Chris is a shy, anxious-looking 31-year-old carpenter who has been hospitalized after making a suicide attempt by putting his head in a plastic bag. He asks to meet with the psychiatrist in a darkened room. He is wearing a baseball cap pulled down over his forehead that is partially covering his eyes. Looking down at the floor, Chris says he has no friends, has just been fired from his job, and was recently rejected by his girlfriend. When the psychiatrist asks Chris to elaborate, he replies, “It’s really hard to talk about this, Doctor. I don’t know if I can. It’s too embarrassing. Well, I guess I should tell you . . . after all, I’m in the hospital because of it. It’s my nose.”“Your nose?” the psychiatrist asks. “Yes, these huge pockmarks on my nose. They’re grotesque! I look like a monster. I’m as ugly as the Elephant Man! These marks on my nose are all I can think about. I’ve thought about them every day for the past 15 years. I even have nightmares about them. And I think that everyone can see them and that they laugh at me because of them. That’s why I wear this hat all the time. And that’s why I couldn’t talk to you in a bright room . . . you’d see how ugly I am.”
The psychiatrist couldn’t see the huge pockmarks that Chris was referring to, even when she later met him in a brightly lit room.
Chris is, in fact, a handsome man with normal-appearing facial pores. The psychiatrist says, “I see no ugly pockmarks. Is it possible that your view of your appearance is distorted, that maybe the pockmarks are just normal-looking facial pores?”
“That’s a hard question to answer,” Chris replies. “I’ve pretty much kept this preoccupation a secret because it’s so embarrassing. I’m afraid people will think I’m vain. But I’ve told a few people about it, and they’ve tried to convince me that the pores really aren’t visible. Sometimes I sort of believe them. I think I probably am distorting and that they’re not so bad. Then I look in the mirror and see that they’re huge and ugly, and I’m convinced that people laugh at them. Then no one can talk me out of it. When people try to, I think they just feel sorry for me and that they’re trying to make me feel better. This has affected me in a lot of ways, Doctor,” Chris adds. “It may be hard for you to believe, but this problem has ruined my life. All I can think about is my face. I spend hours a day looking at the marks in the mirror. But I just can’t resist. I started missing more and more work, and I stopped going out with my friends and my girlfriend. I got so anxious when people looked at me that I started staying in the house most of the time. Sometimes when I did go out, I went through red lights so I wouldn’t have to sit in my car at the light where people might be staring at me. The hat helped a little, but it didn’t cover all the marks. I tried covering them with makeup for a while, but I thought people could see the makeup so that didn’t really help. The only time I really felt comfortable was when I wore my nephew’s Batman mask on Halloween. Then no one could see the marks. I missed so much work that I was fired. My girlfriend stuck it out with me for a long time, but she finally couldn’t take it anymore. One thing that was really hard for her was that I started asking her about 50 times a day whether I looked okay and whether she could see the marks. I think that was the last straw. If I had a choice, I’d rather have cancer. It must be less painful. This is like an arrow through my heart.”
Chris went on to discuss the fact that he had seen a dermatologist to request dermabrasion but was refused the procedure because “the dermatologist said there was nothing there.” He finally convinced another dermatologist to do the procedure but thought it did not help. Eventually, he felt so desperate over the supposed marks that he made two suicide attempts. His most recent attempt occurred after he looked in the mirror and was horrified by what he saw. He told the psychiatrist, “I saw how awful I looked, and I thought, I’m not sure it’s worth it to go on living if I have to look like this and think about this all the time.” His first suicide attempt had also led to hospitalization, but, because Chris was so ashamed of his concern and thought it would not be taken seriously, he had kept it a secret and told the staff only that he was depressed.
DSM-IV-TR Casebook Diagnosis of “Elephant Man”
Chris looks normal but is preoccupied with a supposed defect in his appearance. This preoccupation has clearly caused him much distress and has significantly interfered with his functioning. Although this is a fairly severe case of Body Dysmorphic Disorder (BDD), it is not atypical; occupational, social, and other important areas of functioning may be severely impaired, and suicide attempts are not uncommon. However, the degree of distress and dysfunction associated with this disorder spans a spectrum of severity; some people with this disorder although distressed and perhaps not functioning up to their capacity nevertheless cope relatively well.
Discussion of “Elephant Man” by Katharine A. Phillips, M.D., and Rocco Crino, Ph.D.
Chris has a severe although not atypical case of BDD (Phillips 1996, 2001). Like many other patients do, Chris initially told the hospital staff only that he was depressed, because he worried that if he mentioned his concern about his appearance, he would be considered silly or vain. Before BDD can be effectively treated, it must be appropriately diagnosed (Phillips 1996, 2001). Diagnosis is critically important because untreated BDD can cause severe impairment in functioning, hospitalization, and even suicide. A number of studies have documented that clinicians underrecognize and underdiagnose BDD (Phillips 2001). The patient may not volunteer the symptoms because of embarrassment and shame, and the clinician may not ask. If BDD symptoms are elicited, they may be misdiagnosed as depression, Obsessive-Compulsive Disorder, Social Phobia, Agoraphobia, Avoidant Personality Disorder, Psychotic Disorder NOS, or even Schizophrenia. If these disorders rather than BDD are targeted in treatment, the treatment may fail.
Some patients who present for psychiatric treatment are well informed about BDD (and may even have to convince a skeptical clinician that this is the correct diagnosis!). Others, however, are reluctantly dragged to treatment by distraught family members. Still others begrudgingly see a psychiatrist at the behest of a wary dermatologist or surgeon, and they do so only because the patient views the psychiatric consult as a ticket to a desired cosmetic procedure. Regardless of the patient’s motivation, it is important to provide education about BDD, explaining that it is a relatively common and treatable body image disorder. Many patients welcome the diagnosis and the information that BDD can be treated, whereas others (typically those with poor or absent insight) reject the diagnosis and treatment. It can help to focus on the potential for psychiatric treatment to decrease the excessive preoccupation with the perceived appearance flaws, to diminish suffering, and to improve functioning and quality of life. It is usually fruitless to extensively discuss or argue over whether the defect is “real.” It may instead help to explain that people with BDD versus other people have quite different views of how the BDD sufferer looks for reasons that are not well understood. Then the patient can be encouraged to focus on the potential for treatment to improve his or her life.
Our general approach to patients who want dermatologic treatment, surgery, or other nonpsychiatric treatment (e.g., electrolysis) is to say that no one can predict how an individual patient will respond to such treatment, but as best we know it is usually ineffective for BDD and can even worsen the appearance concerns (Phillips 1996, 2001). We have seen many patients who seriously regret having had such treatment. (Patients who damage their skin by picking at it, however, may require dermatologic as well as psychiatric care.) We explain that psychiatric treatment is much less risky, does not make patients think they look worse, is likely to help them feel better and improve their life, and is worth a try.
We would start treating Chris with a serotonin reuptake inhibitor (SRI) and cognitive-behavioral therapy (CBT). Although research on these two treatments is still limited, they are the best studied and appear efficacious for a majority of BDD patients (Neziroglu and Khemlani-Patel 2002; Phillips 2002). It isn’t known which treatment is more effective or whether the combination is better than either treatment alone. Based on our clinical experience, we would recommend always treating a severely ill patient like Chris with an SRI. He is too depressed and too high a suicide risk to go without one. Furthermore, some BDD patients are too severely depressed, anxious, delusional, or unmotivated to do the work that CBT requires. Treating such patients with an SRI may diminish their BDD symptoms to the point that they can meaningfully participate in CBT. A reasonable treatment for patients with symptoms of moderate severity is use of an SRI or CBT, or both. For mild BDD, it may be preferable to start with CBT. For moderate or mild BDD, however, it is important to also consider other factors, such as comorbidity, the patient’s preference, and the availability of CBT therapists knowledgeable about BDD, when choosing treatment.
Two controlled studies, three open-label trials, and case reports and series indicate that SRIs are often efficacious for BDD (Hollander et al. 1999; Phillips 1996, 2002; Phillips et al. 2001, 2002). Response to an SRI usually results in decreased distress and decreased time spent being preoccupied with the “defect,” improved functioning (such as return to work or school), improvement in depressive symptoms, decreased repetitive behaviors (e.g., mirror checking), and improvement in insight and referential thinking. Importantly, SRIs appear more effective than other medications, including non-SRI antidepressants. An intriguing and clinically important finding is that studies indicate that SRIs alone are efficacious for patients with delusional BDD (i.e., those who are completely convinced that they look abnormal and cannot be convinced otherwise [Hollander et al. 1999; Phillips 2001, 2002]). This approach might sound counterintuitive, as psychotic symptoms in other disorders are typically treated with antipsychotics. Unfortunately, very few data are available on the efficacy of antipsychotics for BDD, but these data (which are largely retrospective) suggest that antipsychotics alone are not effective, even for delusional patients (Phillips 2002).
It is very important to use a high enough SRI dose for a long enough time (Phillips 2001, 2002). Although no studies have compared different SRI doses, clinical experience indicates that patients with BDD usually require higher doses than those typically used for depression. In the first author’s clinical practice, the mean SRI doses have been fluoxetine (Prozac), 66.7 Â± 23.5 mg/day; fluvoxamine (Luvox), 308.3 Â± 49.2 mg/day; paroxetine (Paxil), 55.0 Â± 12.9 mg/day; sertraline (Zoloft), 202.1 Â± 45.8 mg/day; clomipramine (Anafranil), 203.3 Â± 52.5 mg/day; citalopram (Celexa), 71.4 Â± 27.3 mg/day; and escitalopram (Lexapro), 30.4 Â± 10.1 mg/day, all of which are at the upper end of, or even exceed, the recommended dose range (Phillips et al. 2001). It’s also important that the SRI trial is long enough. Most studies (which used fairly rapid titration schedules) have reported an average time to response in the range of 6-9 weeks, with some patients requiring as long as 12, or occasionally even 16, weeks to respond. We commonly see unimproved patients who have previously received many brief (e.g., 4-8 weeks) trials of low-dose SRIs; often, such patients have been diagnosed with depression while BDD was missed.
There is no one-size-fits-all formula for dose titration; it will depend on a number of factors, including illness severity (with quicker titration generally advisable for sicker patients, especially those who are suicidal), medication tolerability, and patient preference. A reasonable goal, however, is to reach the maximum dose recommended by the manufacturer (if a lower dose does not work) by 5-9 weeks from the start of treatment, if tolerated. This approach may result in a higher dose than necessary (although the dose can always be lowered subsequently, if desired), but it has the advantage of not missing a response because of undertreatment, and it also prevents an unnecessarily protracted treatment trial, which could result from slower upward titration.
Clinical experience suggests that, with continued SRI treatment, relapse is rare and many patients further improve. Although formal medication discontinuation studies have not been done, it appears that most patients relapse when an effective SRI is discontinued (Phillips et al. 2001). Therefore, we would treat a patient with severe BDD for years and would consider treating a patient like Chris with an SRI for the rest of his life. Typically, we continue an effective SRI for a minimum of 1-2 years. If the patient wishes to discontinue the medication, we plan this carefully, ideally selecting a time of minimal stress and tapering the SRI slowly over many months. It is unknown whether treatment with CBT may decrease the risk of relapse when an SRI is discontinued; this question is important and needs to be studied.
If Chris doesn’t respond to the first SRI (e.g., a 12- to 14-week trial of citalopram reaching 60 mg/day by weeks 5-6), there are several options (Phillips 1996, 2002). One option is to increase the SRI dose (excluding clomipramine) above the maximum recommended dose (e.g., reaching 80-100 mg/day of citalopram or paroxetine). After an initial 12-week trial, 2-3 weeks on a higher-than-maximum dose is usually adequate to see whether the higher dose will work. We do not use this approach routinely but may use it when the patient has partially but inadequately responded to the maximum recommended dose and is tolerating the medication well. This approach is even more appealing if a number of SRIs have not been useful for the patient, in which case the remaining options are diminishing. Another option is to switch to another SRI and to conduct sequential trials of all of the SRIs, if necessary. A substantial percentage of patients who do not respond to an initial SRI trial will respond to a subsequent SRI (Phillips et al. 2001).
Yet another option is to add an augmenting medication to the SRI. Potentially effective choices include buspirone, an atypical antipsychotic; clomipramine; or another antidepressant (e.g., bupropion [ Wellbutrin ], venlafaxine [ Effexor ]) (Phillips 2002; Phillips et al. 2001). If clomipramine is combined with an SRI, the clomipramine level must be carefully monitored. Augmentation may make more sense for patients who have partially responded to an SRI, but it can also be tried if there has been only a minimal SRI response or no response. Combining an atypical antipsychotic with an SRI, although virtually unstudied, is particularly appealing for a delusional patient. It is not known which augmentation strategy is most effective or whether it is better to augment or switch to another SRI. Augmentation strategies are more appealing if there is a high risk of serious consequences due to relapse, which could occur when switching a patient from a partially effective SRI. Very anxious, agitated, and distressed patients may benefit from the addition of a benzodiazepine to the SRI (although we are reluctant to do this for patients with a history of substance abuse). For patients for whom multiple SRIs have failed, venlafaxine or a monoamine oxidase inhibitor (e.g., phenelzine [Nardil] or tranylcypromine sulfate [Parnate]) is worth trying.
CBT has also been shown to be efficacious for BDD (Neziroglu and Khemlani-Patel 2002; Phillips 1996). Evidence of the efficacy of CBT comes from case series (Marks and Mishan 1988) as well as two randomized studies in which BDD was compared to a no-treatment waiting-list control (Rosen et al. 1995; Veale et al. 1996). One study consisted of patients quite different from Chris, in that all were women who appeared to have relatively mild BDD, and many of them were concerned with weight and body shape (Rosen et al. 1995). Other reports, however, contained men as well as women and included patients with more severe and typical BDD symptoms (Marks and Mishan 1988; Neziroglu and Khemlani-Patel 2002; Veale et al. 1996).
When starting CBT with Chris, we would begin by thoroughly assessing his BDD symptoms. This assessment would include determining his beliefs about his looks; supporting evidence for such beliefs; and his checking behaviors (e.g., mirror checking), reassurance-seeking behaviors, camouflaging behaviors (e.g., wearing a hat and makeup), and avoidance behaviors (e.g., going through red traffic lights, not allowing people in close proximity, avoiding brightly lit rooms). To engage him in treatment, we would focus discussion on the time-consuming, distressing, and impairing nature of his preoccupations. We would educate him about the CBT model and develop an individualized case conceptualization to generate a treatment plan and emphasize how his behaviors reinforce his preoccupations and beliefs.
We would do an initial response prevention to decrease these reinforcing behaviors, explaining that bringing the behaviors under control will minimize his preoccupation and distress. We would make a list of these behaviors and rate each of them in terms of how much anxiety would be provoked if that particular behavior were controlled (e.g., “How anxiety-provoking would it be if you didn’t wear a hat when you leave the house?”). Once anxiety ratings are established, the patient would decrease (ideally, stop) each behavior in a hierarchical fashion starting from the least and moving toward the most anxiety-provoking situations. Checking mirrors and other reflective surfaces (e.g., windows, backs of spoons) is one of the most important behaviors to control. Most BDD patients check so excessively and closely that they are likely to obtain a very distorted view of themselves. Chris stands several inches from the mirror for hours a day intensely staring at and examining his pores, which no doubt makes them appear larger than they actually are. Similarly, checking other reflective surfaces will only further reinforce his distorted image because such surfaces (e.g., car bumpers, shiny plastic or chrome surfaces) provide a distorted reflection. Although mirror checking is difficult to totally control, a realistic goal would be to have Chris stand several feet from the mirror when brushing his hair or doing normal grooming and to have him not approach the mirror at any other time. Some experts would also recommend “mirror retraining,” in which patients learn to objectively (rather than negatively) describe their entire body (not just disliked areas) while looking in the mirror. Such retraining is done only at specified times of the day and must not include excessive checking (i.e., ritualizing).
We would also have Chris do behavioral experiments. These would be designed to test his appearance-related beliefs and provide him with disconfirming evidence of his beliefs. For example, setting up a simple but carefully planned task with a specific hypothesis could test his belief that others take special notice of and are horrified by his “disfigurement.” The hypothesis could be that if he walks into a shop to purchase something, 80% of people will recoil from him with a look of horror on their face and move away from him within 5 seconds. Another hypothesis might be that if he walks down a crowded sidewalk, 75% of people approaching him will cross to the other side of the street before passing him because he is so ugly. Such tasks are carried out by the patient and are best conducted (at least initially) with the clinician, who would also look for evidence of whether the hypothesis is true. After the experiment, the patient and clinician discuss whether the expected outcome occurred and what the patient learned from the task. This process not only begins to expose Chris to his feared situations (i.e., exposure) but also allows the clinician to gently challenge some of his beliefs on the basis of the experiment’s results. Like standard exposure, behavioral experiments are conducted in a hierarchical fashion (from easier to more difficult). In designing such tasks, it is important to clearly spell out the task before it is conducted and to have a very concrete hypothesis, which the patient formulates with the clinician’s help. The behaviors that Chris expects from others need to be clearly defined so that he does not misinterpret normal looks or smiles from others. For example, he should determine how many people actually laugh at him, stare at him intently, or move away from him with a clear look of horror or disgust. Such behavioral experiments would be expanded to include previously avoided situations, such as social gatherings, outings, being in close proximity to others or under bright lights, and waiting at traffic lights. Repeated exposure to such situations would provide evidence contrary to his beliefs and would also assist Chris in habituating to these previously anxiety-provoking situations.
We would also do cognitive restructuring, as developed by Beck, for depression and anxiety disorders. In cognitive restructuring, the patient identifies negative automatic thoughts (e.g., “Everyone here thinks I look deformed”), underlying core beliefs (e.g., “I’ll always be alone because of how I look”), and cognitive errors (e.g., mind reading, fortune telling, catastrophizing). The therapist helps the patient examine the evidence for and against these beliefs and generate more accurate and helpful beliefs. Because most patients have poor or absent insight, as well as prominent depressive symptoms, we generally recommend using cognitive approaches in the form of cognitive restructuring and/or behavioral experiments in addition to standard behavioral techniques, such as exposure and response prevention. In our experience, the combination of behavioral experiments, cognitive restructuring, and exposure and response prevention is essential in the cognitive-behavioral treatment of BDD. It is also important for the clinician to assign homework so that the patient practices these CBT approaches between sessions to maximize gains beyond the sessions.
*Dr. Phillips is Professor of Psychiatry at Brown Medical School and Director of the Body Dysmorphic Disorder and Body Image Program at Butler Hospital in Providence, Rhode Island. Dr. Phillips has been doing research and treating patients with BDD since 1990, which has involved approximately 800 individuals with this disorder. Her pioneering work, which has focused largely on BDD’s psychopathology and pharmacological treatment, has brought this disorder to the attention of the public and professionals alike. She has written and edited several books on BDD and body image, including The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder (Phillips 1996).
**Dr. Crino is Senior Lecturer in the School of Psychiatry at the University of New South Wales and Director of the Anxiety Disorders Unit at St. Vincent’s Hospital in Sydney, Australia. Since 1988, Dr. Crino has worked extensively in the treatment of Obsessive-Compulsive Disorder and related conditions. In 1999, he established a cognitive-behavioral treatment program for BDD. He has published papers in the area of anxiety and related disorders and is coauthor of The Treatment of Anxiety Disorders (Cambridge University Press, 1994).
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Revision date: July 8, 2011
Last revised: by Andrew G. Epstein, M.D.