Dr. Daniel Knoepflmacher (Host): Hello and welcome to On the Mind, the official podcast of the Weill Cornell Medicine Department of Psychiatry. I'm your host, Dr. Daniel Knoepflmacher. In each episode, I speak with experts in various aspects of psychiatry, psychotherapy, neuroscientific research, and other important topics on the mind.

Our topic today is body dysmorphic disorder, or BDD. With the ubiquity of selfies, Instagram filters, and Zoom screens, the activities of modern life often have us looking at ourselves. In an image-obsessed culture, concerns about physical appearance are commonplace. But for those who struggle with BDD, these body-focused concerns reach an obsessive level of preoccupation far beyond the typical worries about looks. BDD usually leads to significant emotional distress, functional impairment, and sometimes bodily harm. It affects both men and women, typically beginning in adolescence.

A recent report from the Journal of the American Academy of Child and Adolescent Psychiatry showed that almost 2% of all teens were affected by BDD, with the diagnosis leading to a significantly increased risk of self-injurious behavior and suicidality among those impacted. Despite the existence of effective treatments, many don't seek out care for BDD, and the diagnosis is often missed by medical professionals.

Today, we'll learn about BDD from a world-renowned expert whose work has helped establish widely accepted standards for the diagnosis and treatment of this devastating condition. I'm pleased to welcome Dr. Katharine Phillips, who's a Professor of Psychiatry in the Weill Cornell Medicine Department of Psychiatry and Director of Research in the General Psychiatry Residency Program. Kathy, it's so great to have you joining me today. Thank you so much for coming on the podcast.

Dr. Katharine Phillips: Oh, thank you so much, Daniel. I'm really delighted to be here today. Thank you.

Dr. Daniel Knoepflmacher: We have a lot to talk about because this is a very rich topic, and I want to start with you. You have a long distinguished career, specific expertise in obsessive-compulsive disorder, and especially our topic today, body dysmorphic disorder. How did you end up as a psychiatrist specializing in these conditions?

Dr. Katharine Phillips: Well, I discovered body dysmorphic disorder, BDD, when I was a resident during my psychiatry training. And I saw some patients who thought something was very wrong with their appearance, which was really ruining their life, but really they looked normal. And I remember one young man in particular, when I was a third-year resident who I spent an hour with evaluating him for the first time. And he said he was depressed. And that because he was depressed, he couldn't work, he was hard to socialize, he mostly just stayed in his house and thought about suicide. And I thought it was straightforward depression.

But as he was leaving my office, I remember his hand was actually on the doorknob and he turned to me and he said, "Should I tell you the real reason I'm here?" And I said, "Yes, of course." And fortunately, I was free at that time. So, he came back and with great difficulty, he was so anxious telling me about this, he was depressed because he thought he was going bald. And it just was devastating to him, and that's why he was suicidal. And he had a perfectly full head of hair, there was no sign of balding. And so I thought, "What is this?" It was hard for me to understand, but I could see how much he was suffering, and how much it was ruining his life.

Then, I heard from another patient, about some perceived abnormality of his appearance, when really he looked entirely normal. And I wondered, you know, might this be something I had seen in DSM-III-R? It was hidden away in the somatoform section, sort of in the back of the book, something called body dysmorphic disorder, but I hadn't ever heard about it in college as a psychology major, in medical school in my residency training, and my supervisors hadn't heard of it either.

So, I went to the library because in those days we didn't have the internet. And I was amazed to see, find out that BDD had been described for more than a century around the world. It had been called dysmorphophobia actually for the most part. But it had slipped through the cracks of modern-day psychiatry. People weren't aware of it, I think, because we didn't have systematic research studies and because it's often hard for patients to talk about. They're embarrassed. They're ashamed. They're afraid you'll consider them vain or silly. And so, we didn't even know what all the clinical features were. We had no treatments, that was the worst part of the situation. This was back in the early '90s. So, I felt I had to do something about it. It just caused so much suffering. A lot of these patients were quite suicidal. It seemed different from OCD, different from schizophrenia, which are diagnoses they tended to get. And so, I embarked on a journey to learn about BDD. And I started by listening to patients and then collecting data on the symptoms, co-occurring disorders, degree of impairment, suicidality, and most importantly, starting to figure out what treatments might work, which led to treatment studies. So, it's been a journey and, you know, a very rewarding one.

Dr. Daniel Knoepflmacher: It all started with what we call a doorknob moment, where you meet with somebody and then, right as they touch the doorknob, they drop the big piece of information that changes everything for you. In your case, it changed your entire career.

Dr. Katharine Phillips: It did. Absolutely.

Dr. Daniel Knoepflmacher: Well, you mentioned other diagnoses like OCD. You mentioned schizophrenia. I think of eating disorders as something, which is an event diagram might overlap a bit with BDD. Can you tell us how one distinguishes between these different diagnoses when you're thinking about BDD

Dr. Katharine Phillips: BDD is often underdiagnosed. It's underrecognized in clinical settings. And one of the reasons is that if the patient talks about it, if the clinician, asks about it, which is important to do, it's not uncommonly misdiagnosed as OCD because they share some features, right? The obsessive preoccupation, the repetitive behaviors. But in BDD, it's about appearance. "There's something wrong with how I look," "My nose looks ugly," "My skin is terribly scarred." I just want to mention in reality, these people look normal to others. But in their mind, they look ugly, hideous, at the very least, unattractive. So, it does get confused with OCD. But if the focus of the obsessions is about how you look and thinking you look abnormal, that's BDD, that's not an eating disorder. Even if the concern involves asymmetry, which it often does in BDD, "My nostrils are a little asymmetrical," "My hair isn't quite even on both sides," that is BDD, not OCD. And that's important because BDD is associated with poorer insight, more suicidality and more substance use disorders, more co-morbid major depressive disorder. And the psychotherapy, the cognitive behavioral therapy is different in some ways.

It's also often confused with social anxiety disorder because if you think you look ugly or abnormal or deformed, and you think other people agree with you, which people with BDD do, even though that's not really the case, it causes a lot of social anxiety, social avoidance. So, I think when you see a patient who's socially anxious and socially avoidant, you always have to ask why. "What is making you anxious when you're around other people?" And ask specifically, "Is it because of something about how you look physically?" And if so the person may have BDD.

Eating disorders are a little trickier. Now, in most cases, it's easy to differentiate BDD from an eating disorder, because BDD usually focuses on perceived defects of the face, most often, the skin. It could be anything about the skin. It's perceived scarring, acne, skin is too red or too white, wrinkles. Second most common concern is hair. It's falling out, the person looks bald, they have too much facial or body hair. It's uneven. It's too curly, too straight. And the nose is the third most common, nose size or shape. But it can be any part of the body. So in those cases, it's easy to differentiate BDD from an eating disorder.

But in some cases, BDD involves concerns about weight and body shape. Now, if someone thinks they're too fat or that parts of their body are too fat, like their stomach or their legs, and they have anorexia nervosa or bulimia nervosa, we consider those body image concerns to be a symptom of the eating disorder, not BDD. And we would treat those symptoms as part of treating an eating disorder. But in some cases, it's a little trickier. There's some people who don't have full-fledged anorexia nervosa or full-fledged bulimia nervosa. And so, we have that leftover category in the feeding and eating disorder chapter of DSM, it's called other specified feeding and eating disorder. It's not quite anorexia, it's not quite bulimia or another eating disorder. And sometimes it's just a little unclear whether concerns with body fat or weight in someone who is not noticeably overweight or doesn't have noticeably fat stomach or legs, for example. So, I'm still unclear whether we would consider that other specified feeding and eating disorder or body dysmorphic disorder.

Dr. Daniel Knoepflmacher: So when somebody is doing a comprehensive evaluation, they're thinking about obsessive-compulsive disorder, social anxiety disorder, you know, eating disorder, this should be in the back of their head something that could be missed. But in order to do that, I realized we haven't actually honed in on the diagnosis itself. So, tell us what BDD is.

Dr. Katharine Phillips: Okay. So, BDD is a common disorder, underrecognized disorder, in which people are preoccupied with the idea that they look abnormal in some way. They look ugly, some say unattractive, and some use more extreme terms like, "I look hideous," "I look like a monster." And they think about this at least an hour a day in order to make the diagnosis, but on average, more like three to eight hours a day. But their view of themselves is distorted. In the eyes of others, the defects or flaws that the patient perceives in their appearance in the eyes of others are actually non-existent or only slight. So, there's a mismatch between how the person with BDD sees themselves and how other people see them.

In addition to this preoccupation with perceived flaws in appearance, people with BDD perform repetitive behaviors, somewhat like OCD compulsions or rituals, things like excessive mirror checking, comparing with others, excessive grooming like hairstyling or makeup application. Sometimes skin picking, they're trying to make their skin look better. Reassurance-seeking, asking other people, "Do I look okay? Can you see this on my face?"

Then importantly, to differentiate BDD from more normal non-pathological concerns with appearance, which most people have, we might refer to it as a bad hair day, to diagnose BDD, the preoccupation must cause clinically significant emotional distress, or clinically significant impairment in functioning. So, I would say at least moderate distress or moderate impairment in functioning and usually it causes both.

Dr. Daniel Knoepflmacher: Yeah. That severity you've alluded to, you talked about the first patient you ever met in your training having suicidal ideation. And I wonder if you could speak to some of the severity of how debilitating this condition can be.

Dr. Katharine Phillips: I'm glad you asked that, because it's easy to trivialize BDD, and I think especially back in the early days, in the early '90s when I got started trying to figure out this disorder, it was considered silly, and it was confused with vanity. We now know that BDD is a brain-based illness. And we know that on average, people with BDD are quite severely impaired in their day-to-day functioning, and they tend, on average, to have very poor quality of life. And the more severe the BDD is, the more impaired their quality of life and the more impaired their functioning tends to be.

Now, there is a range of severity, as there is with OCD or depression. But again, on average, people with BDD are fairly severely impaired. And, as examples, 25% of people with BDD have dropped out of school because of BDD, elementary school, high school, college, because feel they look so ugly and they're so embarrassed by how they look and they think other people are staring at them and maybe laughing at them, and at the very least, agree that they look ugly that they don't want to be around others. So, they may not go to school for that reason. They may be stuck in the mirror and not able to get out the door to school. They may just be too obsessed. And this is a problem, of course, especially in young people. We see a lot of social avoidance, people feeling too embarrassed and ashamed and self-conscious when they're around others. So, it's common for people not to date, to avoid going out with friends. It can impact work performance people may not concentrate as well, they may miss work because they just feel too depressed about how they look, they're too obsessed to focus or concentrate, they don't want to be seen. We found in one study, for example, and this was a group of with sort of moderate BDD, not unusually severe BDD, that about 40% had not worked for at least a week in the past month, because of mental illness, and for most, BDD was the primary diagnosis. So, you know, on average, BDD is quite severe. And I mean, the good news is we can treat BDD.

We also find on just standardized measures of functioning and quality of life that scores are poorer than norms for the community at large, poorer than norms for depression, and poorer than scores for many, many other psychiatric disorders. So, I think it's just important to realize that BDD can cause quite severe impairment in functioning. And I mean, I've seen some people who've been housebound, completely housebound for years. They haven't left their house, because they think they're too ugly to be seen. And they may just sit in the basement of their parents' house or their bedroom and not come out. Sometimes they don't even let their parents see them. So, you know, parents may bring food trays and leave them by the door. And then, the patient won't even open the door to get the food tray until the coast is clear, the parent has left the hallway. Now, that's more severe BDD, but it does happen. Another thing is suicidality, which I'm happy to talk about now or later.

Dr. Daniel Knoepflmacher: Well, let's hear about suicidality. I mean, I just want to emphasize, which you've been saying that this is something which I think is even mentioned in popular culture. People talk about, "Oh, I think I have body dysmorphia." I hear that among non-clinicians and people who I think don't have BDD. It's become part of common parlance, like a lot of psychiatric conditions. And you're saying that even within medicine, sometimes people can say, "Oh, this is a form of vanity," but this is a very serious condition that I think is often underappreciated. So speaking to that, tell us about suicidality.

Dr. Katharine Phillips: Maybe I should first say something about the term body dysmorphia. It's not a diagnostic term. It's a popular term that you hear a lot on social media. You'll find it online, but it doesn't have a clear definition. And so, I think sometimes it's used to refer to the disorder, body dysmorphic disorders. Sometimes it's used to refer to normal body image concerns, which I think there's a risk there of sort of trivializing the disorder BDD, which can be quite severe. Sometimes the term body dysmorphia is actually used incorrectly to apply to body image concerns of people with an eating disorder. So, it's kind of a confusing term. There are a lot of other kind of popular confusing terms out there like acne dysmorphia, skin dysmorphia, penile dysmorphia, zoom dysmorphia. There's a whole lot of dysmorphias, and it's always important to ask, what does the person who is using this term really mean by this term? Is it body dysmorphic disorder, which needs professional treatment? Or is it more common body image concerns, which are not problematic and which don't need mental health treatment?

Dr. Daniel Knoepflmacher: I think we could do a whole episode on the way that psychiatric terminology becomes part of popular culture. I mean, "I feel so PTSD today," or "I'm really OCD about how I arrange my sock drawer." You know, I've heard these terms being used, and it's both in some ways destigmatizing, but also, as you said, confusing. So, thank you for clarifying that. That's an important piece of information. And you were also going to talk about the suicidality.

Dr. Katharine Phillips: Yeah. That's so important. it's so important, if you know someone who you think has BDD, to sort of be aware that, if you're a clinician, you need to carefully assess and monitor patients with BDD. For suicidality, there are very high rates of lifetime suicidal ideation. About 80% of people with BDD have had suicidal ideation and about a quarter or more have actually attempted suicide. And the more severe the BDD is, the more likely they are to have had suicidal ideation or attempted suicide.

A meta-analysis from 2016 found that BDD was associated with higher rates of suicidal ideation and suicide attempts than other disorders that are associated with high rates of suicidality, including OCD and eating disorders. A subsequent study done in a partial hospital setting, nearly 500 patients found that those with BDD were more likely to have suicidal ideation and suicide attempts than any other disorder they examined in their study. That includes OCD, PTSD, unipolar depression, bipolar depression. When it comes to completed suicide, we have very little data. Just one small study that I did, and because the study is small, the numbers I'm going to give you are imprecise. But I think they're meaningful.

We found that the rate of completed suicide in this sample of individuals with BDD was 22 times higher than in the general population, and that was suicide confirmed by death certificate. When we could not obtain the death certificate, but it seemed likely that the person had committed suicide, we added that to confirm suicides. The rate of completed suicide in people with BDD was 36 times higher than the general population. Just to put that in context, context for depression, the rate is about 20 times higher for bipolar disorder, about 15. These are numbers that were found in a meta-analysis. I can also speak as a clinician, you know, it's something you need to very carefully assess and monitor in people with BDD. And fortunately, the treatments we have are very helpful and typically improve suicidality.

Dr. Daniel Knoepflmacher: We're going to delve into the treatments in a bit. One aspect I want to clarify as we're talking about, again, the seriousness of this, what about the prevalence? I mean, you're comparing it to these other conditions. How common is bDD?

Dr. Katharine Phillips: Well, it's more common than OCD. It's more common than anorexia or schizophrenia. In studies that have been done in the general population, the current prevalence of BDD is close to 2% to close to 3%, somewhere in that range. So, not rare and it seems to be more common in studies of adult samples. It seems to be more common in younger adults than in older adults. And it usually starts in early adolescence. Two-thirds of people have onset of BDD before age 18. And I think that's important to recognize, because it's so easy to miss BDD in adolescence. It's so easy to think, "Oh, all adolescents are worried about how they look," or "This is just a passing phase," or something like that.

But because BDD is so often severe and it can really get adolescents off their developmental track, of developing social relationships and getting through high school and college and develop becoming more independent. And so, it can really get adolescents off that important developmental trajectory, and I think can be very, very damaging in that way.

Dr. Daniel Knoepflmacher: Can you give us some specific stories, examples. I mean, we're talking about this in a general sense, but I think often the human experience of those who suffer from a condition like this can be very helpful.

Dr. Katharine Phillips: So, I've seen so many over the years. A fairly typical patient would be a male, BDD affects almost as many males as females, but a man who is just very obsessed with perceived hair loss, which started during his adolescence. And he just is really tortured by this, and thinks that he's going bald when he actually isn't and is very, very self-conscious about his hair and it did make it difficult for him to go to all of his classes in high school, because he would be stuck in front of the mirror trying to comb his hair and shape it and he'd be blow-drying it and putting gels on it to make it look fuller and just couldn't get it to look the way he wanted, so his parents would try and get him out the door to school, and he would just be terribly upset by this, and would be late. And then, in school, he would run to the bathroom throughout the day to try and check his hair. The person I'm thinking of was before we had cell phones. Now, people will repeatedly check their appearance on their phone. And he just thought the kids were laughing at him because of how he looked, which was not the case. He did manage to graduate from high school and managed to get a job, but I think it's definitely affected his dating. He sometimes avoids going out with friends because he just says, you know, "I look bald," but he doesn't. He got a hair transplant, and is very upset that he did, because he thinks that actually made his hair look worse because there's a scar on the back of his head. And he feels, he just regrets having done it and has thought about getting more hair transplants, even though we've discussed many times that that's very, very unlikely to be helpful.

So, he's really suffering. He obsesses about his hair for maybe eight hours a day and isn't dating because of it. He feels too self-conscious, feels women aren't going to want to go out with him because of how he looks. But in reality, he's a very handsome guy. And when he actually tries to date, people do want to date him, but he's so anxious and so afraid he's going to be rejected because of his hair that he doesn't want to. He does his job, but he has difficulty doing it. And he can't concentrate as well because he's distracted by the obsessions about his hair and having to check his appearance and kind of checking how full his hair seems to be, combing it, re-combing it, that sort of thing.

So, he's, I think, an example of someone with sort of moderate BDD definitely interfering with his day to day life, although he is managing to work and does some socializing,

Dr. Daniel Knoepflmacher: You bring up something that's another question I have, which is sometimes the actualization of these preoccupations over time, like you mentioned, skin picking, which could lead to actual scarring, or with plastic surgery, where somebody gets repeated operations that, you know, after a while might change their looks to the point where they look less than normal based on too many procedures. That must be a very difficult point in the progression of BDD, where somebody actually has altered themselves in a way which, I mean, to use this word lightly, but are disfigured in some way because of the compulsions that come up from bDD.

Dr. Katharine Phillips: Yeah, I mean, some people get huge amounts of surgery, dermatologic treatment, which isn't helpful for BDD. And sometimes they do end up looking somewhat unusual. And the good news is we have really good treatments for BDD, right? So as part of the treatment, we work on the skin picking or the hair pulling to help patients stop that behavior. And it's ideal if people with BDD don't get any cosmetic surgery at all, because it doesn't work. And at the very least, we encourage people to delay it so that they can get medication for BDD and/or cognitive behavioral therapy. And after people get one or both of those treatments, which usually help, they often don't want surgery anymore, you know, which is a great outcome.

Dr. Daniel Knoepflmacher: Surgery is not a solution. It does not treat the condition. Let's talk about what does. So, I know that there's both medication interventions and psychotherapy interventions. So, let's start with the medications. Tell us about the effectiveness of medications in the treatment of BDD.

Dr. Katharine Phillips: Our first-line medication for BDD is a serotonin reuptake inhibitor, sometimes called SSRI or an SRI. Common ones are Prozac, Lexapro, Zoloft. These medications are used for a whole range of psychiatric disorders. I mean, they're often called antidepressants, but they also treat other things like anxiety disorders and body dysmorphic disorder and obsessive-compulsive disorder because they are anti-obsessional. They help quiet down and stop the repetitive obsessions, "I look ugly," "I have to get surgery, and people are laughing at me." And they diminish and ideally stop those obsessive thoughts so people have more control over what they are thinking. They decrease the urge to do those compulsive behaviors like mirror checking, comparing with others and grooming, which are very toxic behaviors. They just keep the BDD going. The SRIs make it easier to go out and be around other people. They typically significantly improve depression, anxiety, which often accompany BDD. They improve quality of life and functioning. They can be lifesaving, and they're usually very well tolerated. They're not addicting.

I think one problem is that people often don't get a high enough dose. So, we tend to need higher doses in body dysmorphic disorder, just like OCD. And going to a higher dose often makes all the difference. So for fluoxetine, Prozac, we go as high as 120 milligrams a day. Zoloft, sertraline, we go as high as, if we need to, 400 milligrams a day. Not everyone needs these high doses, but they're usually well-tolerated. And I think for obsessional disorders like body dysmorphic disorder and OCD, these higher doses are often needed, and usually well-tolerated and can really make a difference and make people feel a lot better. So, most people get better with one of these medicines, you know, if they take them every day and they get the right dose. And if one doesn't work, try another one. One may work when another hasn't.

Dr. Daniel Knoepflmacher: And what about psychotherapies? You alluded to them.

Dr. Katharine Phillips: We have great therapy for BDD. The first-line treatment based on studies that have been done is cognitive behavioral therapy that is tailored to BDD specifically. So, cognitive behavioral therapy, CBT, is used for a whole range of disorders, mental health disorders, non-medical disorders, but it always has to be tailored to the disorder's specific symptoms. And so for BDD, we teach cognitive restructuring help people recognize errors in their thinking. Now, we all have errors in our thinking. We all make cognitive errors from time to time, but they're common in people with BDD. For example, thinking, "I can't go to that party tonight. My skin looks terrible. Everyone's going to be thinking I look like a freak." A lot of cognitive errors in there. Fortune telling. Can you really foretell the future? Mind reading. Can you really read people's minds? All-or-nothing thinking. Freak is a really extreme term. And we teach people to recognize these errors and develop more helpful and more accurate thoughts. We do ritual prevention, which consists of helping people learn strategies to cut back on those repetitive behaviors, that checking your appearance in windows, the back of a spoon, mirrors; help people stop the comparing with other people, with celebrities online; help them cut back on the excessive grooming. Also, do something called exposure to help them feel more comfortable in social situations. We do that very gradually because social situations typically make people very, very anxious so we don't push too hard. And we give them skills to feel more comfortable when they're around others.

We also do something called perceptual or mirror retraining to help people develop a more accurate and holistic and non judgmental view of themselves. That's not staring in the mirror. We don't want people taking extra checks in any mirrors or staring in the mirror. That's a ritual that just tends to make BDD worse and we help people cut back on that. But we all run into reflecting surfaces in our lives at times, right? And so, this helps people with BDD learn how to look when they have to look in the mirror, or they catch a glimpse of themselves. We teach some strategies to see themselves more holistically, less judgmentally, not just zeroing in on what they don't like, which is what they tend to do.

So, cognitive behavioral therapy teaches very practical skills. You have to do the homework to learn how to do it, just like if you're learning how to play the trombone, you've got to practice between sessions to get good at it. And eventually, patients learn how to be their own therapist. They practice the CBT skills, hopefully, for the rest of their life and they just kind of weave it into their day to day life.

I would say, for mild BDD, I often recommend cognitive behavioral therapy, although medication is very reasonable. For more moderate BDD, you can do either or both. For severe BDD, I always recommend both treatments. It's very important that people with severe BDD, especially those who are suicidal, get an SRI and also get the cognitive behavioral therapy.

Dr. Daniel Knoepflmacher: What about new promising treatments? Anything in development and research that may be a game-changer?

Dr. Katharine Phillips: Yeah. There are just two recent studies. One hasn't quite been published yet. A study that I and my colleagues did in which it was trained people with BDD versus healthy controls on a computerized task to help enhance what's called holistic visual processing, seeing the big picture. I just have to back up a minute and just explain that studies have shown good studies, including studies using functional MRI, which shows the functioning of the brain. A whole variety of studies have shown that the brains of people with BDD, they see too much detail. Their brains are trying to pull out detail from whatever they are looking at, a face, themselves, a house. Parts of the brain that are specialized to see detail are overactive in people with BDD. And at the same time, parts of the brain, back in the occipital lobe, in the back of the brain are underactive. And those parts of the brain are specialized for what we call global or holistic visual processing. Seeing the big picture, they're underactive, underutilized by the brains of people with BDD. So when people with BDD look at something, the details jump out at them and become overly prominent. So when they look at themselves, a tiny little red dot that we might not see, we wouldn't see, to them looks huge and ugly.

So, two recent studies, they're very preliminary, but suggest that there are ways to enhance this holistic visual processing and thereby enable people with BDD to see themselves more accurately. And one was study I mentioned currently will be published soon that my colleagues and I did in which we trained people, it was total of three hours of training to do a computerized task to enhance their holistic, their ability to see the big picture, and we did before training and after training functional MRIs to look at the function of the brain, and the parts of the brain that have been shown to be underactive in people with BDD were functioning more normally.

Another study done by Jamie Feusner, who's done wonderful work on perceptual visual processing in BDD, found that by using a something called ITBS, a form of transcranial magnetic stimulation, that by stimulating the part of the brain that's underactive in people with BDD, he was able to make that brain circuit function more, that part of the brain function more normally. And people's evaluation of their appearance became more positive after the brain stimulation was done. Just one study of each, you know, the computerized training and the intermittent theta burst stimulation and small samples. So, these approaches need replication, of course. But I think they're very promising. You know, we have great treatments now, but it's always good to have additional treatment options and I'm hopeful that one or both of these approaches will be better studied and that someday there may be evidence-based treatments for BDD.

Dr. Daniel Knoepflmacher: A novel approach using neuromodulation and specific learning modules that are coupled together. This is really drawing on the neurobiology that has been investigated with BDD. Like all of our conditions in Psychiatry and mental health, culture and environment plays a part as well. And I'm just curious what thoughts you have about our modern culture, social media, early life. I mean, we're thinking a lot about adverse events in childhood, anything that is happening to these individuals that maybe they have a genetic risk and then puts them over the threshold into BDD that you know about.

Dr. Katharine Phillips: It's a great question. We don't have all the answers yet, but we know that the cause of BDD is undoubtedly complicated and multifactorial. So in other words, there are multiple causes for BDD and multiple risk factors, there's not one cause like social media. And for one thing, BDD was described back in the 1800s, and that was a long time before we had social media. But we know from good twin studies that BDD is probably somewhere in the range of 40-50% genetically determined. So, people inherit genetic risk for BDD. It doesn't mean that if a parent or a sibling has it, that you will get it. It just increases the your risk somewhat.

And the rest is environmentally determined, and that's a big bucket term. Studies have shown that people with BDD report having experienced more teasing and bullying about competence, about appearance, compared to healthy controls. People with BDD report more childhood neglect and abuse than people without BDD more than people with OCD. These may be risk factors for the development of BDD. Sociocultural pressures almost certainly play a role.

And I'm often asked about social media. We don't really know. We have so little data on the role of social media in BDD and none as a risk factor for BDD. So, we don't really know, but it makes sense that studies suggest that certain forms of social media, image-focused social media, may increase the risk of or worsen body image concerns more generally. We know much less about the disorder BDD specifically. But I think it makes sense that for some people, use of certain forms, certain types of social media, may increase their risk for getting BDD. And especially if someone's already predisposed genetically and perhaps because they've had certain life experiences, maybe certain forms of social media tip them over the edge, you know, into clinical BDD. I think that's entirely possible.

Dr. Daniel Knoepflmacher: Well, it makes me think about potential public health measures. I mean, maybe not necessarily, we don't know the direct risk factors, but we do know that these certain factors exacerbate the condition. So, would there be things within regulations imposed on social media or in other things that you think could be helpful?

Dr. Katharine Phillips: It'shard to know. It's an interesting question. I think regulating social media, you know, at the public health level, might be helpful for some people. This wouldn't put an end to BDD, because as we discussed, the cause is complex, and I don't think exposure to social media is required for most people. We know there are substantial genetic contribution. But, you know, I think perhaps indicating when images, especially those of celebrities, have been altered, so people know what they're looking at isn't real, that could be very helpful, because comparing with others is a very, I think, toxic repetitive behavior, it's a mental repetitive behavior, as opposed to something like mirror checking, which is you can observe someone doing, it's behavioral. It's a very toxic behavior. And people with BDD tend to compare a lot, including with unrealistic images online, celebrities, people who've altered their facial features in other ways, or parts of their body in other ways. So, perhaps indicating what's real and what isn't real would be

. Maybe, this might be more controversial, but limiting teens' access to apps. These are all terms that present unrealistic body image, or that promote cosmetic procedures. In studies of BDD that I've done in youth, a lot of them had already had cosmetic procedures, surgery, dermatologic treatment, and we know those treatments don't help, and they can make BDD much worse.

Dr. Katharine Phillips: Another perspective from a public health perspective, is that cosmetic surgeons in Australia are now required to screen all patients requesting cosmetic surgery. They're required to screen them for BDD before surgery. So, I think this is a great step forward. And I think it would be helpful for anyone doing a cosmetic procedure to screen for BDD, because it really can make the disorder worse. And sometimes the people who provide these treatments are at risk because patients can be very unhappy with the outcome, even if it's objectively acceptable. And there are cases of sometimes occasional patients physically attack surgeons. There's some reports of people who've been murdered by people with BDD. Now, this is not what most people with BDD do, but the outcome can be terrible for both the provider of cosmetic treatment and the patient. So, we don't ever recommend cosmetic treatment. And I think the step they've taken in Australia requiring screening of all patients requesting cosmetic treatment is a very helpful thing, a very helpful step.

Dr. Daniel Knoepflmacher: Well, Kathy, there's a lot more I could ask you. I'm just thinking about all the implications in cultures around the world, the similarities and differences in your work with surgeons and dermatologists. But unfortunately, I'm going to limit it to one last question, which is about any quick resources that you can recommend for people who want to learn more about BDD.

Dr. Katharine Phillips: For clinicians, I've written about BDD on UpToDate, which many people access for free through their electronic medical record. I've also written multiple books on BDD. Understanding Body Dysmorphic Disorder, An Essential Guide is more up-to-date than The Broken Mirror in terms of treatment recommendations, because we've learned about treatment since then. I wrote a book that's more for clinicians in 2017, that is my most up-to-date book on body dysmorphic disorder. All of these are available on Amazon.

The BDD Foundation in the UK has a website that I think is helpful. The International OCD Foundation has, part of their website's devoted to BDD. And recently I posted a few blogs on medication treatment of BDD on the website of the International OCD Foundation. That's probably the most up-to-date information on medication treatment of BDD. And then for therapists, my colleagues and I published a CBT treatment manual to use when treating patients with BDD, as did David Veale and Fugen Neziroglu. These are the two evidence-based CBT therapy manuals that clinicians can use when they're treating patients with BDD, which I think can be helpful.

Dr. Daniel Knoepflmacher: Wow. Well, thank you, Kathy. It's just such a pleasure having you here today on the podcast. I mean, I get to talk to you fairly regularly as we collaborate on a lot of the training for our psychiatry residents, but I've never had the opportunity to sit down and talk with you about BDD. So, this has been a real blessing to have this chance to draw on your profound expertise on this topic. And it's an important one as we keep stressing that it's a serious condition that is often overlooked. So, I'm hoping efforts like this will help change that. So, thank you so much for taking the time out of your very busy schedule to join me today

Dr. Katharine Phillips: Thank you so much for interviewing me and for focusing on this very important disorder. I'm very grateful. Thank you.

Dr. Daniel Knoepflmacher: Thank you. And thank you to all who listened to this episode of On The Mind, the official podcast of the Weill Cornell Medicine Department of Psychiatry. Our podcast is available on all major audio streaming platforms, including Spotify, Apple Podcasts, and iHeart Radio. If you like what you heard today, please tell your friends. Give us a rating and subscribe so you can stay up-to-date with all of our latest episodes. And we have a lot of good ones coming up. So, we'll be back soon and hope to have you listening then.

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