Body Dysmorphic Disorder

Katharine A. Phillips, M.D.

Basic Information

Definition

Body dysmorphic disorder (BDD) is classified as an obsessive-compulsive and related disorder. It is characterized by preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear only slight to others, as well as repetitive behaviors (e.g., excessive grooming, mirror checking) in response to the appearance concerns. The preoccupations cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (usually both). The appearance preoccupations are not better explained by concerns with body fat or weight in a person whose symptoms meet diagnostic criteria for an eating disorder.

Synonyms

Dysmorphophobia
BDD

ICD-10CM CODES
F45.22	Body dysmorphic disorder
DSM-5 CODES
300.50

Epidemiology & Demographics

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Affects 1.7% to 2.9% of the general population (in nationwide epidemiologic studies)
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Weighted prevalence among general cosmetic surgery patients is 13.2%
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Weighted prevalence in rhinoplasty surgery settings is 20.1%
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Weighted prevalence among dermatology outpatients is 11.3%
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Slightly higher prevalence among females (but not in cosmetic surgery or dermatology settings)
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Onset most commonly in early adolescence

Physical Findings & Clinical Presentation

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Excessive preoccupation (obsession) with one or more perceived defects in appearance that are not observable or appear only slight to others. Patients believe they look abnormal, ugly, unattractive, or deformed, whereas in reality they look normal. Any part of the body may be a focus of concern; skin, hair, and nose concerns are most common. Muscle dysmorphia is a form of BDD that occurs primarily in men and focuses on excessive concern that one’s body build is too small or is insufficiently muscular. Most patients are preoccupied with multiple body areas.
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The body areas with which the patient is concerned appear physically normal; if a physical defect is present, it is slight, and the patient’s reaction to it is excessive.
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Most patients have poor insight (i.e., are mostly convinced) or absent insight (i.e., delusional beliefs; are completely convinced) regarding the accuracy of their beliefs about the appearance of the perceived defects.
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Over the course of the disorder, all patients engage in repetitive behaviors such as frequent mirror checking, excessive grooming, skin picking to try to fix perceived skin flaws, reassurance seeking, and repeatedly measuring or feeling the perceived defect. The intent of these behaviors is to check, try to improve, or gain reassurance about the appearance of the perceived flaws. Nearly all patients attempt to camouflage or hide the perceived defects—e.g., with makeup, a hat, hair, or body position.
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Nearly all experience impairment in psychosocial functioning and quality of life; impairment is usually substantial.
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Suicidal ideation, suicide attempts, and completed suicide appear common.
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Commonly co-occurring mental disorders are major depressive disorder, substance use disorders (including abuse of anabolic androgenic steroids in muscle dysmorphia), social anxiety disorder, obsessive-compulsive disorder (OCD), and personality disorder.

Etiology

Likely multifactorial, with both genetic and environmental risk factors (e.g., teasing). Neuropsychological and fMRI studies indicate abnormalities in visual processing consisting of excessive focus on details rather than on larger global and configural elements of visual stimuli. Information processing deficits and biases also characterize BDD, which may also play a role in the disorder’s development and/or maintenance.

Diagnosis

Psychiatric interview

Ask:

1.

Are you very worried about your appearance in any way? OR: Are you unhappy with how you look?
2.

Does this concern with your appearance preoccupy you? If you add up all the time you spend each day thinking about your appearance, how much time would you estimate it takes (at least an hour a day)?
3.

How much distress does this concern cause you?
4.

What effect does this concern have on your life?
5.
Is there anything you feel an urge to do over and over again in response to your appearance concerns? (Give examples, such as mirror checking, comparing with others, skin picking to remove perceived skin flaws)
1. 6.
  
  Determine that the perceived appearance defects are actually nonexistent or only slight

Differential Diagnosis

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Often undiagnosed because of patient’s reluctance to divulge symptoms due to shame and fear of being misunderstood (e.g., considered vain)
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OCD
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Eating disorder
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Social anxiety disorder
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Major depressive disorder

Workup

Clinical evaluation focused on BDD symptoms and associated impairment in functioning.

Treatment

Nonpharmacologic Therapy

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CBT, with a focus on cognitive restructuring, exposure, perceptual retraining, and response prevention; CBT must be specifically tailored to BDD’s unique symptoms.
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Do not try to talk patients out of their concern; it is ineffective.
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Avoid cosmetic procedures; a majority of patients with BDD receive them, but such treatments do not appear effective for BDD. Dissatisfied patients may sue or even become violent toward the treating clinician.

Chronic Rx

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SRIs are medication of choice; high doses often needed.
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Other agents (e.g., neuroleptics, tricyclic antidepressants other than clomipramine) do not appear as beneficial, although limited evidence suggests that atypical neuroleptics and buspirone may be helpful as SRI augmentation agents.
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CBT tailored specifically to BDD is recommended, with an SRI if BDD symptoms are moderate to severe, the patient is suicidal because of BDD symptoms, or comorbidity is present that may benefit from an SRI.
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Support groups if available.
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More intensive BDD-focused treatment (e.g., intensive outpatient, residential treatment) if outpatient care is insufficient.

Disposition

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Untreated BDD tends to be chronic and can lead to social isolation; school dropout; loss of employment; major depression; unnecessary surgery, dermatologic treatment, or other cosmetic treatment; and even suicide.
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With correct diagnosis and treatment, a majority improve.

Pearls & Considerations

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In clinical settings, approximately three quarters have lifetime co-occurring major depressive disorder.
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Reassurance that the patient looks normal is rarely helpful.
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Patients often have an unrealistic expectation of improvement with plastic surgery, dermatologic treatment, and other cosmetic procedures; these treatments do not appear to be effective.
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All patients should be screened and monitored for suicidality.

Patient/Family Education

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Family support and encouragement of appropriate treatment is important.
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Phillips KA: Understanding Body Dysmorphic Disorder: An Essential Guide. Oxford University Press, 2009.
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www.KatharinePhillipsMD.com
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https://bdd.iocdf.org/

Ferri – Body Dysmorphic Disorder