionals in their challenging clinical practice of making decisions regarding MBM today and in the future.

Telephone-Administered Cognitive Behavioral Therapy for Body Dysmorphic Disorder: Case Series

Cognitive behavioral therapy is an effective treatment for body dysmorphic disorder (BDD), but many patients do not receive appropriate treatment due to several treatment barriers and psychosocial care structures. Low-threshold interventions, including those from the field of e-mental health, could improve access to psychotherapy. In addition to internet-administered therapy, telephone-administered therapy may reduce treatment barriers, especially during the COVID-19 pandemic. This article presents four case reports of the same treatment (12 weeks of telephone-administered cognitive behavioral therapy accompanied by a workbook) applied to patients with body dysmorphic disorder during the summer of 2020. Three patients who completed the treatment had clinically relevant reductions in body dysmorphic and depressive symptoms and improved insight. One patient did not complete the telephone-administered therapy because her symptoms worsened, and she needed a more intensive form of treatment. These findings encourage future studies on the efficacy and effectiveness of telephone-administered treatment for BDD and its role in stepped-care models.

"Motivations, demography and clinical features of body dysmorphic disorder among people seeking cosmetic treatments: a study of 199 patients."

BACKGROUND

Motivations for getting aesthetic medicine treatments concern not only the improvement of the physical appearance but also internal aspects such as feeling more confident or happier. Body dysmorphic disorder (BDD) is a disorder that affects from 5 to 15% of aesthetic medicine clients and characterizes by an obsessive preoccupation with a non-visible or minimal defect in appearance.

AIMS

The aim of the study was to assess the main motivations, demography, and clinical features of body dysmorphic disorder among people seeking cosmetic treatments.

METHODS

A single-center study was performed using an anonymous questionnaire on 199 patients of the private aesthetic medicine clinic in Gdansk, Poland.

RESULTS

A typical client of an aesthetic clinic is a woman aged 40 to 50, with higher education, who undergoes aesthetic treatments more than twice a year, mainly with botulinum toxin injections. The most common motivations are the desire to achieve a fresh look, the will to reduce the signs of aging, and to invest in oneself. Furthermore, over 38% of patients stated that they were having critical and recurring thoughts about their appearance, which affected their daily functioning and caused a decrease in their well-being. Almost 20% of them performed repetitive activities, such as frequently looking in the mirror or asking others for opinions about their appearance. 15.6% of patients presented at least two characteristic features of BDD.

CONCLUSIONS

Patients seeking cosmetic treatments may suffer from body dysmorphic disorder, thus the need for aesthetic medicine practitioners to be aware of this disease.

Body Dysmorphic Symptoms in Youth with Obsessive-compulsive Disorder: Prevalence, Clinical Correlates, and Cognitive Behavioral Therapy Outcome

The aims of the study were to estimate the prevalence of body dysmorphic symptoms in a sample of children and adolescents with obsessive-compulsive disorder, possible clinical correlates and whether BDD symptoms predict poorer treatment outcomes after cognitive behavioral therapy. The study included 269 children and adolescents with OCD, aged 7-17 years, from Denmark, Sweden, and Norway, who were treated with 14 weekly sessions of manualized, exposure-based CBT. Twenty-one patients (7.8%) had BDD symptoms. BDD symptoms were associated with older age (p = 0.003) and a higher prevalence of comorbid anxiety disorders (p = 0.025). In addition, patients with BDD symptoms endorsed a greater number of OCD symptoms than did those without BDD symptoms. Having symptoms of BDD did not affect the CBT outcome on OCD. The results of the study suggest that CBT for OCD is equally effective for those with and without comorbid BDD symptoms.

BDD-NET – Ein internetbasiertes Programm bei Körperunzufriedenheit zur niedrigschwelligen Behandlung der körperdysmorphen Störung für den deutschen Sprachraum

Hintergrund: Die Körperdysmorphe Störung (KDS) ist eine schwerwiegende psychische Störung, die mit starker Scham sowie Leidensdruck und Funktionseinschränkungen einhergeht. Kognitive Verhaltenstherapie stellt die aktuell wirksamste evidenzbasierte Behandlungsmethode dar. Aufgrund zahlreicher Behandlungsbarrieren kommen KDS-Betroffene jedoch selten in der psychotherapeutischen Behandlung an, weshalb niedrigschwelligen Behandlungsmethoden (z.B. aus dem Bereich E-Mental-Health) eine wichtige Rolle zukommen könnten. Erste internationale Studien weisen auf die Wirksamkeit von E-Mental-Health-Angeboten bei KDS hin. Material und Methoden: Dieser Beitrag gibt eine Übersicht zur bisherigen Umsetzung und Evidenz von E-Mental-Health-Angeboten für KDS und stellt die ins Deutsche übersetzte Version des BDD-NET-Programms, eines internetbasierten, manuali­sierten, therapeutenbegleiteten Interventionsprogramms, für die KDS vor, welches aus dem Englischen für den deutschen Sprachraum übersetzt und adaptiert wurde. Ergebnisse: BDD-NET umfasst acht Module, die binnen einer 12-wöchigen Behandlung online bearbeitet werden. Die Online-Plattform bietet für die Patienten die Möglichkeit, mit dem BDD-NET-Therapeuten mittels persönlicher Nachrichten zu kommunizieren. Sämtliche Materialien wurden aus dem Englischen übersetzt und vor allem in kultureller Hinsicht adaptiert. Schlussfolgerungen: BDD-NET könnte ein wichtiger Baustein in der Versorgung von KDS-Betroffenen sein. Die Evaluation steht für den deutschen Sprachraum noch aus. Auf Besonderheiten des Settings (z.B. Störungseinsicht als möglicher Behandlungsfokus) sowie praktische Implikationen wird eingegangen. Zudem werden Voraussetzungen und Rahmenbedingungen für eine perspektivische Dissemination diskutiert.

Body Dysmorphic Disorder: Clinical Overview and Relationship to Obsessive-Compulsive Disorder

Body dysmorphic disorder (BDD), characterized by a distressing or impairing preoccupation with nonexistent or slight defects in appearance, is associated with markedly poor quality of life and high rates of suicidality. Onset of BDD is usually in childhood or adolescence and, unless appropriately treated, tends to be chronic. The first-line pharmacologic approach for both delusional and non-delusional BDD is serotonin reuptake inhibitors (SRIs), often at high doses. SRI augmentation and switching strategies can be effective. The first-line psychotherapy is cognitive-behavioral therapy (CBT) tailored to BDD's unique clinical features. Cosmetic treatment (such as surgery or dermatologic treatment), although received by a majority of patients with BDD, is not recommended. BDD has many similarities to obsessive-compulsive disorder (OCD) and appears closely related to OCD but also has some important differences. This article, which updates a 2015 article on BDD that we published in this journal, provides a clinically focused overview of BDD and its relationship to OCD.

Knowledge and competency standards for specialized cognitive behavior therapy for adult obsessive-compulsive disorder

Obsessive-Compulsive Disorder (OCD) is a leading cause of disability world-wide (World Health Organization, 2008). Treatment of OCD is a specialized field whose aim is recovery from illness for as many patients as possible. The evidence-based psychotherapeutic treatment for OCD is specialized cognitive behavior therapy (CBT, NICE, 2005, Koran and Simpson, 2013). However, these treatments are not accessible to many sufferers around the world. Currently available guidelines for care are deemed to be essential but insufficient because of highly variable clinician knowledge and competencies specific to OCD. The phase two mandate of the 14 nation International OCD Accreditation Task Force (ATF) created by the Canadian Institute for Obsessive Compulsive Disorders is development of knowledge and competency standards for specialized treatments for OCD through the lifespan deemed by experts to be foundational to transformative change in this field. This paper presents knowledge and competency standards for specialized CBT for adult OCD developed to inform, advance, and offer a model for clinical practice and training for OCD. During upcoming ATF phases three and four criteria and processes for training in specialized treatments for OCD through the lifespan for certification (individuals) and accreditation (sites) will be developed based on the ATF standards.