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Body Dysmorphic Disorder

by Katharine A. Phillips, MD, Dan J. Stein, MD, PhD

In body dysmorphic disorder, a preoccupation with one or more nonexistent or slight defects in appearance results in significant distress or impairs functioning.

  • People typically spend hours a day worrying about their perceived defects, which may involve any body part.

  • Doctors diagnose the disorder when concerns about appearance cause significant distress or interfere with functioning.

  • Certain antidepressants (serotonin reuptake inhibitors or clomipramine) and cognitive-behavioral therapy often help.

People with body dysmorphic disorder believe they have a flaw or defect in their physical appearance that in reality is nonexistent or slight. They repeatedly do certain things (such as checking themselves in a mirror, excessively grooming themselves, or comparing themselves with others) because they are so concerned about their appearance.

The disorder usually begins during adolescence and may be somewhat more common among women. About 2% of people have the disorder.

Symptoms

Symptoms may develop gradually or abruptly, vary in intensity, and tend to persist unless appropriately treated. Concerns commonly involve the face or head but may involve any body part or several parts and may change from one body part to another. For example, people may be concerned about hair thinning, acne, wrinkles, scars, color of complexion, or excessive facial or body hair. Or people may focus on the shape or size of a body part, such as the nose, eyes, ears, mouth, breasts, legs, or buttocks. Some men with normal or even athletic builds think that they are puny and obsessively try to gain weight and muscle—a condition called muscle dysmorphia. People may describe the disliked body parts as being ugly, unattractive, deformed, hideous, or monstrous. Most people with body dysmorphic disorder are not aware that they actually look normal.

Most people with body dysmorphic disorder have difficulty controlling their preoccupations and spend hours each day worrying about their perceived defects. They may think that other people are staring at them or mocking them because of their perceived defects in their appearance. Most people check themselves often in mirrors, others avoid mirrors, and still others alternate between the two behaviors.

Many people compulsively and excessively groom themselves, pick at their skin (to remove or fix perceived defects), and seek reassurance about the perceived defects. They may frequently change their clothes to try to hide or camouflage their nonexistent or slight defect or try to improve their appearance in other ways. For example, people may grow a beard to hide perceived scars or wear a hat to cover slightly thinning hair. Many have cosmetic medical (most often, dermatologic), dental, or surgical treatment, sometimes repeatedly, to correct their perceived defect. Such treatment is usually unsuccessful and may intensify their preoccupation. Men with muscle dysmorphia may take anabolic steroids (such as testosterone), which may be dangerous.

Did You Know...

  • People may be so concerned about a nonexistent or slight defect in their appearance that they avoid going out in public.

Because people with body dysmorphic disorder feel self-conscious about their appearance, they may avoid going out in public, including going to work, school, and social events. Some with severe symptoms leave their homes only at night, and others not at all. This behavior often results in social isolation. Distress and dysfunction caused by the disorder can lead to depression, repeated hospitalization, and suicidal behavior.

Diagnosis

Body dysmorphic disorder may go undiagnosed for years because people are too embarrassed and ashamed to reveal their symptoms or because they genuinely believe they are ugly. It is distinguished from normal concerns about appearance or vanity because the preoccupations are time-consuming and cause significant distress or impair functioning.

Treatment

Treatment with certain antidepressants—specifically serotonin reuptake inhibitors (see Table: Drugs Used to Treat Depression) or clomipramine (a tricyclic antidepressant)—is often effective.

Cognitive-behavioral therapy that specifically focuses on this disorder may also lessen symptoms. For this therapy, practitioners help people develop more accurate and helpful beliefs about their appearance. Practitioners also help people to stop engaging in their typical repetitive behaviors, such as checking themselves in a mirror and picking at their skin.

Because many people with this disorder do not recognize that they have a problem, doctors may need to use motivational techniques to help people participate in treatment.

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Drugs Mentioned In This Article

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  • ANAFRANIL
  • DELATESTRYL