Body dysmorphic disorder (BDD) affects up to 2% of the population and is associated with serious impairment and disruption among sufferers. Yet, compared to other psychiatric problems, it remains relatively under-researched. Here, I describe our findings from a recent study of the efficacy of cognitive behavioural therapy for adolescent BDD.
Appearance anxiety: a major problem in youth
It is no secret than body image concerns plague many young people today. The Good Childhood Report (2015)1, which was based on survey data from over 28,000 children and adolescents in England, found that 13% of young people are unhappy with the way they look. In fact, more young people were unhappy with their appearance than any other aspect of their life. The same study showed that England may fare particularly poorly when it comes to body image in youth. Out of a total of 15 countries, England ranked 13th for positive body image and 14th for happiness with appearance.
Some young people with appearance worries – probably the majority – manage to navigate through these difficulties and come out the other side relatively unscathed. However, others become increasingly preoccupied and distressed by their appearance and go on develop a full-blown psychiatric disorder, such body dysmorphic disorder (BDD).
Body dysmorphic disorder and its treatment
The hallmark of BDD is excessive preoccupation with perceived flaws in one’s appearance2. These perceived defects are not noticeable, or barely noticeable, to others but the BDD sufferer is nevertheless highly distressed and impaired by their preoccupation [Ed. – you can get a sense of the experience of a BDD sufferer by watching the video at the bottom of this post, produced by the BDD Foundation]. Although once thought to be rare, BDD is now estimated to have a prevalence of approximately 2% in community samples of adults3,4,5. The disorder typically emerges during adolescence6, where it can wreak havoc in all aspects of the teenager’s life, often leading to reduced academic performance, school absenteeism, social isolation, and suicidal behaviour7,8.
Despite being relatively common and highly impairing, BDD has tended to be overlooked when it comes to research. Surprisingly little is known about the disorder, including its epidemiology, aetiology and treatment. In 2005, the National Institute for Health and Clinical Excellence published guidelines for the management of BDD9. They recommended cognitive behaviour therapy (CBT) as a first-line treatment for BDD in children and adolescent, based on the best available evidence at the time. However, this “evidence” was limited to a handful of single case studies and extrapolation from the two randomised controlled trials (RCTs) of CBT for BDD that had been conducted in adults.
The first treatment trial for adolescent BDD
In 2015, we published the first RCT of CBT for adolescent BDD10 and, more recently, the long-term outcomes of the trial11. Thirty adolescents with BDD were randomised to either 14 sessions of developmentally tailored CBT or a control condition, which involved weekly monitoring phone calls and written psychoeducation materials. The controlled phase of the RCT finished after a two-month follow-up. After this, patients in the control condition were offered CBT. Eight participants dropped out at various points along the way, but 22 were followed up at 12-months post-treatment11.
The good news
So what did the trial show? Well the good news was that CBT was effective. As expected, BDD symptoms significantly improved for the CBT group but not the control group (between group effect sizes of 1.13 (95% CI = 0.31 to 1.96) at post-treatment and 0.85 (95% CI = 0.02 to 1.69) at two-month follow-up)10. Significant improvements were also seen on secondary outcomes measures, including insight, depression, and quality of life. Analysis of long-term outcomes showed that treatment gains were maintained at 12-month follow-up11. Furthermore, patients and their parents/carers seemed to like the treatment, reporting high levels of satisfaction.
The not-so-good news
However, when looking at individual outcomes, only 35% of participants were classified as treatment responders and 19% as remitters at post-treatment11. By 12-month follow-up, these figures had improved slightly to 50% and 23% for responders and remitters, respectively. Thus, at 12-month follow-up the vast majority of participants were left symptomatic and only half had experienced a clinically meaningful reduction in BDD symptoms. Furthermore, at this time-point 27% of participants reported wanting cosmetic treatment for a perceived appearance defect, and 23% had actively sought consultations for cosmetic procedures (although none had actually undergone such a procedure).
Perhaps even more concerning: 10% of the original sample attempted suicide during the study – two during the controlled phase of the trial10 and one additional participant during the long-term follow-up11. This figure is particular striking given that suicidality was an exclusion criterion for entering into the trial, but our finding is consistent with previous reports of high rates of suicidal behaviour in unselected clinical samples of adolescents with BDD7,8.
The bottom line is that CBT does seem to be an effective treatment for adolescent BDD, and should be offered to young people suffering with this disorder. However, the results of the trial also highlight the desperate need for further research in this field.
There are a number of obvious ways in which treatment outcomes could potentially be improved, such as by offering more sessions (there is tentative evidence for a dose-response relationship in CBT for BDD12) and combining CBT with pharmacotherapy9. However, there is no escaping the fact that we have a long way to go. To make real headway, a bottom-up approach is needed. Efforts should be focussed on unpicking the mechanisms underlying the development and maintenance of the BDD, in order to in inform the development of improved treatments and ultimately enhance long-term prognosis in this population.
- American Psychiatric Association (2013). The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5). Washington, DC: American Psychiatric Association.
- Rief, W., Buhlmann, U., Wilhelm, S., Borkenhagen, A. D. A., & Brähler, E. (2006). The prevalence of body dysmorphic disorder: a population-based survey. Psychological Medicine, 36(06), 877-885.
- Koran, L. M., Abujaoude, E., Large, M. D., & Serpe, R. T. (2008). The prevalence of body dysmorphic disorder in the United States adult population. CNS spectrums, 13(04), 316-322.
- Buhlmann, U., Glaesmer, H., Mewes, R., Fama, J. M., Wilhelm, S., Brähler, E., & Rief, W. (2010). Updates on the prevalence of body dysmorphic disorder: a population-based survey. Psychiatry Research, 178(1), 171-175.
- Bjornsson, A. S., Didie, E. R., Grant, J. E., Menard, W., Stalker, E., & Phillips, K. A. (2013). Age at onset and clinical correlates in body dysmorphic disorder. Comprehensive Psychiatry, 54(7), 893-903.
- Albertini, R. S. and Phillips, K. A. (1999). 33 cases of body dysmorphic disorder in children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 453– 459.
- Phillips, K. A., Didie, E. R., Menard, W., Pagano, M. E., Fay, C. and Weisberg, R. B. (2006). Clinical features of body dysmorphic disorder in adolescents and adults. Psychiatry Research, 141, 305–314.
- (2005). Obsessive-compulsive disorder: Core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder. NICE, London.
- Mataix-Cols, D., de la Cruz, L. F., Isomura, K., Anson, M., Turner, C., Monzani, B., Cadman, J., Bowyer, L., Veale, D., & Krebs, G. (2015). A pilot randomized controlled trial of cognitive-behavioral therapy for adolescents with body dysmorphic disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 54(11), 895-904.
- Krebs, G., de la Cruz, L. F., Monzani, B., Bowyer, L., Anson, M., Cadman, J., Heyman, I., Turner, C., Veale, D., & Mataix-Cols, D. (in press). Long-term outcomes of cognitive-behavior therapy for adolescent body dysmorphic disorder. Behavior Therapy.
- Wilhelm, S., Phillips, K. A., Didie, E., Buhlmann, U., Greenberg, J. L., Fama, J. M., Keshaviah, A, & Steketee, G. (2014). Modular cognitive-behavioral therapy for body dysmorphic disorder: A randomized controlled trial. Behavior Therapy, 45(3), 314-327.