Body Dysmorphic Disorder

Body dysmorphic disorder (BDD) is a psychiatric disorder characterized by a preoccupation with a nonexistent or slight appearance defect, coupled with behaviors or rituals, such as excessive mirror checking, performed in response to appearance-related anxiety. BDD is a relatively common disorder. It often begins during adolescence and, when untreated, frequently persists over a long period. BDD is not necessarily caused by one specific factor; it is thought to have several possible causes, including, but not limited to, genetic, environmental, and social factors. BDD affects a diverse range of people of all ages and ethnicities. Both men and women experience BDD, with only slightly more women reporting BDD symptoms. While there are several similarities between men’s and women’s BDD symptoms, research has shown that body parts or features of concern may differ by gender. For example, women with BDD are more likely to have appearance concerns related to their skin, stomach, breasts, weight, and legs, and men are more likely to have concerns related to their body build, genitals, and hairline. Other common body parts of concern in BDD include faces and specific facial features such as eyes, noses, and jaws.

Assessment and Diagnosis of BDD

Although BDD is a relatively common disorder, it often goes unrecognized or misdiagnosed. One reason for this underdiagnosis is that people with BDD may not report their symptoms to doctors or health care professionals because they are embarrassed or concerned about seeming vain. Additionally, BDD is often misdiagnosed due to its similarity with other disorders. BDD shares similarities with OCD, hair-pulling disorder (trichotillomania), major depressive disorder, and eating disorders. BDD is categorized as an obsessive- compulsive-related disorder. People with OCD experience obsessions or intrusive thoughts, and perform rituals in an attempt to alleviate these thoughts. Similarly, people with BDD experience obsessions and repetitive behaviors (i.e., rituals), but in BDD the obsessions and rituals are specifically related to appearance concerns. Notably, fixations with true appearance flaws are not diagnosed as BDD, but as an “Other Specified Obsessive-Compulsive and Related Disorder.” Additionally, appearance concerns surrounding one’s body shape or weight that are accompanied by hallmark eating disorder symptoms, including food restriction and bingeing/purging behavior, may be better accounted for by an eating disorder.

What Are Common Signs and Symptoms of BDD?

While some appearance concerns are common for many people, appearance concerns in BDD are extreme and cause significant distress and interference in a person’s daily life. Appearance concerns in BDD can include skin, hair, body shape, or any other aspect of one’s appearance. People often express concerns that their features are too big, small, crooked, that they change over time, or that they look different depending on context (e.g., in a certain type of lighting). People with BDD often perform rituals that temporarily alleviate their appearance concerns. Rituals in BDD often involve spending a lot of time checking or avoiding mirrors or reflective surfaces, covering up the area of concern with makeup or sunglasses, seeking reassurance from others (e.g., asking another person if he or she looks okay), comparing appearances, seek- ing out plastic surgery or other cosmetic procedures, etc. Avoidance is another hallmark symptom of BDD that can manifest in many ways. People might avoid having their photographs taken, attending social events, or leaving the house altogether. Although rituals and avoidance might temporarily relieve distress, appearance concerns will often return soon after a ritual is performed. In addition to these common symptoms, there are certain distinct symptoms that comprise subgroups of BDD. For example, those who lack insight or awareness that their appearance concerns may be due to a distorted body image are convinced that they are hideous and that others perceive or take notice of their flaws (e.g., delusionality). They might be convinced that other people are watching, judging, or mocking their appearance. Muscle dysmorphia is another subgroup of BDD, involving a preoccupation that one’s body shape or form is insufficiently muscular. Individuals with muscle dysmorphia often feel too small, and subsequently spend excessive amounts of time exercising, focusing on their diet, taking steroids, or performing related rituals to “get bigger.”

Treatment

BDD can be responsive to both psychotherapy and medications. Cognitive behavior therapy (CBT) is effective for treating BDD. CBT involves education about the disorder, as well as learning to identify and modify one’s unhelpful thoughts about appearance and developing strategies to help interrupt related rituals. CBT also involves cutting back on avoidance behaviors and rituals. CBT for BDD often involves attentional retraining, which includes learning to focus one’s attention in a different manner when looking in the mirror and other reflective surfaces. Patients learn to accept themselves and treat themselves with kindness and compassion. Treatment also includes instruction in relapse-prevention strategies, which help patients maintain their treatment gains. Although there are no FDA-approved psychopharmacological treatments specifically for BDD, selective serotonin reuptake inhibitor (SSRI) medications are considered the first-line treatment for BDD.

Professional organizations such as ABCT provide listings of practitioners who are experts in cognitive-behavioral therapy, including providers who specialize in treating BDD. You can visit the ABCT website and click on Find a CBT Therapist to find treatment providers in your area who treat BDD. The International OCD Foundation provides information about BDD and related problems and information on where to find treatment. The Anxiety and Depression Association of America also provides information about BDD.