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Body dysmorphic disorder — Clinical Guidelines

Overview

Body dysmorphic disorder (BDD) is a psychiatric condition characterized by excessive preoccupation with perceived flaws in physical appearance, often leading to significant distress and impairment, frequently encountered in dermatologic settings 1 7 12.

Diagnosis

Key Diagnostic Criteria: Preoccupation with an imagined defect or slight physical anomaly, repetitive behaviors or mental acts performed to alleviate distress 1 7 12.

Recommended Screening Tools: Use of validated questionnaires such as the Body Dysmorphic Disorder Questionnaire for screening, particularly in dermatology populations 1 6 7.

Clinical Assessment: Detailed history and psychiatric evaluation to rule out other psychiatric comorbidities 3 7.

Management

First-Line Treatments: Cognitive-behavioral therapy (CBT) is highly effective 3 26 27.

Pharmacotherapy: Selective serotonin reuptake inhibitors (SSRIs), particularly fluoxetine, are recommended with doses typically starting at 20 mg daily and titrating up as needed 7 24.

Adjunctive Treatments: Exposure and response prevention (ERP) therapy can be beneficial 33.

Multidisciplinary Approach: Collaboration with psychiatrists and psychologists for comprehensive care 30.

Special Populations

Pediatrics: BDD often develops in early adolescence with higher rates of functional impairment and suicidality 11.

Comorbidities: High prevalence of other psychiatric comorbidities such as obsessive-compulsive disorder and depression 7 12.

Key Recommendations

Screen dermatology patients for BDD using validated questionnaires to improve early detection (Evidence: Moderate 6 7).

Initiate treatment with SSRIs, starting with fluoxetine 20 mg daily, adjusting as necessary for efficacy (Evidence: Moderate 7 24).

Integrate CBT, particularly ERP, into treatment plans to address maladaptive behaviors (Evidence: Moderate 3 26 27).

Recognize and address BDD in pediatric patients due to higher risk of severe functional impairment (Evidence: Moderate 11).

Screen for and manage comorbid psychiatric conditions alongside BDD treatment (Evidence: Moderate 7 12).

References

1 Salameh P, El Khoury J, Hallal M, Bader E, El Sater RA, Maamari M et al.. Body Dysmorphic Disorder Questionnaire: Arabic Adaptation and Validation in Dermatology Population. International journal of methods in psychiatric research 2025. link 2 Saade N, Chedraoui C, Mitri MT, Salameh P, Said Y, El Khoury J. The prevalence of body dysmorphic disorder in outpatient dermatology clinics: a systematic review. Clinical and experimental dermatology 2024. link 3 Sejdiu Z, Stitzlein E, Rieder EA, Andriessen A, Greenberg JL, Oza VS et al.. Appearance Dissatisfaction and Body Dysmorphic Disorder in the Dermatology Patient. Journal of drugs in dermatology : JDD 2024. link 4 Husain W, Zahid N, Jehanzeb A, Mehmood M. The psychodermatological role of cosmetic dermatologists and beauticians in addressing charismaphobia and related mental disorders. Journal of cosmetic dermatology 2022. link 5 Dworakowski O, Drüge M, Schlunegger M, Watzke B. Body dysmorphic disorder of female genitalia: a qualitative study of Swiss obstetrician-gynecologists' experiences and practices. Archives of gynecology and obstetrics 2022. link 6 Fletcher L. Development of a multiphasic, cryptic screening protocol for body dysmorphic disorder in cosmetic dermatology. Journal of cosmetic dermatology 2021. link 7 Herbst I, Jemec GBE. Body Dysmorphic Disorder in Dermatology: a Systematic Review. The Psychiatric quarterly 2020. link 8 AlShahwan MA. Prevalence and characteristics of body dysmorphic disorder in Arab dermatology patients. Saudi medical journal 2020. link 9 Marron SE, Gracia-Cazaña T, Miranda-Sivelo A, Lamas-Diaz S, Tomas-Aragones L. Screening for Body Dysmorphic Disorders in Acne Patients: A Pilot Study. Actas dermo-sifiliograficas 2019. link 10 Salinas M, Floodgate W, Ralphs R. Polydrug use and polydrug markets amongst image and performance enhancing drug users: Implications for harm reduction interventions and drug policy. The International journal on drug policy 2019. link 11 Dennin MH, Lee MS. Body dysmorphic disorder in pediatric dermatology. Pediatric dermatology 2018. link 12 Koblenzer CS. Body dysmorphic disorder in the dermatology patient. Clinics in dermatology 2017. link 13 Bouman TK, Mulkens S, van der Lei B. Cosmetic Professionals' Awareness of Body Dysmorphic Disorder. Plastic and reconstructive surgery 2017. link 14 França K, Roccia MG, Castillo D, ALHarbi M, Tchernev G, Chokoeva A et al.. Body dysmorphic disorder: history and curiosities. Wiener medizinische Wochenschrift (1946) 2017. link 15 Brohede S, Wyon Y, Wingren G, Wijma B, Wijma K. Body dysmorphic disorder in female Swedish dermatology patients. International journal of dermatology 2017. link 16 Veale D, Gledhill LJ, Christodoulou P, Hodsoll J. Body dysmorphic disorder in different settings: A systematic review and estimated weighted prevalence. Body image 2016. link 17 Sarwer DB, Spitzer JC, Sobanko JF, Beer KR. Identification and management of mental health issues by dermatologic surgeons: a survey of American Society for Dermatologic Surgery members. Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.] 2015. link 18 Dogruk Kacar S, Ozuguz P, Bagcioglu E, Coskun KS, Uzel Tas H, Polat S et al.. The frequency of body dysmorphic disorder in dermatology and cosmetic dermatology clinics: a study from Turkey. Clinical and experimental dermatology 2014. link 19 Gupta R, Huynh M, Ginsburg IH. Body dysmorphic disorder. Seminars in cutaneous medicine and surgery 2013. link 20 Situm M, Buljan M. How to protect medical professionals from unrealistic expectations of clients in corrective dermatology?. Acta clinica Croatica 2010. link 21 Szepietowski JC, Salomon J, Pacan P, Hrehorów E, Zalewska A. Body dysmorphic disorder and dermatologists. Journal of the European Academy of Dermatology and Venereology : JEADV 2008. link 22 Harth W, Hermes B. Psychosomatic disturbances and cosmetic surgery. Journal der Deutschen Dermatologischen Gesellschaft = Journal of the German Society of Dermatology : JDDG 2007. link 23 Buescher LS, Buescher KL. Body dysmorphic disorder. Dermatologic clinics 2006. link 24 Crerand CE, Phillips KA, Menard W, Fay C. Nonpsychiatric medical treatment of body dysmorphic disorder. Psychosomatics 2005. link 25 Mackley CL. Body dysmorphic disorder. Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.] 2005. link 26 Wilson JB, Arpey CJ. Body dysmorphic disorder: suggestions for detection and treatment in a surgical dermatology practice. Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.] 2004. link 27 Dufresne RG, Phillips KA, Vittorio CC, Wilkel CS. A screening questionnaire for body dysmorphic disorder in a cosmetic dermatologic surgery practice. Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.] 2001. link 28 Phillips KA, Dufresne RG, Wilkel CS, Vittorio CC. Rate of body dysmorphic disorder in dermatology patients. Journal of the American Academy of Dermatology 2000. link90215-9) 29 Phillips KA, Dufresne RG. Body dysmorphic disorder. A guide for dermatologists and cosmetic surgeons. American journal of clinical dermatology 2000. link 30 Kells BE, Kime DL, Kennedy JG, Freeman R. Dysmorphophobia: a case successfully treated using a multidisciplinary approach. Dental update 1996. link 31 Snaith P. Body image disorders. Psychotherapy and psychosomatics 1992. link 32 Bloch S, Glue P. Psychotherapy and dysmorphophobia: a case report. The British journal of psychiatry : the journal of mental science 1988. link 33 Marks I, Mishan J. Dysmorphophobic avoidance with disturbed bodily perception. A pilot study of exposure therapy. The British journal of psychiatry : the journal of mental science 1988. link 34 Hardy GE. Body image disturbance in dysmorphophobia. The British journal of psychiatry : the journal of mental science 1982. link 35 Connolly FH, Gipson M. Dysmorphophobia--a long-term study. The British journal of psychiatry : the journal of mental science 1978. link

Body dysmorphic disorder