Clinical characteristics among sexual minority and heterosexual women with body dysmorphic disorder.

Body dysmorphic disorder (BDD) is a common disorder associated with substantial comorbidity, impairment, and poor quality of life. Research on subcultural variations of BDD is limited but may impact assessment and treatment of the disorder. The current study examined clinical features in a sample of sexual minority (SM; n = 43) and heterosexual (n = 155) women with diagnosed BDD. Participants completed self-report and clinician-administered measures of demographic and clinical characteristics. Results indicated largely similar clinical features across groups with some exceptions: compared to non-SM women, SM women were younger (M = 25.50 vs 31.96 years, p < .001), had better BDD-related insight (M = 14.51 vs 16.26, p = .01), endorsed a greater number of disliked body parts, and were more likely to express preoccupation with body build (OR = 4.6, 95% CI [2.0, 10.9]), chin/jaw (OR = 4.7, 95% CI [2.1, 10.3]), and shoulders (OR = 10.1, 95% CI [2.7, 37.9]), possibly reflecting nuanced beauty ideals within the SM community. There were no significant group differences in other body parts of concern, BDD severity, or depression. Future studies are needed in larger, more inclusive samples to explore the relationship between diverse identities on BDD and its associated features.

Time to Response in Therapy for Body Dysmorphic Disorder: A Comparison of Cognitive Behavioral Therapy and Supportive Psychotherapy.

Psychotherapy has been shown to be effective for individuals with body dysmorphic disorder (BDD); however, time to treatment response for different treatments have not yet been examined. We randomized 120 patients to either weekly cognitive behavioral therapy (CBT) or supportive psychotherapy (SPT) at two academic medical research centers. In this secondary data analysis, we aimed to determine the time to first response (30% or greater reduction in BDD symptom severity) in both treatment conditions among those who attended at least one post-baseline assessment (n = 109). As previously reported, CBT for BDD was associated with more consistent improvement in symptom severity and quality of life than SPT. In a pooled analysis combining both sites, the median time to first response was shorter for CBT (76 days [10.9 weeks], 95% CI: 76-107 days) than for SPT (88 days [12.6 weeks], 95% CI: 88-nonestimable days; Χ2df=1 = 3.85, p = .0498). For CBT, the estimated 75th percentile response times were 148 days [21.1 weeks] at site 1 and 134 days [19.1 weeks] at site 2. Response times were not estimable for SPT at either site because the response rate was too low. Thus, therapy clients seeking treatment for BDD and clinicians should be aware that an initial treatment response requires more than 11 therapy sessions for the majority of clients, and that 21 or even more sessions may be required. Treatment response is likely to occur earlier with CBT for BDD (the first-line therapy for BDD) than with supportive psychotherapy.

Dermatology in Contemporary Times: Building Awareness of Social Media's Association With Adolescent Skin Disease and Mental Health.

BACKGROUND: The contribution of psychological disorders to the burden of skin disease has been poorly explored in adolescent patients. The review aims to provide insights into the psychological, social, occupational, and social medias' association with acne, atopic dermatitis (AD), and aesthetics in adolescent patients. METHODS: The project used a modified Delphi process comprising face-to-face discussions followed up online.  The systematic literature search results informed the 14 draft statements. During an expert panel meeting, the draft statements underwent the panel's evaluation at a workshop, followed by a plenary discussion adopting five statements using evidence from the literature coupled with the panel's opinions and experiences.  Results: Studies reported an association between poor sleep, social impairment, and mental health disorders, including body dysmorphic disorder (BDD) with acne or AD in adolescents with acne or AD. Education for patients and parents may improve self-management skills and self-responsibility, promoting better outcomes for acne and AD. The use of certain types of social media can contribute to unrealistic expectations regarding the outcomes of cosmetic procedures. Social media use may also be associated with, and potentially contribute to unrealistic appearance expectations and certain mental health conditions. However, social media use may have benefits, such as connection, diversity, social support, increased self-esteem, safe identity experimentation, and an increased opportunity for self-disclosure.  Conclusions: The association with negative life events, BDD, suicidal ideation, depression, and anxiety are thought to be high for adolescent patients with acne or AD. Using social media for information has both positive and negative aspects. Awareness of the risks and benefits of receiving health information about dermatological disease among adolescents needs to be improved through the education of patients and clinicians. Action-oriented items need to be developed to help dermatologists address these issues in clinical practice.Rieder EA, Andriessen A, Cutler V, et al. Dermatology in contemporary times: building awareness of social media's association with adolescent skin disease and mental health. J Drugs Dermatol. 2023;22(8):817-825. doi:10.36849/JDD.7596.

Body Dysmorphic Disorder in Women.

Body dysmorphic disorder (BDD) consists of distressing or impairing preoccupation with perceived defects in physical appearance that are actually nonexistent or only slight. This common and often-severe disorder, which affects more women than men, frequently goes unrecognized. BDD is associated with marked impairment in functioning, poor quality of life, and high rates of suicidality. Most patients seek cosmetic treatment, which virtually never improves BDD symptoms. In contrast, serotonin-reuptake inhibitors, often at high doses, and cognitive behavioral therapy that is tailored to BDD's unique clinical features are often effective. This article provides a clinical overview of BDD, including BDD in women.

Mechanisms of cognitive-behavioral therapy effects on symptoms of body dysmorphic disorder: a network intervention analysis.

BACKGROUND: Body dysmorphic disorder (BDD) is a severe and undertreated condition. Although cognitive-behavioral therapy (CBT) is the first-line psychosocial treatment for this common disorder, how the intervention works is insufficiently understood. Specific pathways have been hypothesized, but only one small study has examined the precise nature of treatment effects of CBT, and no prior study has examined the effects of supportive psychotherapy (SPT). METHODS: This study re-examined a large trial (n = 120) comparing CBT to SPT for BDD. Network intervention analyses were used to explore symptom-level data across time. We computed mixed graphical models at multiple time points to examine relative differences in direct and indirect effects of the two interventions. RESULTS: In the resulting networks, CBT and SPT appeared to differentially target certain symptoms. The largest differences included CBT increasing efforts to disengage from and restructure unhelpful thoughts and resist BDD rituals, while SPT was directly related to improvement in BDD-related insight. Additionally, the time course of differences aligned with the intended targets of CBT; cognitive effects emerged first and behavioral effects second, paralleling cognitive restructuring in earlier sessions and the emphasis on exposure and ritual prevention in later sessions. Differences in favor of CBT were most consistent for behavioral targets. CONCLUSIONS: CBT and SPT primarily affected different symptoms. To improve patient care, the field needs a better understanding of how and when BDD treatments and treatment components succeed. Considering patient experiences at the symptom level and over time can aid in refining or reorganizing treatments to better fit patient needs.

Mechanisms of cognitive behavioral therapy vs. supportive psychotherapy in body dysmorphic disorder: An exploratory mediation analysis.

Body dysmorphic disorder (BDD) is common, severe, and often chronic. Cognitive behavioral therapy (CBT) is the first-line psychosocial treatment for BDD, with well-established efficacy. However, some patients do not improve with CBT, and little is known about how CBT confers its effects. Neurocognitive processes have been implicated in the etiology and maintenance of BDD and are targeted by CBT-BDD treatment components. Yet, the malleability of these factors in BDD, and their potential role in mediating symptom improvement, are not well understood. Understanding how treatment works could help optimize treatment outcomes. In this secondary data analysis of a randomized clinical trial of CBT vs. supportive psychotherapy (SPT) in BDD (n = 120), we examined whether treatment-related changes in detail processing (Rey-Osterrieth Complex Figure test), maladaptive appearance beliefs (Appearance Schemas Inventory-Revised), and emotion recognition (Emotion Recognition Task) mediated treatment outcome. All constructs improved over time and were associated with symptom improvement. CBT was associated with greater improvements in maladaptive beliefs than SPT. None of the variables examined mediated symptom improvement. Findings suggest that with successful treatment, individuals with BDD demonstrate reduced neurocognitive deficits (detail processing, emotion recognition, maladaptive beliefs) and that CBT is more likely than SPT to improve maladaptive appearance beliefs. More work is needed to understand mechanisms of change and thus maximize treatment outcomes.

Predictors of pharmacotherapy outcomes for body dysmorphic disorder: a machine learning approach.

BACKGROUND: Serotonin-reuptake inhibitors (SRIs) are first-line pharmacotherapy for the treatment of body dysmorphic disorder (BDD), a common and severe disorder. However, prior research has not focused on or identified definitive predictors of SRI treatment outcomes. Leveraging precision medicine techniques such as machine learning can facilitate the prediction of treatment outcomes. METHODS: The study used 10-fold cross-validation support vector machine (SVM) learning models to predict three treatment outcomes (i.e. response, partial remission, and full remission) for 97 patients with BDD receiving up to 14-weeks of open-label treatment with the SRI escitalopram. SVM models used baseline clinical and demographic variables as predictors. Feature importance analyses complemented traditional SVM modeling to identify which variables most successfully predicted treatment response. RESULTS: SVM models indicated acceptable classification performance for predicting treatment response with an area under the curve (AUC) of 0.77 (sensitivity = 0.77 and specificity = 0.63), partial remission with an AUC of 0.75 (sensitivity = 0.67 and specificity = 0.73), and full remission with an AUC of 0.79 (sensitivity = 0.70 and specificity = 0.79). Feature importance analyses supported constructs such as better quality of life and less severe depression, general psychopathology symptoms, and hopelessness as more predictive of better treatment outcome; demographic variables were least predictive. CONCLUSIONS: The current study is the first to demonstrate that machine learning algorithms can successfully predict treatment outcomes for pharmacotherapy for BDD. Consistent with precision medicine initiatives in psychiatry, the current study provides a foundation for personalized pharmacotherapy strategies for patients with BDD.

Learning of the same task subserved by substantially different mechanisms between patients with Body Dysmorphic Disorder and healthy individuals.

It is generally believed that learning of a perceptual task involving low-level neuronal mechanisms is similar between individuals. However, it is unclear whether this assumption also applies to individuals with psychiatric disorders that are known to have altered brain activation during visual processing. We investigated this question in patients with body dysmorphic disorder (BDD), a psychiatric disorder characterized by distressing or impairing preoccupation with nonexistent or slight defects in one's physical appearance, and in healthy controls. Participants completed six training sessions on separate days on a visual detection task for human faces with low spatial frequency (LSF) components. Brain activation during task performance was measured with functional magnetic resonance imaging (fMRI) on separate days prior to and after training. The behavioral results showed that both groups of participants improved on the visual detection task to a similar extent through training. Despite this similarity in behavioral improvement, neuronal changes in the Fusiform Face Area (FFA), a core cortical region involved in face processing, with training were substantially different between groups. First, activation in the right FFA for LSF faces relative to High Spatial Frequency (HSF) faces that were used as an untrained control increased after training in BDD patients but decreased in controls. Second, resting state functional connectivity between left and right FFAs decreased after training in BDD patients but increased in controls. Contrary to the assumption that learning of a perceptual task is subserved by the same neuronal mechanisms across individuals, our results indicate that the neuronal mechanisms involved in learning of a face detection task differ fundamentally between patients with BDD and healthy individuals. The involvement of different neuronal mechanisms for learning of even simple perceptual tasks in patients with BDD might reflect the brain's adaptations to altered functions imposed by the psychiatric disorder.

Credibility and expectancy of smartphone-based cognitive behavioral therapy among adults with body dysmorphic disorder.

BACKGROUND: Few patients receive cognitive behavioral therapy, the gold-standard for body dysmorphic disorder (CBT-BDD). Smartphones can make evidence-based interventions, like CBT-BDD, more accessible and scalable. A key question is: how do patients view it? Low credibility and expectancy would likely translate to low uptake and engagement outside of research settings, diminishing the impact. Thus, it is important to understand patients' beliefs about digital CBT-BDD. METHODS: We compared credibility and expectancy in a coach-guided app-based CBT-BDD trial (N=75) to a previous in-person CBT-BDD trial (N = 55). We further examined the relationship of perceptions of digital CBT-BDD to baseline clinical and demographic factors and dropout. RESULTS: Credibility did not differ between the in-person (M=19.3) and digital (M=18.3) trials, p=.24. Expectancy for improvement was moderately higher for in-person (M=58.4) than digital (M=48.3) treatment, p=.005. In the digital trial, no demographic variables were associated with credibility or expectancy. Better BDD-related insight and past non-CBT BDD therapy were associated with greater expectancy. Credibility was associated with lower likelihood of dropout. DISCUSSION: Digital CBT-BDD was regarded as similarly credible to in-person CBT-BDD but with lower expectancy. Tailored expectancy-enhancing strategies could strengthen this novel approach, particularly among those with poorer insight and without prior BDD treatment.

Early response to cognitive behavioral therapy for body dysmorphic disorder as a predictor of outcomes.

Individuals with body dysmorphic disorder (BDD) suffer from distressing or impairing preoccupations with perceived imperfections in their appearance. This often-chronic condition is associated with significant functional impairment and elevated rates of psychiatric comorbidity and morbidity, including depression, substance use disorders, and suicidality. Cognitive behavioral therapy (CBT) for BDD has been shown to be efficacious. However, this intervention is long (up to 24 weeks) relative to many manualized approaches for other related conditions, there is a significant shortage of clinicians trained in CBT for BDD, and some patients drop out of treatment and/or do not respond. Thus, there is great interest in understanding and predicting who is most likely to respond, to better allocate clinical resources. This secondary data analysis of participants enrolled in prior uncontrolled and controlled studies of CBT for BDD explored whether early response to CBT, operationalized as percentage change in symptom severity within the first four weeks and the first 12 weeks of this 24-week treatment, predicts clinical outcomes for patients with BDD (n = 90). The findings indicated that minimal early symptom change was not indicative of eventual non-response. This suggests that patients and clinicians should not be discouraged by limited early improvement but should instead continue with a full course of treatment before reevaluating progress and alternative interventions. Overall, the results support the view that treatment success is more likely if a longer CBT protocol is followed. More work is needed to understand mechanisms of change and thus match optimal interventions to patient characteristics.

An Evaluation of the Body Dysmorphic Disorder Symptom Scale as a Measure of Treatment Response and Remission in Psychotherapy and Medication Trials.

The Body Dysmorphic Disorder Symptom Scale (BDD-SS) is a self-report tool that captures an array of representative behavioral and cognitive symptoms commonly displayed by individuals with BDD. The BDD-SS is regularly used among experts in the field, though its utility as a measure of treatment response has not yet been formally evaluated. Results from two clinical trials of BDD treatment were pooled from an archived database to create a sample of 220 BDD participants who received either psychosocial or medication-based interventions for BDD. We used baseline BDD-SS scores to describe psychometric properties, baseline correlations with other scales to examine the content validity of the BDD-SS, and longitudinal symptom data to evaluate capacity to detect clinically relevant change. Results indicated that the BDD-SS has good psychometric properties and is able to detect symptom change over time, although it showed lower rates of reliable change with treatment relative to the gold standard rater-administered Yale-Brown Obsessive-Compulsive Scale Modified for BDD (BDD-YBOCS). The BDD-SS offers meaningful information about treatment response in a self-report format and may be particularly useful to employ in clinical practice settings as a means of gathering symptom and treatment response data via self-report when rater-administered interviews are not feasible, although it may underestimate the extent of improvement with treatment.

Knowledge and competency standards for specialized cognitive behavior therapy for adult obsessive-compulsive disorder.

Obsessive-Compulsive Disorder (OCD) is a leading cause of disability world-wide (World Health Organization, 2008). Treatment of OCD is a specialized field whose aim is recovery from illness for as many patients as possible. The evidence-based psychotherapeutic treatment for OCD is specialized cognitive behavior therapy (CBT, NICE, 2005, Koran and Simpson, 2013). However, these treatments are not accessible to many sufferers around the world. Currently available guidelines for care are deemed to be essential but insufficient because of highly variable clinician knowledge and competencies specific to OCD. The phase two mandate of the 14 nation International OCD Accreditation Task Force (ATF) created by the Canadian Institute for Obsessive Compulsive Disorders is development of knowledge and competency standards for specialized treatments for OCD through the lifespan deemed by experts to be foundational to transformative change in this field. This paper presents knowledge and competency standards for specialized CBT for adult OCD developed to inform, advance, and offer a model for clinical practice and training for OCD. During upcoming ATF phases three and four criteria and processes for training in specialized treatments for OCD through the lifespan for certification (individuals) and accreditation (sites) will be developed based on the ATF standards.

Specialty knowledge and competency standards for pharmacotherapy for adult obsessive-compulsive disorder.

Obsessive-compulsive disorder (OCD) affects approximately one person in 40 and causes substantial suffering. Evidence-based treatments can benefit many; however, optimal treatment can be difficult to access. Diagnosis is frequently delayed, and pharmacological and psychotherapeutic interventions often fail to follow evidence-based guidelines. To ameliorate this distressing situation, the International OCD Accreditation Task Force of the Canadian Institute for Obsessive-Compulsive Disorders has developed knowledge and competency standards for specialized treatments for OCD through the lifespan. These are foundational to evidence-based practice and will form the basis for upcoming ATF development of certification/accreditation programs. Here, we present specialty standards for the pharmacological treatment of adult OCD. We emphasize the importance of integrating pharmacotherapy with clear diagnosis, appreciation of complicating factors, and evidence-based cognitive behavioral therapy. Clear evidence exists to inform first- and second-line pharmacological treatments. In disease refractory to these initial efforts, multiple strategies have been investigated, but the evidence is more equivocal. These standards summarize this limited evidence to give the specialist practitioner a solid basis on which to make difficult decisions in complex cases. It is hoped that further research will lead to development of a clear, multi-step treatment algorithm to support each step in clinical decision-making.

Rates of remission, sustained remission, and recurrence in a randomized controlled trial of cognitive behavioral therapy versus supportive psychotherapy for body dysmorphic disorder.

BACKGROUND: Little data exist on remission rates following psychotherapy for body dysmorphic disorder (BDD). METHODS: Using data from a large study of therapist-delivered cognitive behavior therapy (CBT) versus supportive psychotherapy (SPT) for BDD (N = 120), we estimated remission rates at treatment endpoint, and rates of delayed remission, sustained remission, and recurrence at 6-month follow-up. We also examined improvement in broader mental health outcomes among remitters. RESULTS: Full or partial remission rates at end-of-treatment were significantly higher following CBT (68%) than SPT (42%). At 6-month follow-up, an additional 10% (CBT) and 14% (SPT) experienced delayed remission, 52% (CBT) and 27% (SPT) experienced sustained remission, and 20% (CBT) and 14% (SPT) experienced recurrence. Remission was never achieved by 18% (CBT) and 45% (SPT). Participants in remission at end-of-treatment experienced significant improvements in functional impairment, depression severity, BDD-related insight, and quality of life compared to nonremitters. CONCLUSIONS: Full or partial remission rates are high following CBT for BDD and higher than after SPT.

Predictors and moderators of symptom change during cognitive-behavioral therapy or supportive psychotherapy for body dysmorphic disorder.

BACKGROUND: Research on predictors of treatment outcome in body dysmorphic disorder, a common and severe disorder, is very limited, and no prior studies have examined moderators of outcome. Because treatment is often but not always efficacious, it is important to identify who is more likely to benefit. We examined predictors and moderators of improvement with therapist-delivered cognitive-behavioral therapy versus supportive psychotherapy in the only study of these treatments for body dysmorphic disorder. This report presents secondary analyses from a study whose primary findings have previously been published (Wilhelm et al., 2019). METHODS: Participants (N=120) with DSM-IV body dysmorphic disorder were randomized to therapist-delivered weekly cognitive-behavioral therapy or supportive therapy for 24 weeks. Using reliable and valid measures, we tested baseline body dysmorphic disorder severity, insight/delusionality, and depression severity as predictors and moderators of overall and treatment modality-specific symptom change. We explored additional variables as predictors and moderators of outcome. RESULTS: Greater treatment credibility (p=0.02) and presence of obsessive-compulsive personality disorder (p=0.03) predicted greater improvement. Serotonin-reuptake inhibitor treatment at baseline (unchanged during the study) (p=0.01) predicted less improvement. No other variables predicted or moderated outcome (all p>0.05). LIMITATIONS: The study was not powered a priori to detect predictor or moderation effects, which limited our ability to detect them unless they were strong. CONCLUSIONS: Because greater treatment credibility predicted better outcomes, fostering credibility during therapy may maximize gains. Improvement was not impeded by more severe body dysmorphic disorder, depressive symptoms, or poorer insight. No variables moderated treatment-specific improvement.

Introduction to knowledge and competency standards for specialized treatments for obsessive-compulsive disorder throughout the lifespan: Phase two series by the International Accreditation Task Force of the Canadian Institute for Obsessive Compulsive Disorders (CIOCD, www.ciocd.ca).

This paper presents an introduction to the phase two series of papers by the 14 nation International Obsessive-Compulsive Disorders Task Force (ATF) of the Canadian Institute for Obsessive Compulsive Disorders. These papers present evidence-based knowledge and competency standards developed by the ATF for specialized treatments for obsessive-compulsive disorder (OCD) through the lifespan, operationalized as clinician abilities. Specialty standards for OCD do not currently exist and are deemed by experts to be foundational to transformative improvement globally in quality and accessibility of evidence-based treatments for this crippling disorder. Currently available guidelines for care are deemed to be essential but insufficient because of highly variable clinician knowledge and competencies specific to this disorder. The ATF standards encompass specialized cognitive behavior therapy, and pharmacotherapy, for pediatric and adult OCD. Evidence-based methodology with integration of expert opinion are described. Upcoming ATF phases three and four will involve development and implementation of training criteria and processes for certification (individual clinicians) and accreditation (clinical sites) based on the ATF standards. These standards will require periodic review and updating commensurate with advances in clinical research. We hope that this international initiative constitutes a significant step forward to inform and advance evidence-based specialized treatment and training for OCD.

Body Dysmorphic Disorder: Clinical Overview and Relationship to Obsessive-Compulsive Disorder.

Body dysmorphic disorder (BDD), characterized by a distressing or impairing preoccupation with nonexistent or slight defects in appearance, is associated with markedly poor quality of life and high rates of suicidality. Onset of BDD is usually in childhood or adolescence and, unless appropriately treated, tends to be chronic. The first-line pharmacologic approach for both delusional and non-delusional BDD is serotonin reuptake inhibitors (SRIs), often at high doses. SRI augmentation and switching strategies can be effective. The first-line psychotherapy is cognitive-behavioral therapy (CBT) tailored to BDD's unique clinical features. Cosmetic treatment (such as surgery or dermatologic treatment), although received by a majority of patients with BDD, is not recommended. BDD has many similarities to obsessive-compulsive disorder (OCD) and appears closely related to OCD but also has some important differences. This article, which updates a 2015 article on BDD that we published in this journal, provides a clinically focused overview of BDD and its relationship to OCD.

Empirically defining treatment response and remission in body dysmorphic disorder.

BACKGROUND: The number of clinical trials in body dysmorphic disorder (BDD) has steadily increased in recent years. As the number of studies grows, it is important to define the most empirically useful definitions for response and remission in order to enhance field-wide consistency and comparisons of treatment outcomes across studies. In this study, we aim to operationally define treatment response and remission in BDD. METHOD: We pooled data from three randomized controlled trials of cognitive-behavior therapy (CBT) for BDD (combined n = 153) conducted at four academic sites in Sweden, the USA, and England. Using signal detection methods, we examined the Yale-Brown Obsessive Compulsive Scale modified for BDD (BDD-YBOCS) score that most reliably identified patients who responded to CBT and those who achieved remission from BDD symptoms at the end of treatment. RESULTS: A BDD-YBOCS reduction ⩾30% was most predictive of treatment response as defined by the Clinical Global Impression (CGI) - Improvement scale (sensitivity 0.89, specificity 0.91, 91% correctly classified). At post-treatment, a BDD-YBOCS score ⩽16 was the best predictor of full or partial symptom remission (sensitivity 0.85, specificity 0.99, 97% correctly classified), defined by the CGI - Severity scale. CONCLUSION: Based on these results, we propose conceptual and operational definitions of response and full or partial remission in BDD. A consensus regarding these constructs will improve the interpretation and comparison of future clinical trials, as well as improve communication among researchers, clinicians, and patients. Further research is needed, especially regarding definitions of full remission, recovery, and relapse.

Body dysmorphic disorder: a treatment synthesis and consensus on behalf of the International College of Obsessive-Compulsive Spectrum Disorders and the Obsessive Compulsive and Related Disorders Network of the European College of Neuropsychopharmacology.

Body dysmorphic disorder (BDD) is characterized by a preoccupation with a perceived appearance flaw or flaws that are not observable to others. BDD is associated with distress and impairment of functioning. Psychiatric comorbidities, including depression, social anxiety, and obsessive-compulsive disorder are common and impact treatment. Treatment should encompass psychoeducation, particularly addressing the dangers associated with cosmetic procedures, and may require high doses of selective serotonin reuptake inhibitors* (SSRI*) and protracted periods to establish full benefit. If there is an inadequate response to SSRIs, various adjunctive medications can be employed including atypical antipsychotics*, anxiolytics*, and the anticonvulsant levetiracetam*. However, large-scale randomized controlled trials are lacking and BDD is not an approved indication for these medications. Oxytocin* may have a potential role in treating BDD, but this requires further exploration. Cognitive-behavioural therapy has good evidence for efficacy for BDD, and on-line and telephone-assisted forms of therapy are showing promise. CBT for BDD should be customized to address such issues as mirror use, perturbations of gaze, and misinterpretation of others' emotions, as well as overvalued ideas about how others view the individual.