1. Body Dysmorphic Disorder Diagnosis and Management
J. Kevin Thompson, Ph.D.
Department of Psychology
University of South Florida

2. Overview What is Body Image What is Body Dysmorphic Disorder?
Characteristics of BDD with Hair as a Primary Focus
Identifying BDD Patients
What to do with a BDD Patient

3. Body Image: Definition
Body image: a subjective evaluation of your outward
appearance, contrasted with an objective evaluation (from
someone else)
More than 50% of American women and 45% of American
men are dissatisfied with their overall appearance and
body image
Body image dissatisfaction leads to many appearance
enhancing behaviors, including weight loss, exercise,
cosmetics use, cosmetic surgery, and hair restoration.
*Thompson et al. (1999). Exacting beauty: Theory, assessment and treatment of body image disturbance. American Psychological Association.

4. Psychological Conditions with a Body Image Component
Hypochondria
Somatic Delusions
Anorexia Nervosa
Bulimia
Gender Identity
Disorder
Sexual Dysfunction
Schizophrenia
Depression
Social Phobia
Body Dysmorphic
Disorder
We also know that body image dissatisfaction can play an important role in several psychological conditions. Of these, we most commonly think about body image when we consider anorexia nervosa and bulimia. However, body image can play an important role in hypochondriasis, somatic delusions, gender identity disorder, and schizophrenia. In addition, thoughts about the body can contribute to sexual dysfunctions, depression, and social anxiety. Finally, body image dissatisfaction plays a critical role in body dysmorphic disorder.

5. DSM-IV-TR Diagnostic Criteria for Body Dysmorphic Disorder
Preoccupation with an imagined or slight defect in appearance. If a slight physical anomaly is present, the persons concern is markedly excessive.
The preoccupation causes significant distress or impairment in social, occupational, or other important areas of functioning.
Avoidance of social situations or anxiety in social situations, depression, behaviors to
modify appearance, etc.
The first part of the diagnostic criteria. Both the nature of the defect, as well as the degree of distress is somewhat ambiguous. It is considered a somatoform disorder, although it is most often compared to obsessive-compulsive disorder, an anxiety disorder.

6. Appearance Complaints in Patients with BDD
Hair Nose Head shape
Skin Eyes Body build
Lips Chin Entire face
Stomach Teeth Breasts
In cases of BDD, any part of the body may become the focus of attention. Phillips and colleagues have suggested that the skin, nose, and hair are the most commonly affected features. Both Rosen and colleagues as well as Sarwer and colleagues have found that weight-related features, such as the waist, hips, and thighs, also may be the focus of BDD.

7. Characteristics of BDD
Age of onset: late adolescence
Course of illness: chronic, not episodic
Gender differences: equal ratio
(Crerand et al., Plastic and Reconstructive Surgery, 2006)

8. Co-morbid Psychopathology
Mood and anxiety disorders
84-90% lifetime; 54-69% current
Substance use disorders
Up to 47% lifetime; 2-35% current
Eating disorders
7-14% lifetime; 4% current
Personality disorders
57-72%
(Crerand et al., PRS, 2006)

9. Psychological Assessment of Patients
What are patients’ motivations and expectations and are they realistic?
Identify patients who have psychiatric conditions that may contraindicate treatment or need further evaluation.
In-depth evaluation of body image concerns (i.e.., is hair loss the only concern, or one among many?)

10. Assessment of Motivations and Expectations
Personal Motivations
Ask:
“Why are you interested in treatment now?” (self vs. other influences)
Social and Treatment Outcome Expectations
“How do you anticipate your life will be different following treatment?”
“What do you think you will look like after treatment?
What if your expectations are not met?

11. Assessment of Physical Appearance and Body Image
Nature of appearance concern (specific, visible)
“What do you dislike about your appearance?”
Degree of distress or preoccupation
“When does the feature bother you the most?”
Degree of impact on daily functioning
“Does your concern about your appearance
prevent you from doing certain activities?”
Previous treatments to improve appearance
Are there other areas of concern than hair loss?

12. Red Flags for Identifying BDD
Hair concerns that are difficult for others to see
Unrealistic expectations of treatment outcomes
Worrying about hair repeatedly throughout the day or for long periods of time (e.g., more than 1 hour)
Use of camouflaging and cover-up strategies
Reassurance seeking
Mirror checking, or avoidance of mirrors
Avoidance of social situations
General reduction in quality of life (e.g., no longer socializing)
Disruption in daily activity (e.g., unemployed or housebound)

13. Other Red Flags
The patient presents with detailed descriptions of his or her ideas of how to improve his or her appearance (i.e., essentially telling the professional how to perform the procedure)
The patient presents with numerous pictures of him- or herself (or pictures of models or Hollywood celebrities), depicting the desired changes in appearance
In addition to hair loss, the patient has other appearance areas of concern
Multiple previous consultations or treatments that the patient reports were not effective

14. BDD? Further Evaluation and Treatment
If BDD appears to be present:
A) referral for psychological/psychiatric evaluation
ask for evaluation of BDD, along with other possible co-
morbid conditions (e.g., depression, anxiety)
B) if any of these conditions are present, consider referral for
psychological treatment (cognitive-behavioral therapy,
medications)
C) if BDD and other conditions ruled out, consider treatment:
extensive pre-treatment briefings regarding expectations
of outcome