Body Dysmorphic Disorder

Updated: Nov 23, 2016
  • Author: Iqbal Ahmed, MBBS, FRCPsych(UK); Chief Editor: David Bienenfeld, MD  more...
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Overview

Practice Essentials

The essential feature of body dysmorphic disorder (BDD) is preoccupation with an imagined defect in appearance or disproportionate concern with a slight physical anomaly. By definition, BDD causes significant distress or impairment in important areas of functioning.

Signs and symptoms

Common areas of perceived imperfections (order of frequency) in BDD include the following: [11]

Body Part of Concern (Open Table in a new window)

Women Men
Skin Skin
Hair Hair
Nose Nose
Legs Body build
Eyes Eyes
Weight Genitals
Breasts Legs
Stomach Pectoral muscles
Teeth Stomach
Hips Lips
Face size/shape Ears
Lips Weight
Chin Face size/shape
Cheeks Teeth
Height Chin
Jaw Head size/shape
Head size/shape Arm/wrist
Feet Cheeks
Buttocks Height
Ugly face Ugly face
Forehead Jaw
Ears Forehead
Fingers Fingers
Hands Hands
Neck Feet
Shoulders Buttocks
Body build Neck
Arm/wrist Face muscles
Eyebrows Eyebrows

The clinical picture typically illustrates many of the following behaviors:

  • Ritualistic behaviors aimed at confirming the “defect” or avoiding its recognition by others
  • Need for constant reassurance from others
  • Expenditure of considerable time (1 hour or more, sometimes as much as 8 hours) daily on thoughts and behaviors relating to the “defect”
  • Repeated seeking of dermatologic or cosmetic referral for correction of the “defect”

Asking the following 4 questions may be helpful:

  1. Are you worried about how you look? (Yes/No); if you are, do you think about your appearance problems a lot and wish you could think about them less? (Yes/No)
  2. How much time per day, on average, do you spend thinking about how you look? - (a) Less than 1 hour a day; (b) 1-3 hours a day; (c) more than 3 hours a day
  3. Is your main concern with how you look that you aren’t thin enough or that you might become too fat? (Yes/No)
  4. How has this problem with how you look affected your life? - (a) Has it often upset you a lot? (Yes/No); (b) has it often gotten in the way of doing things with friends, your family, or dating? (Yes/No); (c) has it caused you any problems with school or work? (Yes/No); (d) are there things you avoid because of how you look? (Yes/No)

Patients are likely to have BDD if they give the following answers:

  • Question 1 - Answer of “yes” to both parts of the question
  • Question 2 - Answer of (b) or (c)
  • Question 3 - Whereas an answer of “yes” answer may indicate that BDD is present, it is possible that an eating disorder is a more accurate diagnosis
  • Question 4 - Answer of “yes” to any of the 4 parts of the question

See Presentation for more detail.

Diagnosis

No specific laboratory tests or imaging studies are indicated for suspected BDD. Screening questionnaires may be helpful. A mental status examination should be carried out and may include the following findings:

  • Mood - Depressed mood, as well as irritability and anxiousness
  • Thought process - Perseveration on physical appearance, particularly in association with the perceived defect
  • Thought content - Thoughts about the perceived defect that may be so divorced from reality as to become delusional; suicidal and homicidal ideation may be present

Except for the amount of time and energy spent on the preoccupation, findings from the mental status examination are usually within normal limits.

See Workup for more detail.

Management

Medications that may be employed in treating BDD include the following:

  • Selective serotonin reuptake inhibitors (SSRIs; eg, fluoxetine, fluvoxamine, sertraline, and escitalopram) - These agents are generally preferred
  • Tricyclic antidepressants (TCAs; in particular, clomipramine)
  • Neuroleptics (eg, pimozide)
  • Trazodone
  • Lithium
  • Benzodiazepines
  • Monoamine oxidase inhibitors (MAOIs) - These should be given only if all other modalities fail and probably should be prescribed only by experienced specialists

Psychotherapy (especially CBT) and behavioral modification therapy are highly recommended in addition to treatment with SSRIs. Approaches include the following: [78]

  • Cognitive Restructuring
  • Exposure techniques
  • Response (ritual) prevention
  • Cognitive imagery/perceptual retraining
  • Relapse Prevention
  • Structured daily homework

General strategies are as follows:

  • Consistent treatment, generally by the same physician
  • Supportive office visits scheduled at regular intervals
  • Gradual shifting of focus from symptoms to personal and social problems
  • Efforts to prevent body inspection rituals and reassurance seeking [1, 2]

Surgical considerations include the following:

  • Given that more than 90% of BDD patients report symptoms that are unchanged and often exacerbated after surgical procedures, plastic or cosmetic surgery intended to correct the perceived defect in BDD is contraindicated
  • In all suspected cases of BDD, any proposed surgical treatment must be thoroughly documented and discussed with patients

See Treatment and Medication for more detail.

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Background

Body dysmorphic disorder (BDD)—formerly referred to as dysmorphophobia, dysmorphic syndrome, dermatologic hypochondriasis, or dermatologic nondisease in various contexts—is a relatively common and often severe psychiatric illness that is likely underrecognized and underreported. [3, 4, 5, 6, 7] It is classified in the category of obsessive-compulsive and related disorders in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). [8] If left untreated, BDD can become a chronic condition.

The essential feature of BDD is a preoccupation with an imagined defect in appearance or disproportionate concern with a slight physical anomaly. These preoccupations most often involve the nose, the ears, the face, hair, or features related to sexuality (eg, breasts in women or muscular build or penis size in men); however, any body part may occupy the patient’s focus.

Social values and mass media greatly influence body image and, in turn, self-image. Most people have concerns related to appearance; however, this concern is considered pathologic when it interferes with social or occupational functioning. By definition, BDD causes significant distress or impairment in these areas. [9]

BDD usually appears during early adolescence. Parents of children with BDD may seek psychiatric evaluation after witnessing excessive mirror checking, time-consuming grooming, and an inability to be reassured about the perceived flaw. From a developmental perspective, some preoccupation with appearance is common during adolescence; the hallmark of BDD in adolescents is, as noted, clinically significant distress or impairment in functioning.

A key characteristic of BDD is that patients seek actions, such as cosmetic surgery, to correct their perceived malformation. Patients whose symptoms are exclusively focused on a preoccupation with body weight and shape or perceived inappropriateness of sexual characteristics are not diagnosed with BDD and frequently meet criteria for other disorders, such as anorexia nervosa or gender identity disorder.

Data suggest that quality of life and psychosocial functioning are at least as poor in patients with BDD as in those with obsessive-compulsive disorder (OCD). [10] BDD is associated with high rates of hospitalization (48%), as well as high rates of suicidal ideation and attempts. [11, 12] A history of suicidal ideation attributed primarily to BDD is reported in 45–70% of those with BDD, and past suicide attempts are reported in 22–24%. [13]

BDD affects 2.4% of the general population and reportedly affects as many as 7–15% of those undergoing cosmetic surgery. [8, 14, 15, 16] Persons with BDD who choose to undergo plastic surgery are generally unhappy with the results and often subsequently become concerned with another body part. They are often consumed by thoughts about the postoperative site. Surgeons and dermatologists have occasionally been victims of violence, even murder, by BDD patients who are in despair over their procedural outcomes. [17]

Diagnostic criteria (DSM-5)

Specific DSM-5 criteria for BDD are as follows [8] :

  • The individual is preoccupied with 1 or more perceived defects or flaws in physical appearance that are not observable by or appear slight to others
  • At some point during the course of the disorder, the individual has performed repetitive behaviors (eg, mirror checking, excessive grooming, skin picking, or reassurance seeking) or mental acts (eg, comparing his or her appearance with that of others) in response to the appearance concerns
  • The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
  • The appearance preoccupation cannot be better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder

The diagnosis may also specify whether muscle dysmorphia is present. In such cases, individuals are preoccupied with the idea that their physical build is too small or not muscular enough. This specifier is used even if individuals are also preoccupied with other body areas.

In addition, the diagnosis may specify patients’ level of insight into their BDD beliefs as follows:

  • Good or fair insight - The individual recognizes that the BDD beliefs are definitely or probably untrue, or at least that they may or may not be true
  • Poor insight - The individual feels that the BDD beliefs are probably true
  • Absent insight or delusional beliefs - The individual is completely convinced that the BDD beliefs are true
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Pathophysiology

At present, the pathophysiology of BDD is understood to only a highly limited extent; however, it remains a subject of continuing research. [18] Studies have highlighted a variety of plausible mechanisms, including such hypotheses as abnormal visual processing and hypo−N-methyl-D-aspartate (NMDA) receptor (NMDAR) signal transduction. [19, 20] A more robust understanding of BDD’s pathophysiology will surely inform and improve available treatment options.

Patterns of heritability have been noted. Family members of patients diagnosed with BDD show a prevalence rate of BDD that is 4-8 times that found in the general population. There is also a heritable association with BDD in patients with OCD. Accordingly, genetic factors are suspected of playing a role in the pathogenesis of BDD. [21] Unfortunately, the studies that could more fully illuminate the molecular genetic basis of BDD have yet to be done. [22]

A 2000 study by Deckersbach et al found that patients with BDD had impaired verbal and nonverbal memory encoding strategies. [23] This finding suggests an involvement of executive memory deficits with a lesion of the frontostriatal connections. A similar abnormality in memory encoding also occurs in patients with OCD. Additionally, enlarged white matter volume and asymmetry of the caudate nucleus, favoring the left side, have been observed in patients with BDD.

A 2007 study by Feusner et al found that BDD may be associated with fundamental differences in visual processing of faces. [22] The study also found that subjects with BDD had greater left hemisphere activation and might have a cognitive style that relies more on extraction and processing of details. The authors suggested that BDD patients may process faces in a piecemeal manner, whereas healthy controls’ perception of faces may be more configural and holistic.

Several studies have explored the possible role of disrupted serotonergic transmission in the development of BDD. Many of these are based on evidence that illustrates the effectiveness of selective serotonin reuptake inhibitors (SSRIs) in the treatment of BDD. Overall, the exact role for serotonergic transmission in the etiology of BDD remains the subject of continuing research. [22, 24]

In addition to the neuroanatomic, neurochemical, and genetic models for explaining BDD, several cognitive-behavioral models have been developed. It is recognized that most people are unsatisfied with at least 1 aspect of their appearance; the signal characteristic of people with BDD is that they are obsessed with any such perceived defects.

Individuals with BDD are believed to use maladaptive cognitive processes that overemphasize the importance of perceived attractiveness. [25, 26] By this logic, their disproportionate emphasis on physical attractiveness leads them to view themselves negatively, so that they experience low self-esteem, anxiety, shame, and sadness, commonly reporting to maladaptive coping methods such as mirror-gazing or avoidance. [27]

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Etiology

At present, the causes of BDD have not been established, though numerous theories have been advanced.

Heredity may contribute to the development of this condition. The prevalence of BDD is 4 times higher in first-degree relatives of BDD patients than in relatives of probands without the disorder. BDD appears to be related to OCD, in that it occurs frequently in OCD patients and their relatives and responds to the same medications. [28, 29, 30, 31]

Brain anomalies may be important causes. Functional abnormalities in visual processing, frontostriatal, and limbic systems have been documented. Diffusion-weighted magnetic resonance imaging (MRI) of white matter suggested a relation between impaired insight (a clinically important phenotype) and fiber disorganization in tracts connecting visual with emotion/memory processing systems. [32]

Another study found disturbances in whole-brain structural topologic organization in subjects with BDD. [33] The authors also found evidence of abnormal connectivity between regions involved in lower-order visual processing and those involved in higher-order visual and emotional processing, as well as interhemispheric visual information transfer, which may relate to abnormalities in information processing.

A study investigating the potential role of early-life sexual, physical, or emotional abuse in the development of BDD found that subjects with BDD had more retrospective experiences of sexual and physical abuse during childhood or adolescence than healthy control subjects did. [34] Such findings suggest that abuse might be a potential risk factor in the development of BDD.

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Epidemiology

United States statistics

Because of frequent comorbidity with other conditions, the diagnosis of BDD is often overlooked. BDD is estimated to affect 1-2% of the general US population. [35, 36] Given that the condition is underdiagnosed, this may be an underestimate. Patients underreport to their physicians because of intense shame. The prevalence of BDD appears to be significantly higher among people receiving dermatologic care—as high as 11.9% in one study. [37]

The prevalence of BDD in patients undergoing plastic or cosmetic surgery ranges from 7% to 15%. [16] Patients who undergo cosmetic surgery do not seem to have increased incidence of generalized body dissatisfaction; however, when surveyed about specific body parts, they have a much higher incidence of specific body part dissatisfaction. [38]

International statistics

The international incidence and prevalence of BDD have not been determined with any precision or accuracy.

BDD is a relatively common disorder among individuals seeking aesthetic surgery in Iran, being seen in about a quarter of those seeking rhinoplasty. [39] In São Paulo, Brazil, the prevalence of BDD in dermatologic patients was evaluated in a sample of 150 patients in a cosmetic group, 150 patients in a general dermatology group, and 50 control subjects; the prevalence in the cosmetic group was 14%, compared with 6.7% for the general group and 2% for the control group. [40]

Age-related demographics

The onset of BDD typically occurs in adolescence or young adulthood (average age of onset, 16-17 years [41] ). The condition may also occur in older adults who are overly concerned with their aging appearance. The course of BDD is usually continuous over time, with waxing and waning symptoms. For many patients, BDD becomes chronic. The body part that is the focus of concern may remain the same or may change over time.

Sex-related demographics

BDD affects men and women with nearly equal frequency; female-to male ratios are in the range of 1:1 to 3:2. [42] In terms of most clinical features, male and female BDD patients appear to be more similar than different, [8] though males and females tend to focus on different types of perceived defects. [43, 11]

Women more often have comorbid anxiety and panic disorder and are obsessed with legs and breasts; they are also more likely to have a comorbid eating disorder. Men, particularly those who engage in weightlifting or body building, are more likely to become preoccupied with their muscle size (so-called muscle dysmorphia). [44] Men are also more likely to have genital preoccupations, to have a diagnosis of substance abuse (50% of cases), and to be single.

Race-related demographics

No data are available on the relationship between BDD and race. However, cultural values and preferences may influence symptom content to some degree. Taijin kyofusho, a syndrome included in the traditional Japanese diagnostic system, has a subtype resembling BDD. [8]

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Prognosis

BDD results in significant suffering, occupational dysfunction, or social malaise. Many patients affected by BDD have comorbid conditions such as OCD, major depression, delusions, or social phobia.

If fully and appropriately treated with both pharmacotherapy and psychotherapy, BDD generally has a good prognosis. A small prospective study of the course of BDD found the probability of full recovery to be relatively high (0.76) and the probability of recurrence after remission to be low (0.14 over 8 years). [45] The presence of a delusional intensity of belief or comorbid conditions may necessitate more extensive and intensive therapy and follow-up.

Of those with a primary diagnosis of BDD, 30% also meet the criteria for OCD. The 2 conditions have many features in common, including repetitive thoughts concerning a perceived defect and activities centered on concealing or confirming the perceived deformity that consume most of the patient’s time. Compared with OCD, BDD has much higher rates of poor insight, ideas of reference, overvalued ideas, and delusions.

Major depression is a common comorbidity, occurring in some 60% of patients with BDD; these patients also are at increased risk for suicide. [46, 47] Suicidal ideation attributed primarily to BDD is reported in 45-70% of those with BDD, and past suicide attempts are reported in 22-24%. [13] Preliminary data from a pilot study suggest that the annual rate of completed suicide in BDD may be unexpectedly high (at 0.3%). [13]

Individuals with BDD have variable degrees of awareness concerning the psychiatric nature of the illness. Many continue to agonize about an imagined defect even when they are cognizant that their concerns are excessive. Other people with BDD are regarded as delusional and have no insight into their unusual behavioral tendencies.

In many cases, individuals with BDD experience drastic social and occupational dysfunctions that may progress to the point of social isolation. Psychosocial functioning tends to remain poor over time, with few attaining functional remission. [48, 49]

In one study, BDD was evident in almost 50% of subjects with an eating disorder. [50] Accordingly, efforts should be made to recognize BDD in patients with eating disorders, especially because the presence of this disorder will affect treatment.

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Patient Education

In both cognitive-behavioral psychotherapy and behavioral modification, patient education is an important component of care; education of family members is also valuable. For patient education resources, see the Depression Center, as well as Anorexia Nervosa and Depression.

A helpful online resource for patients is BDD Central. Helpful online resources for family education include the following:

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