Transcript Research Day - University Psychiatry

Body Dysmorphic Disorder
Katharine A. Phillips, M.D.
Professor of Psychiatry and Human Behavior
The Warren Alpert Medical School of Brown University
Director, BDD Program, Butler Hospital
Providence, RI
Questions
• What class of medications appears efficacious for
BDD?
A. MAOIs
B. Tricyclics (excluding clomipramine)
C. SRIs
D. Neuroleptics
Questions
• What class of medications appears efficacious for
delusional BDD?
A. Typical antipsychotics
B. Atypical antipsychotics
C. SRIs
D. Benzodiazepines
Questions
• What type of psychotherapy appears efficacious
for BDD?
A. Supportive therapy
B. Exposure/behavioral experiments, response
prevention, and cognitive restructuring
C. Psychodynamic psychotherapy
D. Relaxation techniques
Questions
• Cosmetic treatment (e.g., surgery,
dermatologic treatment) for BDD appears to
be:
A. Always effective
B. Usually effective
C. Rarely effective
Questions
• The following behaviors are common in patients
with BDD:
A. Excessive mirror checking
B. Compulsive grooming
C. Skin picking
D. All of the above
E. None of the above
Teaching Points
• BDD is relatively common but often goes
unrecognized
• BDD causes significant distress and impaired
functioning, and individuals with BDD have very
poor quality of life
• SRIs and CBT are often effective; additional
treatment research is greatly needed
Outline
• Diagnostic criteria
• Prevalence
• Clinical features
• Treatment
• Diagnosis
BDD DSM-IV Criteria
A. Preoccupation with an imagined defect in appearance.
If a slight physical anomaly is present, the person’s
concern is markedly excessive.
B. The preoccupation causes clinically significant distress
or impairment in social, occupational, or other important
areas of functioning.
C. The preoccupation is not better accounted for by
another mental disorder (e.g., dissatisfaction with body
shape and size in Anorexia Nervosa).
Prevalence of BDD
• Community: 0.7% - 1.7%
• Nonclinical student samples: 2.2% - 13%
• Dermatology: 9% - 12%
• Cosmetic surgery: 6% - 15%
• Inpatient psychiatry: 13% - 16%
• Outpatient psychiatry:
» OCD: 8% - 37%
» Social phobia: 11% - 13%
» Anorexia: 39%
» Major depression: 0% - 42%
BDD Is Underdiagnosed
• In 5 of 5 studies, no patient with BDD had the diagnosis in
their clinical record
• In 2 studies, patients with BDD had revealed their symptoms
to only 15% and 41% of providers
• BDD is underdiagnosed:
» Embarrassment and shame
» Fear of being misunderstood or negatively judged
» Don’t know it’s a treatable disorder
» Patients aren’t asked
Phillips et al 1993, Phillips et al 1996, Zimmerman & Mattia 1998, Grant et al 2001, Grant et al 2002,
Phillips et al 2006, Conroy et al, in press
Demographic Features
• Age: 32.1 ± 11.7 (range 6 to 80)
• Sex:
Male
39%
Female 61%
• Marital status:
Single
67%
Married 20%
Divorced 12%
Phillips et al, 1993, 1997, 2005
N=434
Cognitions
• Obsessional, embarrassing, shameful preoccupations
• Difficult to resist or control
• Time consuming (average 3-8 hours a day)
• Associated with low self-esteem, depressed mood,
anxiety, introversion, rejection sensitivity
• Insight is usually absent or poor (~35% currently have
delusional beliefs about their appearance)
• Ideas or delusions of reference are common (68%)
20%
10%
ei
gh
30%
N
os
e
40%
H
ai
r
60%
Sk
in
80%
50%
St t
om
Ey ach
es
Th
ig
h
Te s
et
h
Le
gs
Bu (ov
ild era
ll)
/b
U
o
gl
ne
y
st
Fa fac
ru
e
ct
ce
(g
en ure
s
i
Li ze
ps /sh era
ap l)
Bu
e
tto
C cks
hi
n
Ey
eb
H ro
ip w
s s
W
Percent of subjects
Body Areas of Concern
100%
90%
70%
0%
Body areas
N=434
Phillips et al, 1993, 1997, 2005
Compulsive and Safety Behaviors
100
90
90%
89%
88%
80
70
Percent
60
51%
50
47%
40
32%
30
20
10
0
Camouflaging
Comparing/
Scrutinizing
Phillips et al, 1993, 1997, 2005
Mirror Checking
Questioning/
Reassurance
Seeking
Grooming
Skin Picking
N=434
Functioning and Quality of Life
SF-36
100
80
ES=1.54
ES=1.87
BDD
ES=1.70
60
100
Community
80
Depression
60
40
40
20
20
0
0
Mental Health
3
2.5
2
1.5
1
0.5
0
Q-LES-Q
ES=1.84
BDD
Community
Role Limitations/ Social Functioning
Emotional
Social Adjustment Scale-SR
ES=2.07
BDD
Community
100
GAF/SOFAS
80
60
40
N=176
20
0
GAF
SOFAS
Phillips et al, Comp
Psychiatry, 2005
Prospective Suicidality Data Over 3 Years
Variable
Annual Weighted Mean
•
•
•
•
•
Suicidal ideation
57.8%
Suicide attempt
2.6%
Suicide attempt attributed to BDD 1.5%
Number of attempts
2.5 ± 2.1
Number of attempts
2.0 ± 2.9
attributed to BDD
• Completed suicides
0.35% (SMR=45)
N=185
Phillips KA, Menard W: Am J Psychiatry 2006
Cosmetic Treatment
Percent of Subjects
80
70
60
Sought
50
Re ce ive d
40
30
20
10
0
Any
Treatment
Dermatologic
Surgical
Other
medical
Phillips et al, Psychosomatics 2001; Crerand et al, Psychosomatics 2005
Dental
Paraprofessional
N=450
Outcome of Cosmetic Treatment
90
Percent of Treatments
N=700
80
N=489
Overall BDD
Body Part
70
60
50
40
30
N=140
20
10
N=96
N=68
N=73
0
Improved
Same
Worse
Total number of treatments = 872
Phillips et al, Psychosomatics 2001; Crerand et al, Psychosomatics 2005
N=450
Efficacy of SRIs for BDD
• Case series: SRIs appear more effective than other psychotropics
(n=5, Hollander et al 1989; n=30, Phillips et al 1993; n=130, Phillips 1996)
• Open-label trials
» Fluvoxamine: Response in 83% and 63% (n=15, Perugi et al 1996; n=30,
Phillips et al 1998)
» Citalopram: Response in 73% (n=15, Phillips & Najjar 2003)
» Escitalopram: Response in 73% (n=15, Phillips 2006)
• Controlled cross-over trial: Clomipramine is more effective
than desipramine
(n=29, Hollander et al 1999)
• Placebo-controlled trial: Fluoxetine is more effective than
placebo
(n=67, Phillips et al 2002)
No medication is FDA-approved for the treatment of BDD
Clomipramine vs Desipramine
35
30
DMI
25
DMI
20
CMI
CMI
15
10
5
Week 0
Week 4
N=23; F=11.02; df=1,21; p=.003
Week 8
Week 12
Week 16
Hollander et al, Arch Gen Psychiatry, 1999
BDD-YBOCS score
Fluoxetine vs Placebo (n=67)
34
32
30
28
26
24
22
20
‡
Placebo
Fluoxetine
18
base
1
2
‡ p=0.038
3
4
6
8
12
Week
Response to placebo = 6/33 (18%) vs fluoxetine = 18/34 (53%);
F (1,64) = 16.5, p<.001
Phillips et al, Arch Gen Psychiatry, 2002
10
c2 = 8.8, p = .003
Response of Delusional vs Nondelusional
Subjects (n=67)
11/20
% Responders
60
6/12
50
6/17
40
30
Placebo
20
Fluoxetine
10
0/15
0
Delusional
c2=9.6, p=.002
Phillips et al, Arch Gen Psychiatry, 2002
Nondelusional
c2=1.4, p=.23
SRI Dosing and Trial Duration
• Use an SRI -- for delusional patients, too
• No trials have compared SRI doses. Relatively high
doses appear often needed. Some patients benefit from
doses exceeding the maximum recommended (not CMI).
• Average time to response is 4-9 weeks; some patients
need 12-16 weeks
• If no response or partial response after 12-16 weeks →
augment or switch SRIs
Phillips et al, 2006
Pimozide vs Placebo
Augmentation of Fluoxetine (n=28)
% Responders
30
25
20
2/11
3/17
15
10
5
0
Pimozide
Chi-square=.001, df=1, p=.97
Placebo
Phillips, Am J Psychiatry, 2005
Other Medication Considerations
• SRI augmentation options: buspirone, clomipramine,
venlafaxine, bupropion, atypical neuroleptics,
antiepileptics, lithium, stimulants
• Switching to another SRI
• Other agents as monotherapy (e.g., venlafaxine,
levetiracetam)?
• Much more pharmacotherapy research is needed – e.g.,
augmentation, relapse prevention, pediatric studies
Allen et al, 2003; Phillips, 2002; Phillips and Hollander, in press
Efficacy of CBT for BDD
• Case series (n=5-17)
» BDD improved with eight to sixty 90-minute individual sessions or in
twelve 90-minute group sessions (Neziroglu & Yaryura-Tobias, 1993;
McKay et al, 1997; Wilhelm et al, 1999)
• No-treatment waiting list control (n=54)
» Group CBT provided in eight weekly 2-hour sessions was more effective
than no treatment (Rosen et al, 1995)
• No-treatment waiting list control (n=19)
» Individual CBT provided in twelve weekly 1-hour sessions was more
effective than no treatment (Veale et al, 1996)
Core CBT Strategies for BDD
• Cognitive Restructuring:
» Identify: 1) Unrealistic negative thoughts
2) Cognitive errors (e.g., mind reading)
3) Unrealistic underlying core beliefs and
attitudes
» Develop more accurate and helpful beliefs
• Behavioral Experiments
» Design and do experiments to empirically test
dysfunctional thoughts and beliefs
Core CBT Strategies for BDD
• Graded Exposure
» Construct an exposure hierarchy
» Gradually face feared and avoided situations (often
social) without ritualizing or camouflaging
» Combine with behavioral experiments and cognitive
restructuring
• Ritual Prevention
» Stop or cut down on excessive mirror checking,
grooming, and other compulsive behaviors
Additional CBT Strategies
•
•
•
•
•
•
Perceptual retraining
Mindfulness skills
Habit reversal (for skin picking and hair pulling)
Activity scheduling; scheduling pleasant activities
Motivational interviewing
Structured daily homework is essential
Other Types of Psychotherapy
• Not well studied; not currently recommended as the
only treatment for BDD
• May be helpful in addition to an SRI or CBT for some
patients – e.g., those with:
» Life stressors
» Relationship problems
» Problematic personality traits
» Poor treatment compliance
Usually, to diagnose BDD
you have to ask specifically
about BDD symptoms
Diagnosing BDD
• Appearance concerns: Are you very worried about your
appearance in any way? (OR: Are you unhappy with how
you look?) If yes, Can you tell me about your concern?
• Preoccupation: Does this concern preoccupy you? Do
you think about it a lot and wish you could think about it
less? (OR: How much time would you estimate you think
about your appearance each day?)
• Distress or impairment: How much distress does this
concern cause you? Does it cause you any problems -socially, in relationships, or with school or work?
Clues to the Presence of BDD
• Behaviors such as mirror checking, reassurance seeking,
skin picking, grooming, or camouflaging (e.g., with a hat)
• Ideas or delusions of reference
• Avoidance of activities; being housebound
• Comorbid social phobia, depression, OCD, substance
abuse/dependence
• Excessive seeking and/or nonresponse to cosmetic
treatment--e.g., dermatologic or surgical
Questions
• What class of medications appears efficacious for
BDD?
A. MAOIs
B. Tricyclics (excluding clomipramine)
C. SRIs
D. Neuroleptics
Questions
• What class of medications appears efficacious for
delusional BDD?
A. Typical antipsychotics
B. Atypical antipsychotics
C. SRIs
D. Benzodiazepines
Questions
• What type of psychotherapy appears efficacious
for BDD?
A. Supportive therapy
B. Exposure/behavioral experiments, response
prevention, and cognitive restructuring
C. Psychodynamic psychotherapy
D. Relaxation techniques
Questions
• Cosmetic treatment (e.g., surgery,
dermatologic treatment) for BDD appears to
be:
A. Always effective
B. Usually effective
C. Rarely effective
Questions
• The following behaviors are common in patients
with BDD:
A. Excessive mirror checking
B. Compulsive grooming
C. Skin picking
D. All of the above
E. None of the above
Answers to Questions
1: C. SRIs
2: C. SRIs
3: B. Exposure/behavioral experiments, response
prevention, and cognitive restructuring
4: C. Rarely effective
5: D. All of the above