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Comorbid Social Anxiety and Body Dysmorphic Disorder: Managing the Complicated Patient

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Comorbid Social Anxiety and Body Dysmorphic Disorder: Managing the Complicated Patient Social Anxiety and Body Dysmorphic Disorder Comorbid Social Anxiety and Body Dysmorphic Disorder: Managing the Complicated Patient Eric Hollander, M.D., and Bonnie R. Aronowitz, Ph.D. © CopyrightPatients with body dysmorphic2000 Physiciansdisorder (BDD) have anPostgraduate obsessive preoccupation Press,with an imagined Inc. defect in appearance or, if a slight physical abnormality exists, a grossly excessive concern with it. This preoccupation causes significant distress or impairment of social, occupational, or other functioning. So- cial anxiety is a prominent component of BDD, and social avoidance resulting from BDD symptoms may markedly impair social functioning. In severe cases, avoidance of social situations in combination with occupational and academic impairment may result in patients becoming housebound. The prevalence of BDD is 1% to 2% in the U.S. population and 11% to 12% in patients with social anxiety disorder. Behav- iors associated with BDD include mirror checking, physician visits, hair grooming, use of cosmetics, and social avoidance. Distress over BDD may lead patients to undergo repeated cosmetic surgeries in futile at- tempts to conceal or correct perceived defects. Additionally, depression and suicide are frequent complica- tions of BDD. Pharmacologic and nonpharmacologic treatments for the management of BDD with coexist- ing social anxiety are presented in this article. (J Clin Psychiatry 1999;60[suppl 9]:27–31) One personal copy may be printed ody dysmorphic disorder (BDD) has been termed Diagnostic probes for the assessment of BDD include B“the distress of imagined ugliness.”1 The American ascertainment of the content and degree of preoccupation Psychiatric Association’s Diagnostic and Statistical with appearance, level of distress about perceived defects, Manual of Mental Disorders, Fourth Edition (DSM-IV) resultant functional impairment, and consideration of cos- characterizes BDD as a preoccupation with an imagined metic surgery or other procedures to change appearance defect or defects in appearance that causes significant dis- (Table 1). In addition, comorbidity with other Axis I anxi- tress or impairment in social, occupational, or other func- ety and mood disorders should be determined (Figure 2). tioning.2 The DSM-IV stipulates that this preoccupation is not better accounted for by another mental disorder such COSMETIC SURGERY AND BDD as anorexia nervosa. Areas of perceived defect in BDD typically include the The existence of functional impairment is a DSM-IV body in general or head, face, sexual body parts, arms and requirement for the diagnosis of BDD, and this distin- legs, skin, and body odor (Figure 1). The behavioral pro- guishes a somewhat excessive concern with physical ap- file of BDD includes social avoidance, multiple dermato- pearance common in the population3 from the clearly dys- logic and cosmetic surgeries, mirror checking, multiple functional preoccupation present in BDD. Although physician visits, hair grooming, and excessive application cosmetic surgery applicants may share certain characteris- of cosmetics. In addition, patients with BDD may engage tics with BDD patients, important differences exist be- in compulsive rituals to conceal their perceived defects. tween the 2 populations. Cosmetic surgery applicants demonstrate significantly less preoccupation with their defect than BDD patients, From the Department of Psychiatry, The Mount Sinai who may be obsessively preoccupied 24 hours a day. Thus, School of Medicine, New York, N.Y. BDD patients are more likely to have comorbid social anx- Supported in part by grant FD-R-000941-01 from the Food iety disorder and depression secondary to their preoccupa- and Drug Administration and by the Seaver Foundation, New York, N.Y. tion with appearance compared with cosmetic surgery ap- Presented at the symposium “New Frontiers in the plicants. In addition, cosmetic surgery applicants tend to be Management of Social Anxiety Disorder: Diagnosis, Treatment, and Clinical Course.” This symposium was held in conjunction dissatisfied with a specific body part, whereas BDD pa- with the 151st Annual Meeting of the American Psychiatric tients tend to shift the focus of their dissatisfaction over Association, May 31, 1998, Toronto, Ontario, Canada, and time and develop new preoccupations. Moreover, cosmetic supported by an educational grant from SmithKline Beecham Pharmaceuticals. surgery applicants have no functional impairment because Reprint requests to: Eric Hollander, M.D., Department of of their concern over a particular body part, whereas BDD Psychiatry, Box 1230, The Mount Sinai School of Medicine, 1 Gustave L. Levy Place, New York, NY 10029 (e-mail: patients have significant impairment in social, occupa- [email protected]). tional, and academic functioning (Table 2).4 J Clin Psychiatry 1999;60 (suppl 9) 27 Hollander and Aronowitz Figure 1. Areas of Perceived Physical Defect in Patients With Figure 2. Diagnostic Flowchart for Body Dysmorphic Body Dysmorphic Disorder Disordera Sexual Body Parts 5.1% Are you preoccupied with some aspect of your Arms/Legs 12.8% appearance that you think doesn’t look right? General Body 15.4% Yes No Skin 10.2% Have you had, or are you thinking of having, cosmetic surgery or procedures to change your appearance? Body Odor Yes No © Copyright 2000 Physicians2.5% Postgraduate Press, Inc. Normal cosmetic surgery? No Yes Rule out Comorbidity? Look for Head/Face OCD Anxiety disorder 54.0% Social anxiety disorder Delusions Transsexualism Depression Gender identity disorder OCD Anorexia nervosa Delusional disorder (all types except somatic Table 1. Diagnostic Probes for Body Dysmorphic Disorder type) Have you ever been very worried about yourOne appearance personal in any way? copy may be printed If yes, what was your concern? aAbbreviation: OCD = obsessive-compulsive disorder. Did you think (body part) was especially unattractive? How do you feel about the appearance of your face, skin, hair, nose, or the shape or size or other aspect of any other body part? Were you preoccupied with this concern? Did you think about it a lot and wish you could worry about it less? associated features, comorbid Axis I disorders, familial What effect has this preoccupation with your appearance had on your psychiatric history, or treatment response. These findings life? support the fact that BDD includes a psychotic subtype Has it caused you a lot of distress or significantly interfered with your social life, school achievement, work, or other activities? rather than that the delusional form warrants classification Has your concern had any effect on your family or friends? as a separate disorder. Muscle dysmorphia, or bigorexia, in men has been termed a delusional form of BDD (E.H. unpublished data, In cosmetic surgery applicants, there is good concor- 1998, and reference 6). Patients with muscle dysmorphia dance between the plastic surgeon and patient about the are preoccupied with muscularity and obsessed with their perceived defect, whereas BDD patients have concerns body size being too small or insufficiently lean. Compul- grossly disproportionate to their actual defects. Poor con- sive behavior includes engaging in continuous exercise to cordance between patient and plastic surgeon about the ex- the point of being “gym rats,” weight lifting even follow- istence or degree of the perceived defect inevitably contrib- ing physical injury such as shoulder dislocation, and use of utes to poor surgical outcome. BDD patients are thus at anabolic steroids to “bulk up.” However, it is likely that greater risk for poor surgical outcome in comparison with muscle dysmorphia is responsive to selective serotonin re- cosmetic surgery applicants. Poor outcomes in BDD in- uptake inhibitors (SSRIs).7 clude a perception of being damaged by surgery and may lead to lawsuits or threats against or actual homicide of the SOCIAL ANXIETY DISORDER plastic surgeon by the patient or someone close to the pa- tient. The DSM-IV characterizes social anxiety disorder as a persistent fear of social or performance situations during PSYCHOTIC VERSUS NONPSYCHOTIC BDD which the individual is exposed to possible scrutiny. In individuals under the age of 18 years, symptoms must per- Patients with BDD demonstrate excessive concern over sist for at least 6 months.2 The focus of fear is humiliation slight physical anomalies; this overvalued ideation or de- and embarrassment in social situations. Exposure to social lusional conviction about perceived defects was found in situations often is associated with extreme anxiety, includ- 48.7% of BDD patients.5 However, when the psychotic ing panic symptomatology.2 Although the patient ac- or delusional subtype of BDD was compared with the non- knowledges that the fear is unreasonable or disproportion- psychotic subtype, there were no differences in demo- ate to the situation, feared social situations are typically graphics, phenomenology, course of illness and outcome, avoided. This avoidance or endurance with marked dis- 28 J Clin Psychiatry 1999;60 (suppl 9) Social Anxiety and Body Dysmorphic Disorder Table 2. Multivariate Analysis of Variancea for Survey Questions Related to BDD Diagnostic Criteria: Plastic Surgery Applicants Versus BDD Patientsb Cosmetic Surgery Medical Plastic Universal BDD Subjects Applicants Surgery Applicants F Tests Scheffé (N = 17) (N = 98) (N = 27) Significance Paired Question Mean SD Mean SD Mean SD Levels Contrastsc Have physical defect 0.94 0.24 0.72 0.45 0.54 0.51 .014 + Preoccupied
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