The management of body dysmorphic disorder in adolescents: A systematic literature review

1 Introduction

Body dysmorphic disorder (BDD) is a chronic psychiatric condition, where patients are abnormally preoccupied with perceived defects in parts of their bodies. BDD results from the complex relationship between biological predisposing factors and environmental stressors [1,2]. Over the last two decades, there has been a sharp increase in the prevalence of BDD, particularly in adolescence [3]. It has been hypothesised that the rising prevalence of BDD among adolescents is due to the increased use of social media, which precipitates comparison and body dissatisfaction [4,5]. For example, Facebook and Instagram are strongly associated with body image dissatisfaction, a precursor of BDD [6]. Psycho-social factors underpin BDD and these factors are reinforced through sociocultural beauty tropes [7], such as subconscious tendencies to categorise people as “attractive” or “unattractive” [8], inherent biases on feature symmetry and skin homogeneity [9], and links between feeling attractive and self-esteem [10]. Due to these factors, a degree of body dissatisfaction exists within society, leading to possible negative evaluations of a person’s own body [11].

Unsurprisingly, it is often the same features that make an “attractive” face that become the subject of discontent, with skin homogeneity being one of the most significant areas of concern [12]. In extreme cases, body dissatisfaction can become pathological, with a perceived flaw in appearance consuming a person’s life, leading to social withdrawal and even suicidality. Patients with BDD show a preference for symmetry and partake in repetitive compulsions [13]; however, there is a lack of compelling evidence to demonstrate the correlation between obsessive-compulsive disorder (OCD) and BDD from a neurobiological standpoint [14]. Similarly, the appearance-related concerns in patients with BDD have been described as ego-syntonic in nature, suggesting that they are less likely to be intrusive thoughts as seen in OCD, and more closely linked to overvalued ideas as seen in autism spectrum disorder (ASD) [13].

The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), outlines the diagnostic criteria for BDD [15]. These criteria, which are outlined below, are commonly used to aid the clinical diagnosis of BDD.

1. Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others.

2. Repetitive behaviours such as mirror checking, excessive grooming, skin picking, camouflaging, and reassurance seeking.

3. Clinically significant distress or impairment in social, occupational, or other important areas of functioning.

4. Preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder.

There are issues within the hierarchical organisation of the DSM-5, as it states that a diagnosis of BDD should not be made if the presentation can be accounted for by another disorder, such as an eating disorder [16]. This highlights the link between BDD and eating disorders, as well as the somewhat diminished position of BDD. Additionally, the DSM-5 emphasises the importance of identifying the patient’s level of insight into their condition, noting that over a third of patients have delusional BDD beliefs [15]. The presence of delusional beliefs differentiates BDD from other body dissatisfaction disorders, where the concern is often proportionate to reality [2,11]. Due to insufficient insight, patients with BDD rarely present to psychiatric services.

Although mental health expertise is required to determine the severity of BDD, simple screening tools, such as the BDD Questionnaire, are easily administered and interpreted to identify and diagnose BDD [17]. In the general adult population, the prevalence of BDD is 1.9%, which is higher than the prevalence of other body image disorders with greater public awareness, such as anorexia nervosa (0.3%) and bulimia nervosa (1%) [18]. It is suspected that the true prevalence of BDD is much higher than current estimates due to embarrassment and shame over the perceived “flaw,” which drives secrecy and fear of judgment [19]. BDD disproportionately affects adolescents, with over two-thirds of patients being diagnosed before they turn eighteen [19]. One-fifth of adolescents with BDD reported dropping out of school, severely impacting their learning, social life, and future career [20]. The diagnosis of BDD in adolescence is associated with high comorbidity with other psychiatric conditions, such as depression, anxiety, and OCD, and therefore, a large proportion of adolescents with BDD are hospitalised [20].

Treatment of BDD is challenging and spans cognitive behaviour therapy (CBT), pharmacology, and dermatology [21,22]. The National Institute for Health and Care Excellence (NICE) guidelines recommend offering CBT as the first-line treatment for adolescents with BDD, with selective serotonin reuptake inhibitors (SSRIs) used as second-line treatment [23]. Other management strategies have emerged with the development of psychodermatology [24], a relatively new field that addresses the bio-psycho-social interactions between skin and mind. Although the availability of these services is increasing, it is still insufficient to meet patient demand, particularly for adolescent patients [25]. Further treatment may be informed by the suggested alignment of BDD and ASD [22], which proposes that therapies such as inference-based therapy and motivational interviewing could help increase engagement and maintain treatment adherence [26].

Greater insight is needed into the management of BDD in adolescence, as there are notable gaps in treatment evidence [27]. Therefore, a systematic literature review was conducted to examine the current state of treatment for BDD in adolescents in the UK, to establish a baseline of current treatment, and to identify specific areas for further research. The UK was selected as the context, as this is where the researchers are based. This enquiry is structured around the PICO model as outlined in the Cochrane Handbook for Systematic Reviews of Interventions [28]. PICO stands for: Patient or problem; Intervention; Comparison, and Outcome(s) and the application of this model is shown in Table 1.

2 Materials and methods

This systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The PRISMA statement consists of a checklist that acts as guidance on how to conduct, authorise, or report such a review. Following this resource ensures that a minimum standard of quality is met, facilitating repeatability, review updates, and contributing to the medical educational knowledge [29].

3 Results

In adherence to the PRISMA guidelines for systematic literature reviews, the selection process is displayed in Figure 1, which shows the number of papers collected, screened, and excluded. The systematic search resulted in six articles that met the stated eligibility criteria.

Figure 1

A flow diagram to illustrate the selection process.

Of the six papers, three investigated the effectiveness of CBT in adolescence, of which one was a case series which inferred the rationale for the other two studies: A randomised control trial and a follow up study. One was a retrospective case note review of access to treatment specific to BDD in adolescence, and two were narrative literature reviews written from the nursing perspective: One analysing the practical challenges of implementing the NICE guidelines and the other synthesising all current treatment approaches [23]. Data extraction was done in adherence to the defined outcomes. In Table 6, the characteristics of selected studies, primary outcome measure, and key findings are displayed.

The characteristics of the participants enrolled in each study are outlined in Table 7. In total, 119 participants were included in this systematic review, taking into consideration that Krebs et al. [36] utilised the same participants as Mataix-Cols [35]. Other than Krebs et al. [34], most of the studies had a female bias, perhaps reflecting the higher prevalence of BDD amongst women. The studies did not specify other demographics of participants such as race, ethnicity, or socioeconomic status, so it is difficult to assess generalisability.

4 Discussion

The analysis of findings is presented here using three headings drawn from the NICE Stepped Care Model [23]. The original model has six steps, but we combined steps 3–6 as they were variations on treatments (Table 5). This left three areas of discussion:

• Awareness and recognition of BDD in adolescence

• Screening and assessment of BDD in adolescence

• Treatment for BDD in adolescents

5 Conclusion

Although all six of the identified papers supported current best-practice of psychological intervention as first-line treatment, several issues were raised regarding lack of awareness, lack of training, poor resource allocation, and insufficient rigorous evidence in the field. With the disproportional impact of BDD on adolescents and the rapid acceleration in prevalence, this is an avenue that demands more research. The identified papers revealed issues in the current state of management of BDD for adolescents in the UK. It was found that there is a societal stigma towards BDD, which results in delayed help seeking by up to two decades [33]. This stigma was found to be propelled by the growth of social media which has normalised body dissatisfaction – a significant risk factor for developing BDD [37]. Misdiagnosis of BDD was found to be commonplace because BDD is not a part of the core curriculum for mental health professionals working with adolescence, leading to a lack of trained staff to manage this increasingly prevalent condition [33,38]. Therefore, it was reported that when sufferers finally build the courage to seek help, they may not be met with understanding or appropriate support. If psychological support is inadequate to disrupt a patient’s delusional beliefs, they are far more likely to request cosmetic procedures, causing unnecessary patient harm [36]. Despite the issues raised, three papers affirmed that psychological therapy, specifically CBT with exposure with response prevention, is an effective tool to reduce the severity of BDD in adolescence [34–36].

The NICE Stepped Care Model [23] provides guidance for the management of adults, adolescence, and young people with BDD and OCD in the UK. The identified literature criticised this grouping, identifying that BDD is diagnostically distinct from OCD [33]. It was also revealed that the guidelines are based on significantly limited evidence, especially for young people where both the number and quality of studies were negligible [33]. This systematic review echoes this sentiment, as the search only revealed one novel randomised control trial.

In drawing together the key findings, this systematic review identifies three areas of further research. These include inquiry into mental health professionals’ perspectives on the current state of BDD management in adolescence, a review of the rate of BDD remission in relation to CBT treatment, and research into the extent to which schools are able to influence teenagers’ ideas about body image.