Body dysmorphic disorder — assessment and stepped management (MEQ)

(i) Definition and differentials. BDD: preoccupation with perceived appearance defect(s) that are slight or unobservable to others, with repetitive behaviours/mental acts (checking, camouflage, comparing) causing distress/impairment, within OCRD. Here: skin/nose focus, multi-hour rituals, poor insight, functional drop-out — classic BDD. OCD: multi-theme obsessions/compulsions not limited to appearance (can co-occur). Eating disorders: weight/fatness and eating control primary. Psychosis: primary non-appearance delusions/hallucinations/thought disorder; poor/absent insight alone does not equal schizophrenia. Discriminators: content of preoccupation, ritual function, developmental/weight history, full MSE.[7]

(ii) Assessment and risk. Chronology; body areas; hours/day; rituals and camouflage; cosmetic history (filler with migration of concern); insight; depression; substances; family reassurance. Suicide risk: passive death wishes require full risk assessment (ideation, intent, plan, means, protective factors) — clinical BDD has high lifetime SI/attempts. BDD-YBOCS: clinician-rated severity (time, interference, distress, resistance, control domains) — tracks response, does not diagnose alone. Collateral if available.[1][6]

(iii) Psychological plan. Specialised CBT-BDD: psychoeducation on maintaining cycle; cognitive work on appearance beliefs; graded exposure (mirror, reduced camouflage, social experiments) with response prevention (no checking/reassurance rituals); reduce accommodation. Evidence from modular CBT RCTs supports specialised protocols, not generic counselling.[3][5]

(iv) Pharmacotherapy. Sertraline 50 mg for 4 weeks is inadequate dose/duration for BDD. Discuss options: titrate sertraline toward high (OCD-range) doses as tolerated, or switch to fluoxetine (strongest placebo-controlled BDD RCT) with planned titration often toward 40–80 mg oral daily, aiming for a 12–16 week adequate trial including weeks at maximum tolerated therapeutic dose; early review for activation/suicidality and side-effects; combine with CBT-BDD. Clomipramine is a later option after SSRI failure with ECG/anticholinergic cautions.[2][5]

(v) Cosmetic advice and non-response. Elective cosmetic procedures do not treat BDD; dissatisfaction and migration of concern are common — advise against further procedures as a cure and coordinate with providers if needed. If non-response: re-check diagnosis, adherence, true CBT-BDD fidelity, substances, depression/risk; switch SSRI or move to clomipramine; escalate care intensity for risk/housebound status; maintain SRI after response to reduce relapse.[4][5]