Body dysmorphic disorder (BDD) belongs to a group of somatoform disorders or somatic symptom disorders (SSD) that manifest as medically unexplained physical symptoms. They are considered as psychiatric conditions since diagnostic tests return negative results. The chief complaints include localized or multisystem pain, neurological problems, and gastrointestinal ailments. Related problems that do not meet the DSM-IV-TR criteria for SSD are malingering (symptom manifestation meant to attain an environmental goal), factitious disorder (self-inflicted injury), and psychosomatic illness (Veale et al., 2014).
The differentiating feature of SSD symptoms is that they are unintentional; thus, they cause excessive distress and impaired daily functioning. Improved treatment outcomes could be achieved through early evaluation, psychotherapy, effective therapeutic relationships, and referrals to mental health providers. This paper discusses the impact of BDD on nursing care and recommended interventions for this disorder based on evidence-based practices.
Statement on BDD
BDD is defined as a psychological disorder characterized by preoccupations with a perceived body part defect, obsessions, compulsive behavior, and major depression and social phobia (Wilhelm et al., 2014). People with BDD often have pervasive concerns over the physical appearance of the face, head, or any other body part. They may complain of acne, dermal scarring, facial asymmetry, balding, or hirsutism (Wilhelm et al., 2014).
As a result, they spend an inordinate amount of time grooming to conceal or rectify perceived imperfections. The individual has no conscious control of these preoccupations; hence, he/she is prone to depressive symptoms, disability, surgery seeking, and suicide ideation (Wilhelm et al., 2014). BDD affects a significant proportion of the population; its prevalence rate is about 2% (Veale et al., 2014). Its etiology is multifactorial with psychobiological agents being the leading causes. Known BDD risk factors include genetic predisposition, individual disposition, bullying in childhood, dermal scars, and distorted perceptual/cognitive experiences of one’s body.
Significance and Impact on Nursing
BDD is a frequent but an under-recognized condition. Therefore, nurses should learn to recognize and treat this disorder to reduce depressive symptom severity and avoid psychosocial impairment. Without early evaluation, BDD can lead to higher social costs related to school absenteeism, reduced workplace productivity, and psychiatric comorbidities (Veale et al., 2014). For this reason, improved BDD recognition among nurses and knowledge of psychotherapeutic interventions, such as cognitive-behavioral therapy (CBT), are critical.
Since most people with BDD will first present at non-psychiatric care settings, understanding the diagnostic criteria for this condition is a crucial component of quality patient care. Importantly, the nursing staff working in dermatology and mental health clinics should be able to identify symptoms and provide CBT or pharmacological treatment. Further, therapies should focus on psychiatric causes to decrease symptom severity and improve outcomes.
Based on a review of four articles, evidence-based therapies for BDD are primarily psychopharmacological treatment and CBT. According to Enander et al. (2016), the National Institute for Health and Clinical Excellence (NICE) guidelines recommend selective serotonin reuptake inhibitors (SSRIs) or CBT for adults to realize symptom remission. However, barriers related to inadequate therapists and costly treatments limit CBT utilization levels in hospitals.
The interventions tested in this study were CBT (BDD-NET) and online supportive therapy that excluded face-to-face therapeutic sessions. Other studies have also investigated the efficacy of CBT in treating BDD in clinical settings. A randomized clinical trial by Wilhelm et al. (2014) used ‘a manualized CBT’ that included psychoeducation, motivational enhancement methods, cognitive reorganization, ritual prevention, and mindfulness training to treat BDD. Post-treatment improvements in depression, patient satisfaction, and symptom (surgery seeking behavior) remission were measured in the participants from the baseline. Therefore, a CBT approach incorporating flexible and psychotherapeutic treatments for the distinctive features of BDD is a common intervention for managing this condition.
CBT is superior to other psychological treatments. Veale et al. (2014) compared the post-treatment outcomes of subjects in a cognitive behavior therapy group and those who received anxiety management. CBT was found to decrease depressive symptom severity, the frequency of appearance anxiety, and delusional feelings after 12 weeks. Further, evidence shows that significant symptom abatement in individuals receiving this intervention compared to those in a waiting list (controls), irrespective of the type of CBT used – individual or group-based (Prazeles, Nascimento, & Fontenelle, 2013).
Further, the intervention can prevent relapses after extended periods. Studies comparing the patient responses to CBT between BDD and obsessive-compulsive disorder groups show decreases in symptom severity in both cohorts (Prazeles et al., 2013). Results from meta-analyses confirm that CBT and drugs (serotonin response inhibitors) are potent medications for this condition. Mental disorder medications as clomipramine and citalopram are also effective treatments for BDD (Prazeles et al., 2013).
The primary outcome that could be expected from psychotherapy or pharmacotherapy is BDD symptom remission. Enander et al.’s (2016) study found decreases in depression, daily functioning, and physical health following an internet-based CBT. Overall, the BDD-NET was more effective than supportive therapy. The intervention was linked to significant reductions in “symptom severity, depression, global functioning, and quality of life” (Enander et al., 2016, p. 7). Additionally, relapse into BDD was not immediate; it took three months for the symptoms to reappear. In this study, no significant adverse events were seen in the subjects during the intervention. Participant satisfaction levels were high, affirming the acceptability of BDD-NET as an evidence-based tool for treating BDD.
The results of Wilhelm et al.’s (2014) RCT are consistent with those of other BDD studies. The significant outcomes measured included BDD symptom severity, inaccurate beliefs, depression, functional impairment/disability, and client satisfaction using validated scales. In this study, more CBT-BDD participants were responsive to the intervention than waitlist subjects (50% vs. 12%), and they had subclinical BDD symptoms after 24 weeks (Wilhelm et al., 2014). Further, there were significant improvements in the durability of symptom remission, depression, disability, and satisfaction relative to baseline.
Veale et al.’s (2014) study measured symptom reduction, delusional BDD, depression severity, avoidance behavior, anxiety disorders, and body image concerns after CBT and AM interventions. CTB was found to be better than anxiety management in all these measures, except delusional BDD, after 12 weeks. The results of Prazeres et al.’s (2013) systematic review also support the use behavioral therapies, including CBT, to treat body dysmorphic disorder. The findings indicate that individual and group cognitive-behavioral therapy, behavioral therapy, cognitive therapy, and pharmacotherapy are evidence-based treatments for dealing with BDD symptoms. Thus, a nurse-led comprehensive psycho-pharmacotherapeutic intervention can lead to improved and durable symptom remission in BDD patients.
Implications for Nursing Practice
In patients presenting with complaints about body part defects, it is critical for the nurse to assess them for BDD. Exaggerated preoccupations with a physical anomaly coupled with clinically significant depressive symptoms will lead to a BDD diagnosis. Thus, the nurse should investigate the magnitude and effects of the complaints to detect this condition. Screening tools, such as BDDQ, can be used to evaluate the impact of the preoccupations on the patient’s daily functioning (Veale et al., 2014).
Early evaluation and detection can help avoid unnecessary treatments and inform referral to a mental health professional. BDD appears to be a relatively prevalent, but an under-recognized condition in clinical settings. Therefore, training programs to improve BDD awareness and diagnostic criteria among nurses working in dermatology clinics can increase disorder recognition and treatment.
The management of this condition involves psychotherapy and pharmacotherapy. Appearance-enhancing treatments may not be effective in reducing symptom severity. The findings of the articles reviewed support the use of CBT as an effective intervention for treating BDD. It decreases post-intervention symptom severity, depression, distorted beliefs, and functional impairment in people with BDD (Enander et al., 2016; Veale et al., 2014; Wilhelm et al., 2014). CBT also improves patient satisfaction with physical appearance, resulting in reduced surgery seeking behavior. It is essential for the clinician not to dismiss individual preoccupations during an assessment. Instead, he/she should focus on the magnitude of such concerns to diagnose BDD.
Nurses should be able to offer psycho-education to a patient as an initial step in the treatment of suspected BDD. Subsequently, the individual should be referred to a psychiatrist for specialized care, which may involve CBT and SSRIs. Therefore, early detection, diagnosis, and appropriate care can lead to improved patient outcomes. The nurse should inform a patient with suspected BDD that he/she has a body image problem that requires psychological treatment. The rationale for referrals is to alleviate depressive symptoms and psychosocial dysfunction that affect daily functioning.
Enander, J., Andersson, E., Mataix-Cols, D., Lichtenstein, L., Alstrom, K., Andersson, G., … Ruck, C. (2016). Therapist guided internet based cognitive behavioural therapy for body dysmorphic disorder: Single blind randomised controlled trial. The British Medical Journal, 352:i241, 1-9. Web.
Prazeles, A. M., Nascimento, A. L., & Fontenelle, L. F. (2013). Cognitive-behavioral therapy for body dysmorphic disorder: A review of its efficacy. Neuropsychiatric Disease and Treatment, 9, 307-316. Web.
Veale, D., Anson, M., Miles, S., Pieta, M., Costa, A., & Ellison, N. (2014). Efficacy of cognitive behaviour therapy versus anxiety management for body dysmorphic disorder: A randomised controlled trial. Psychotherapy and Psychosomatics, 83, 341-353. Web.
Wilhelm, S., Phillips, K. A., Didie, E., Buhlmann, U., Greenberg, J. L., Fama, J. M., … Steketee, G. (2014). Modular cognitive-behavioral therapy for body dysmorphic disorder: A randomized controlled trial. Behavioral Therapy, 45(3), 314-327. Web.