NEW YORK CITY— While many parents and physicians may dismiss teenage preoccupation with appearance as simply a typical adolescent concern, Katharine A. Phillips, MD, knows that sometimes it’s not a phase, it’s a disorder. In teens, the severe body image problem known as body dysmorphic disorder can lead to complications ranging from social impairment to suicide.

At an American Medical Association media briefing on child and adolescent health, Dr. Phillips described the disorder, in which adolescents become so preoccupied with a perceived defect or flaw that they can spend three to eight hours a day obsessing about it, although she has seen patients so consumed that the disorder infringes on their sleep, engaging them for 20 or more hours a day. In reality, the perceived defect is minimal or nonexistent, according to Dr. Phillips, Director of the Body Dysmorphic Disorder Program at Butler Hospital and Professor of Psychiatry at Brown Medical School, both in Providence, Rhode Island. Body dysmorphic disorder usually has an early-adolescence onset at about age 13, although Dr. Phillips has seen symptoms in children as young as 5. “Adolescence is a tough time to have body dysmorphic disorder, because it’s such an important developmental period,” Dr. Phillips said; most teenagers do not realize that they have an illness that is treatable once it is correctly identified and addressed.

In a study of 69 adolescent patients with body dysmorphic disorder, fewer than 5% reported improvement after treatment with surgery, dermatologic treatment, or other nonpsychiatric medical treatment. As Dr. Phillips explained to NeuroPsychiatry Reviews, this is because people with body dysmorphic disorder have a problem not with their actual physical appearance but rather with their body image. “Changing a surface characteristic through surgery or dermatologic treatment doesn’t change their body image, and they continue to obsess and worry and think the procedure wasn’t good enough. In some cases they think it made them look worse, even when it didn’t.” Frequently, they will switch their dissatisfaction and obsession to another area of the body. This is how body dysmorphic disorder differs from normal concerns with appearance, she related, as most people who have cosmetic procedures are relatively happy with the results.

MOST EFFECTIVE TREATMENT

The most effective course for patients with body dysmorphic disorder, Dr. Phillips believes, is psychiatric treatment. As for which medications are most successful in treating body dysmorphic disorder, Dr. Phillips thinks that any serotonin reuptake inhibitor (SRI) is a good choice, although no studies in body dysmorphic disorder have compared the efficacy of one SRI with another. These medications include escitalopram, citalopram, fluoxetine, fluvoxamine, paroxetine, clomipramine, and sertraline. Despite the lack of comparison studies, the most studied medications in body dysmorphic disorder are escitalopram, fluoxetine, citalopram, and clomipramine, but Dr. Phillips noted that these medications were studied in adults, not adolescents. “It does appear [that other SRIs] are effective as well, and generally if one SRI works for a given psychiatric disorder, they all are potentially effective,” Dr. Phillips explained. Of course, she said, individual responses vary, so finding the best treatment “is very much trial and error.”

She related that her team has had promising results in a recent, small study showing that a higher proportion of adult patients were “very much improved” on escitalopram therapy as compared with “much improved,” as had been found in studies of other SRIs. Also, time to response was faster in this study than had been previously demonstrated. “But we can’t draw too much of a conclusion because we didn’t directly compare [escitalopram] to another SRI,” she acknowledged.

Currently, Dr. Phillips and her research team, in collaboration with researchers at the University of Cincinnati and at Mount Sinai Medical School in New York City, are conducting a study of fluoxetine versus placebo in adolescents with body dysmorphic disorder. As she emphasized, there is a tremendous need for research in the treatment of body dysmorphic disorder in adolescents, because that is when body dysmorphic disorder symptoms typically manifest. “But virtually all the treatment studies have been done in adults so far,” she reiterated. Indeed, while body dysmorphic disorder usually has an adolescent onset, there is often a considerable delay in treatment, as patients typically wait until adulthood before seeking help specifically for the disorder.

Cognitive-behavioral therapy focused on body dysmophic disorder also appears to often be effective. However, this treatment has not been studied in adolescents, and such research is greatly needed.

MISSED DIAGNOSIS

“A very common mistake that I see made by clinicians is that they pick up on accompanying depression but miss the diagnosis of body dysmorphic disorder—often because the patients are very secretive about it and the clinicians aren’t very familiar with it,” Dr. Phillips said. And often the patient is prescribed a non-SRI antidepressant that does not seem to work as well for body dysmorphic disorder as do SRIs. Depression is one comorbidity that Dr. Phillips thinks is largely attributable to body dysmorphic disorder. As she elaborated, patients “might think they look ugly or like a monster or like a burn victim, and think people are making fun of them. They get depressed, so often the comorbidity is targeted although the body dysmorphic disorder is the main problem or the problem causing the depression.”

The other issue Dr. Phillips has found is that when SRIs are prescribed, “the doses aren’t pushed up very high. We think that for body dysmorphic disorder most patients need higher doses than you would typically use for depression. So the bottom line is that a lot of these patients are undertreated, either in terms of getting an SRI dosage that isn’t high enough to treat body dysmorphic disorder or getting a non-SRI antidepressant.”

Dr. Phillips believes that more people with body dysmorphic disorder seek and access mental health care than is thought, but she suspects that “the vast majority of them do not have their body dysmorphic disorder recognized, diagnosed, or treated.” She suggests that mental health professionals, when initially screening a patient for psychiatric illness, ask very simple questions: Are you happy with your appearance? Do you worry about the way that you look? If the patient dislikes their appearance, the clinician can next determine whether the concerns are preoccupying (occurring for at least one hour per day) and cause clinically significant distress or impairment in functioning. If these criteria are met, the patient is likely to have body dysmorphic disorder.

Dr. Phillips encourages physicians to ask these questions, as her experience has shown that most people with body dysmorphic disorder want to be asked about their condition. Physicians should also be aware of the clues to body dysmorphic disorder, such as when the patient covers his or her face with a hat or hair, or wears big, bulky clothes in the summer, or insists upon wearing sunglasses indoors. Other indicators include skin lesions on the face, or multiple surgeries or procedures that continue to leave the patient unhappy.

A DISABLING DISORDER

It is important for parents and physicians to recognize body dysmorphic disorder as a disorder and not dismiss it as simply a passing phase. As Dr. Phillips pointed out, if body dysmorphic disorder is not treated, “a lot of kids can get off track developmentally.” It is not uncommon for teenagers with body dysmorphic disorder to drop out of high school or college and withdraw from family and friends, interrupting their academic and social development. In more severe cases, body dysmorphic disorder can be the cause of suicidal thinking, suicide attempts, and violent behavior. Therefore, treating body dysmorphic disorder involves more than addressing the symptoms, as the patient must also be reacclimated to study and work environments in order to realize his or her full potential. This concern was borne out in a broad sample of adolescent and adult patients with body dysmorphic disorder in which her research group found that one third of patients were unemployed because of psychopathology. Body dysmorphic disorder was the primary disorder for the majority, and as Dr. Phillips explained, patients with body dysmorphic disorder “are a pretty disabled group as a whole, but they span the spectrum. People with body dysmorphic disorder have different levels of functioning but on average do poorly.”

A study of participants identified during adolescence as having body dysmorphic disorder, and who are currently being followed, is also being carried out by Dr. Phillips’ research group. So far, the data suggest that if body dysmorphic disorder is not treated correctly in adolescence, it can become chronic. “However,” she said, “when it’s treated, it seems that most people eventually get better. The key here is whether they get the right treatment or not.”

—Heidi W. Moore

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