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evidence that Lynn G had body dysmorphic disorder, the case was dismissed. Nonetheless, this case brought to light the potential legal concerns associated with treating persons with body dysmorphic disorder. In addition to the potential legal hazards associated with treating patients with body dysmorphic disorder, reports suggest that these patients may become violent toward their surgeons. A survey of aesthetic surgeons reported that 2 percent had been physically threatened by a patient with body dysmorphic disorder; 10 percent reported that they had received threats of both violence and legal action.91 At least two surgeons have been murdered by patients who appeared to have symptoms consistent with body dysmorphic disorder.129,130 Similar reports of violence have been published in the dermatology literature.131 Because of the legal and personal safety issues associated with treating persons with body dysmorphic disorder, coupled with the evidence that cosmetic treatments rarely improve body dysmorphic disorder symptoms, there is growing consensus that body dysmorphic disorder should be considered a contraindication for cosmetic treatments. Given that persons with body dysmorphic disorder seek cosmetic medical treatments with great frequency, it is important that all patients be assessed for the potential presence of body dysmorphic disorder before undergoing treatment. A general psychological screening, consisting of an assessment of patient motivations and expectations, psychiatric status and history, body image concerns and body dysmorphic disorder symptoms, and an observation of the patient’s office behavior, can identify persons for whom surgery may be inappropriate.132–135 Such a screening may include an interview with the patient and/or use of self-report assessments. Patients with suspected body dysmorphic disorder can be referred to a mental health professional for additional screening and treatment.7,133 Pharmacologic Treatment Unlike cosmetic treatments, pharmacologic treatments appear to be much more effective interventions for persons with body dysmorphic disorder. Until recently, knowledge regarding pharmacotherapy for body dysmorphic disorder was limited to the results of case reports, retrospective chart reviews, and open-label trials.70,136 –141 Despite their inherent methodological weaknesses, these studies consistently suggested that selective serotonin reuptake inhibitors were beneficial in treating body dysmorphic disorder. Randomized, controlled trials have also provided evidence for the efficacy of selective serotonin reuptake inhibitors in the treatment of body dysmorphic disorder. Hollander et al.142 reported that the selective serotonin reuptake inhibitor clomipramine was more effective than desipramine, a nonselective serotonin reuptake inhibitor, in their randomized, double-blind, crossover study. More recently, fluoxetine was found to be superior to placebo in a randomized, controlled trial.143 In this study of 67 patients, 53 percent of those treated with fluoxetine had a favorable response compared with 18 percent of those treated with placebo. Patients who responded favorably to fluoxetine experienced significant improvements in quality of life and daily functioning.86 Despite these promising results, many patients treated with selective serotonin reuptake inhibitors experience only partial response to treatment. Some patients need long trials of high dosages of the medication,139,144 whereas others need to switch to a different selective serotonin reuptake inhibitor.144 Augmentation studies of selective serotonin reuptake inhibitors with antipsychotic medications such as olanzapine or pimozide have yielded mixed results.139,145,146 Despite the fact that some patients may be delusional, the use of antipsychotic medications alone for the treatment of either body dysmorphic disorder variant has not been supported.46,144 The nondelusional and delusional variants of body dysmorphic disorder appear to respond equally well to selective serotonin reuptake inhibitors.140,142 Although selective serotonin reuptake inhibitor medications have produced the most favorable results thus far, a recent case report suggests that bupropion, an atypical antidepressant, may also improve body dysmorphic disorder symptoms.147 Psychotherapeutic Treatment Cognitive behavioral therapy is another common treatment approach. Cognitive behavioral therapy involves the identification and modification of problematic, appearance-related cognitions and behaviors. Strategies used in cognitive behavioral therVolume 118, Number 7 • Body Dysmorphic Disorder 175e apy include self-monitoring of thoughts and behaviors related to appearance (e.g., monitoring the amount of time spent mirror gazing); cognitive techniques (e.g., challenging distorted thoughts about one’s appearance); and behavioral exercises (e.g., exposing the patient to a feared situation and preventing engagement in compulsive behaviors).69 Several studies, including two randomized, controlled clinical trials,61,62 suggest that cognitive behavioral therapy is an efficacious treatment for body dysmorphic disorder.148 –150 CONCLUSIONS AND DIRECTIONS FOR FUTURE RESEARCH
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