Body dysmorphic disorder (BDD) is defined by the American Psychiatric Association in its Diagnostic and Statistical Manual of Mental Disorders(DSM) as a condition marked by excessive preoccupation with an imaginary or minor defect in a facial feature or localized part of the body. The diagnostic criteria specify that the condition must be sufficiently severe to cause a decline in the patient’s social, occupational, or educational functioning. The most common cause of this decline is the time lost to obsessing about the “defect.” Changes in the fifth edition of the DSM (DSM-5, 2013) include moving BDD to the category of obsessive-compulsive and related disorders. Previously, BDD was classified as a somatoform disorder—disorders characterized by physical complaints that appear to be medical in origin but that cannot be explained in terms of a physical disease, the results of substance abuse, or by another mental disorder.
Although cases of BDD have been reported in the psychiatric literature from a number of different countries for over a century, the disorder was first defined as a formal diagnostic category by the DSM-III-R in 1987. The word dysmorphic comes from two Greek words: dys, which means “bad” or “ugly,” and morphos, which means “shape” or “form.” BDD was previously known as dysmorphophobia.
BDD is thought to affect 1%–2% of the population in the United States and Canada, although some doctors think that it is underdiagnosed because it coexists so often with depression and other disorders. In addition, individuals are often ashamed of grooming rituals and other behaviors associated with BDD and may avoid telling their doctor about them.
The usual age of onset of BDD is late childhood or early adolescence; the average age of individuals diagnosed with the disorder is 17, although the disorder may develop in older individuals who become preoccupied with the physical effects of aging. The disorder affects men and women equally, but there are no reliable data regarding racial or ethnic differences in the incidence of the disorder. BDD has a high rate of comorbidity, which means that people diagnosed with the disorder are likely to be diagnosed with another psychiatric disorder, most commonly major depression, social phobia, or obsessive-compulsive disorder (OCD). About half of all men (but not women) diagnosed with BDD also have a substance abuse disorder. About 29% of individuals with BDD eventually try to commit suicide.
BDD is characterized by an unusually exaggerated degree of worry or concern about a specific part of the face or body (such as the nose or breasts), rather than the general size or shape of the body. It is distinguished from anorexia nervosa and bulimia nervosa, where patients are preoccupied with their overall weight and body shape. Studies have found that between 40% and 76% of people with BDD seek nonpsychiatric treatments such as cosmetic surgery or dermatological treatments, and the rates of people with BDD among all cosmetic surgery patients range from 7% to 15%; rates are similar in dermatology practices.
Since the first publication of DSM-IV in 1994, some psychiatrists have suggested that a subtype of BDD exists, which they termed muscle dysmorphia. Muscle dysmorphia is marked by excessive concern with one’s muscularity and/or fitness. Persons with muscle dysmorphia spend unusual amounts of time working out in gyms or exercising rather than obsessing about a feature such as the skin or nose. Muscle dysmorphia is more prevalent among males. To accommodate muscle dysmorphia as a classification, the DSM-IV-TR has added references regarding body build and excessive weightlifting to DSM-IV’s description of BDD, and the proposed changes for DSM-5 include muscle dysmorphia as a specifier in the diagnostic criteria for BDD. The muscle dysmorphia version of BDD is associated with higher suicide rates and higher rates of substance abuse.
BDD and muscle dysmorphia can both be described as disorders resulting from the patient’s distorted body image. Body image refers to the mental picture individuals have of their outward appearance, including size, shape, and form. It has two major components: how people perceive their physical appearance and how they feel about their body. Significant distortions in self-perception can lead to intense body dissatisfaction and dysfunctional behaviors aimed at improving appearance. Some patients with BDD are aware that their concerns are excessive; others do not have this degree of insight. About 50% of patients diagnosed with BDD also meet the criteria for a delusional disorder, which is characterized by beliefs that are not based in reality. The DSM-5 revised description of body dysmorphic disorder emphasizes that the individual performs repetitive behaviors such as mirror checking, skin picking, or comparing themselves to others. Learning to control these repetitive behaviors can be crucial to a BDD treatment plan.
Causes and symptoms
The causes of BDD fall into two major categories, neurobiological and psychosocial.
Research indicates that patients diagnosed with BDD have serotonin levels that are lower than normal. Serotonin is a neurotransmitter—a chemical produced by the brain that helps to transmit nerve impulses across the junctions between nerve cells. Low serotonin levels are associated with depression and other mood disorders. However, because these studies are conducted after the person has been diagnosed with BDD, it is not possible to know whether the low serotonin levels cause the BDD or are an effect of the disorder.
A young person’s family of origin has a powerful influence on his or her vulnerability to BDD. Children whose parents are themselves obsessed with appearance, dieting, and/or bodybuilding, or who are highly critical of their children’s looks, are at greater risk of developing BDD.
An additional factor in some young people is a history of childhood trauma or abuse. Buried feelings about the abuse or traumatic incident emerge in the form of obsession about a part of the face or body. This “reassignment” of emotions from the unacknowledged true cause to another issue is called displacement. For example, an adolescent who frequently felt overwhelmed in childhood by physically abusive parents may develop a preoccupation with muscular strength and power.
Another important factor in the development of BDD is the influence of the mass media in developed countries, particularly the role of advertising in spreading images of supposedly physically perfect men and women. Impressionable children and adolescents absorb the message that anything short of physical perfection is unacceptable. They may then develop distorted perceptions of their own faces and bodies.
The central symptom of BDD is excessive concern with a specific facial feature or body part. The parts of the body most frequently involved are the skin, hair, nose, teeth, breasts, eyes, and even eyebrows, but any feature can be a focus of the obsession.
Other symptoms of body dysmorphic disorder include:
- Ritualistic behavior. Ritualistic behavior refers to actions that the patient performs to manage anxiety and that take up excessive amounts of his or her time. Patients are typically upset if someone or something interferes with or interrupts their ritual. In the context of BDD, ritualistic behaviors may include exercise or makeup routines, assuming specific poses or postures in front of a mirror, or skin picking (dermatillomania).
- Camouflaging the “problem” feature or body part with makeup, hats, or clothing. Camouflaging appears to be the single most common symptom among persons with BDD, occurring in 94% of patients.
- Abnormal behavior around mirrors, car bumpers, large windows, or other reflective surfaces. A majority of patients diagnosed with BDD frequently check their appearance in mirrors or spend long periods of time doing so. A minority, however, react in the opposite fashion and avoid mirrors whenever possible.
- Frequently requesting reassurance from others (related to appearance).
- Frequently comparing one’s appearance to others.
- Avoiding activities outside the home, including school and social events.
BDD patients have high rates of self-destructive behavior, including performing surgery on themselves at home (liposuction followed by skin stapling, sawing down teeth, and removing facial scars with sandpaper) and attempted or completed suicide. Many are unable to remain in school, form healthy relationships, or keep steady jobs. In one group of 100 patients diagnosed with BDD, 48% had been hospitalized for psychiatric reasons, and 30% had made at least one suicide attempt.
The loss of functioning resulting from BDD can have serious consequences for the patient’s future. Adolescents with BDD often cut school and may be reluctant to participate in sports, join church- or civic-sponsored youth groups, or hold part-time or summer jobs. One study found that 32% of participants had missed work for at least a week in the previous month because of their BDD, while 32% of those still in school had missed classes for a week. Adults with muscle dysmorphia have been known to turn down job promotions to have more time to work out in their gym or fitness center. The economic consequences of BDD also include overspending on cosmetics, clothing, or plastic surgery.
The diagnosis of BDD in children and adolescents is often made by physicians in family practice, as they are more likely to have developed long-term relationships of trust with the patient. With adults, it is often specialists in dermatology, cosmetic dentistry, or plastic surgery who may suspect that the patient has BDD because of frequent requests for repeated or unnecessary procedures. The diagnosis is made on the basis of the patient’s history together with the physician’s observations of the patient’s overall mood and conversation patterns. People with BDD often come across to others as generally anxious and worried. In addition, the patient’s dress or clothing styles, if attempting to hide the “problem” feature, may suggest a diagnosis of BDD.
Several questionnaires are used for assessing the presence of BDD. Researchers sometimes use a semi-structured interview called the BDD Data Form to collect information about the disorder from patients. This form includes demographic information, information about body areas of concern and the history and course of the illness, and the patient’s history of hospitalization or suicide attempts, if any. Another diagnostic questionnaire frequently used to identify BDD patients is the Structured Clinical Interview for DSM-III-R Disorders, or SCID-II. Other questionnaires used in assessments include the Yale-Brown Obsessive Compulsive Scale Modified for Body Dysmorphic Disorder and the Body Dysmorphic Disorder Examination.
There are no brain imaging studies or laboratory tests used to diagnose BDD. Some studies using brain imaging have identified some characteristics similar to those seen in obsessive-compulsive disorder, although studies are not in complete agreement on whether these findings are diagnostic of BDD.
The standard treatment regimen for body dysmorphic disorder is a combination of medications and psychotherapy. Surgical, dental, or dermatologic treatments have been found ineffective and in some cases may exacerbate symptoms. In one study, cosmetic surgeons reported that 40% of their patients with BDD had made legal or physical threats against them.
The medications most frequently prescribed for patients with BDD are the selective serotonin reuptake inhibitors (SSRIs), most commonly fluoxetine (Prozac) or sertraline (Zoloft). Other SSRIs that have been used with this group of patients include fluvoxamine (Luvox) and paroxetine (Paxil). Only fluoxetine is approved by the FDA for use in children; another SSRI, escitalopram (Lexapro), is approved for use in adolescents aged 12 and up.
The relatively high rate of positive responses to SSRIs among BDD patients led to the hypothesis that the disorder has a neurobiological component related to serotonin levels in the body. An associated finding is that patients with BDD require higher dosages of SSRI medications to be effective than patients who are being treated for depression with these drugs.
According to experts at the Mayo Clinic in Rochester, Minnesota, it is important for BDD patients to continue to take their medications even when they are feeling better, because symptoms may suddenly recur. It is also important to attend psychotherapy sessions consistently.
The most effective approach to psychotherapy with BDD patients is cognitive-behavioral therapy, of which cognitive restructuring is one component. Because the disorder is related to delusions about one’s appearance, cognitive-oriented therapy that challenges inaccurate self-perceptions is more effective than purely supportive approaches. Relaxation techniques also work well with BDD patients when they are combined with cognitive restructuring.
The DSM-IV-TR notes that the disorder “has a fairly continuous course, with few symptom-free intervals, although the intensity of symptoms may wax and wane over time.”
Given the pervasive influence of the mass media in contemporary Western societies, the best preventive strategy involves challenging those afflicted with the disorder and who consequently have unrealistic images of attractive people. Parents, teachers, primary healthcare professionals, and other adults who work with young people can point out and discuss the pitfalls of trying to look “perfect.” In addition, parents or other adults can educate themselves about BDD and its symptoms, and should pay attention to any warning signs in their children’s dress or behavior. They also can modulate their own behaviors of pointing out or highlighting physical “imperfections” in themselves or in their children, because there is a link between parents with such concerns and children with BDD.