What is Body Dysmorphic Disorder?

Body Dysmorphic Disorder
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 Body Dysmorphic Disorder is a psychiatric disorder, which involves a preoccupation with one or more perceived defects or flaws in one’s appearance.

Classified among the “Obsessive Compulsive and Related Disorders” in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), Body Dysmorphic Disorder (BDD) affects approximately 2.4% of adults in the United States.

The DSM-5 diagnostic criteria include:

  • Preoccupation with one or more perceived defects or flaws in physical appearance that are not apparent or are minimally apparent to others
  • During the course of the disorder, the performance of repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (e.g., comparing one’s own appearance with that of others) in response to the appearance concerns
  • Preoccupation causes clinically significant distress or impairment in social, occupational, or other area of functioning
  • Not better accounted for by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder
    • The disorder may include:
      • Muscle dysmorphia – preoccupation with the idea that his or her body build is too small or insufficiently muscular

Areas of preoccupation vary greatly, with the most common areas being the face and skin (e.g., acne, scars, symmetry, wrinkles, pallor), hair (e.g., thinning, excessive body hair), or nose.

Preoccupation is typically characterized by unwanted, intrusive thoughts or images regarding the body area as distressing. The preoccupation is often dominated by the belief that the body area is ugly, abnormal, deformed, or disfigured in some way and is often consuming to the individual, dominating their thoughts.

 This creates a high level of distress. Co-occurring psychopathology is very common.

Repetitive behaviors are common in BDD, performed compulsively in an attempt to decrease the individual’s distress.  Common compulsions include camouflaging areas of concern, comparing one’s features to that of others’, mirror checking, reassurance seeking, skin picking, exercising, seeking cosmetic/medical/surgical consultation, and avoidance. Although these behaviors are intended to hide, correct, check, or seek reassurance about the area of concern, they often result in further distress and reinforcement of the problematic cycle of symptoms.

The preoccupation with appearance and compulsive behaviors interfere with the individual’s daily functioning and cause very significant distress.

The onset of BDD is typical during early adolescence and its course is chronic. Both males and females are affected by BDD, with some variation in symptomatology; Males are more likely to present with muscle dysmorphia and genitalia preoccupation, while females are more vulnerable to co-occurring eating disorders.

BDD is often severe in nature, and is associated with markedly high rates of psychiatric hospitalizations and suicidality, both attempted and completed suicides.

Insight into the inaccuracy of the individual’s perception of the body area is often poor, and the individual is often convinced of their perceptions, despite any feedback to the contrary.

There are numerous factors that may contribute to the cause and maintenance of BDD.  Genetics likely play a role in the disorder, with first-degree relatives more likely to have BDD or related disorder. Environmental factors, such as culture, early life experiences, and personal history of abuse or neglect may also play a role as well as neuroanatomy and neurochemistry. 

Evidence-based treatments for BDD include pharmacotherapy and psychotherapy. Pharmacological treatment shown to decrease obsessional thought processes, repetitive behaviors, and often associated anxiety and depression include serotonin reuptake inhibitors (i.e., SRIs, SSRIs).  Empirically-supported psychotherapy includes a BDD-specific cognitive behavioral therapy (CBT) which targets the distorted beliefs and perceptions as well as the repetitive behaviors. CBT aims to challenge the individual’s unhelpful thoughts regarding his or her appearance and develop cognitive flexibility and non-judgmental self-acceptance. An exposure therapy process is used to challenge the individual to gradually learn to more adaptively respond to distressing symptom triggers and decrease avoidance behaviors.

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American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. 5thed. Washington, DC: American Psychiatric Association; 2013:251-4.

Wilhelm, S, Phillips, K., Steketee, G.  Cognitive Behavioral Therapy for Body Dysmorphic Disorder. Guilford Press: 2012.

Wilhelm S, Buhlmann U, Cook L, Greenberg JL, Dimaite RA. A cognitive–behavioral treatment approach for body dysmorphic disorder. Cognitive and Behavioral Practice. 2010;17(3):241–247.

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