Body Dysmorphic Disorder

What is Body Dysmorphic Disorder? 

Body Dysmorphic Disorder (BDD) is a complex mental health condition, classified within the obsessive-compulsive and related disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM). BDD differs from typical appearance concerns and body dissatisfaction as it is characterized by excessive appearance-related preoccupations, repetitive compensatory behaviours and causes clinically significant distress or impairment in functioning for the person experiencing BDD (1). Studies estimate that the prevalence of BDD is between 1.7%–2.9% of the population (1, 2).  

People experiencing BDD can become so fixated on their perceived flaws that they feel defined by them and many report feelings of shame, self-disgust, hopelessness and embarrassment. People experiencing BDD may also fear rejection or humiliation. These time-consuming thoughts and feelings can interfere with a person’s quality of life, often resulting in feelings of distress, depression or low mood. People can live with BDD for many years before seeking assistance, with high rates of underdiagnosis and undertreatment (3). This is mainly due to feelings of shame or fear of stigma that prevents help seeking, lack of awareness of living with a mental health disorder or lack of awareness that BDD is a treatable condition (3).  

Characteristics 

DSM diagnostic criteria includes: 

Preoccupation with one or more perceived defects or a markedly excessive concern where there is a slight physical anomaly.

Common areas of concern for people with BDD include: 

• skin 
• face, including the size or shape of the eyes, nose, ears and lips 
• size or shape of virtually any body part, including buttocks, thighs, abdomen, legs, breasts and genitals 
• symmetry of particular body parts. 

However, any body part or perceived appearance defect can be of concern in BDD. Some people may be concerned with the overall size and shape of their body, for instance in the muscle dysmorphia form of BDD. While some preoccupations are specific in nature, others are vague or relate more to a general perception of unattractiveness or deformity. The nature, focus and number of preoccupations can change over time.  
 
Repetitive behaviours or mental acts performed in response to appearance concerns.

These behaviours are often attempts to correct or hide perceived defects. They are typically time-consuming and difficult to resist or control.

Such behaviours may include: 

• camouflaging flaws by covering them with clothes or makeup 
• spending large amounts of time examining one’s appearance in reflective surfaces or avoiding these surfaces completely 
• time-consuming grooming routines 
• frequently seeking reassurance from others 
• comparing one’s appearance to others 
• skin picking 

Clinically significant distress or impairment in daily life activities as a result of intense preoccupation with physical appearance.

Impairment can range from moderate (e.g., avoiding some social situations) to extreme and incapacitating (e.g., being unable to leave the home). 
 
The appearance preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder. 
 
Specifiers: 

• People with BDD may have varied degrees of insight about their BDD beliefs. Insight regarding these beliefs can range from ‘absent’ (i.e., the person is completely convinced that the BDD beliefs are true) to ‘good’ (i.e., the person recognizes that the BDD beliefs are not true). However, people with BDD often experience delusions of reference, believing that the people around them notice their ‘defect’ and view them negatively because of it.   
• Muscle dysmorphia is a subtype of BDD, in which a person experiences a preoccupation with their body build, believing it is too small or insufficiently muscular. As a result, people with muscle dysmorphia may spend an excessive amount of time exercising and/or using supplements and/or taking performance-enhancing drugs. 

Other considerations  

Several mental health conditions  frequently co-occur with BDD, including depressive disorders, anxiety disorders, obsessive-compulsive disorder, and substance misuse disorders (1). 

Eating disorders can also co-occur with BDD, in which case both disorders should be diagnosed. For a person with an eating disorder, concerns about weight or body shape are considered a symptom of the eating disorder rather than BDD. However, weight concerns may occur in BDD. 

Warning signs 

The following behaviors, thoughts and feelings may be warning signs for BDD (2): 

• Frequently looking at or checking the perceived ‘defect’ in reflective surfaces  
• Avoiding reflective surfaces  
• Trying to camouflage or hide body parts 
• Engaging in excessive amounts of exercise 
• Spending excessive time on grooming 
• Frequently comparing their body/body part to others 
• Frequently or often seeking reassurance about appearance 
• Not believing people when they provide reassurance  
• Avoiding social activities or feeling anxious around other people  
• Not leaving the home/bedroom  
• Seeing many healthcare professionals for assistance with concerns about appearance 
• Seeking cosmetic surgeries to alter appearance 
• Purchasing large amounts of cosmetic products  
• Picking at skin with fingers or tweezers 
• Feeling anxious, depressed, ashamed or suicidal  

Impacts and complications  

BDD is associated with marked impairment in psychosocial functioning, notably poor quality of life, and high suicidality rates (1, 2).  

As a consequence of the preoccupation and the associated distress, there is almost always significant impact on the person and impairment in one or more areas of social, occupational, academic, and role functioning. People experiencing BDD may avoid social activities and intimate relationships and may stop attending education or work (4). At its worst, BDD may stop people from leaving their home or bedroom entirely.  As a result, social anxiety, isolation, depression and suicidality are very common in BDD.  Therefore, it is important to recognize and appropriately treat BDD as soon as possible. 

Causes and risk factors  

BDD usually begins in adolescence, though it can affect anyone at any age. It affects men and women equally (1). The exact cause of BDD is unknown, and will differ from person to person, but is likely a result of multiple interactions between genetics, psychological and environmental factors (1).  

These may include: 

• A family history of BDD or a similar mental health disorder
• Levels of certain brain chemicals 
• Factors linked to personality
• Life experiences e.g., childhood trauma or bullying  

There is currently limited research into the experiences of diverse populations and BDD, however it is important to note that BDD can affect people of all ages, genders and cultures.  

Treatment options  

Access to evidence-based treatment has been shown to reduce the severity, duration and impact of BDD (1). Treatment for BDD may include therapy and/or medication. Cognitive behavioural therapy (CBT) in combination with selective serotonin reuptake inhibitors (SSRIs) have been shown to be effective for BDD (2, 5). 

It is never advised to ‘watch and wait’. If you or someone you know may have BDD, accessing support and treatment is important. Early intervention is key to improved health and quality of life outcomes.

Recovery

It is possible to recover from BDD, even if a person has been living with the illness for many years. The path to recovery can be long and challenging, however, with the right team and support, recovery is possible. Some people may find that the recovery journey brings new understanding, insights and skills.

Getting help 

If you suspect that you or someone you know may have BDD, it is important to seek help immediately. A GP is a good ‘first base’ to seek support and access treatment.

To find help in your local area go to NEDC Service Locator. 

Find information about helplines via our Get Help page.

 Download the Body Dysmorphic Disorder fact sheet here. 

References

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed, text vision. 2022. 

2. Bjornsson A, Didie E, Phillips K. Body dysmorphic disorder. Dialogues in Clinical Neuroscience. 2010;12(2):221-232. 

3. Schulte J., Schulz C., Wilhelm S., & Buhlmann U. Treatment utilization and treatment barriers in individuals with body dysmorphic disorder. 2BMC psychiatry. 2020; 20(1), 69. 

4. Rief Winfried, Buhlmann Ulrike, Wilhelm Sabine, Borkenhagen Ada, Brähler Elmar. The prevalence of body dysmorphic disorder: a population-based survey. Psychological Medicine. Cambridge University Press; 2006;36(6):877–85.  

5. Veale D, Singh A. Understanding and treating body dysmorphic disorder. Indian Journal of Psychiatry. 2019;61(7):131.