Body dysmorphic disorder: diagnosis and treatment of imagined ugliness

Body dysmorphic disorder (BDD), a preoccupation with an imagined or slight defect in appearance, has been described for more than a century and reported around the world. However, this distressing and impairing disorder often goes undiagnosed, even though available data suggest that it is relatively common. Virtually any body part can be the focus of concern, with preoccupations most often involving the hair, nose, or skin. Most patients engage in excessive and repetitive behaviors such as mirror checking, skin picking, and reassurance seeking. Insight is generally poor, and many patients are frankly delusional. Most patients experience significant impairment in functioning, and suicide attempts are relatively common. Although the majority of patients with BDD seek often costly nonpsychiatric treatment-most often, surgical or dermatologic-such treatment usually appears to be unsuccessful. In contrast, preliminary data from open studies suggest that the serotonin reuptake inhibitors are often, and perhaps preferentially, effective for BDD. Augmentation, combination, and switching strategies may be useful in treatment-resistant cases. Preliminary data suggest that cognitive-behavioral strategies using exposure and response prevention may also be effective. Investigation of all aspects of this understudied disorder, including controlled treatment trials, is greatly needed.