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Body Dysmorphic Disorder

By

Katharine A. Phillips

, MD, Weill Cornell Medical College;


Dan J. Stein

, MD, PhD, University of Cape Town

Last full review/revision Jun 2021| Content last modified Jun 2021
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In body dysmorphic disorder, a preoccupation with one or more nonexistent or slight defects in appearance results in significant distress and/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 (selective serotonin reuptake inhibitors or clomipramine) and cognitive-behavioral therapy often help.

People with body dysmorphic disorder believe they have one or more flaws or defects in their physical appearance that in reality are 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 perceived appearance flaws.

Body dysmorphic disorder usually begins during adolescence and may be somewhat more common among women. About 2% to 3% of people have the disorder.

Symptoms

Symptoms of body dysmorphic disorder 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 of the body and may change from one body part to another. For example, people may be concerned about perceived 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 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 skin 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. Most 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 home only at night, and others not at all. Thus this disorder often results in social isolation. In very severe cases, body dysmorphic disorder is incapacitating. Distress and dysfunction caused by the disorder can lead to depression, drug or alcohol problems, repeated hospitalization, suicidal behavior, and suicide.

Over their lifetime, about 80% of people with body dysmorphic disorder experience suicidal ideation, and one quarter to nearly 30% attempt suicide.

Many people with body dysmorphic disorder also have other mental health disorders, such as major depressive disorder, a substance use disorder, social anxiety disorder, or obsessive-compulsive disorder.

Diagnosis

  • A doctor's evaluation, based on specific diagnostic criteria

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 significantly impair functioning.

Doctors diagnose body dysmorphic disorder when people do the following:

  • Are preoccupied with one or more flaws in their appearance that other people think are insignificant or do not see

  • Repeatedly perform excessive behaviors (such as checking themselves in a mirror, grooming themselves excessively, or comparing themselves to others) because they are so concerned about their appearance

  • Feel very distressed or become less able to function normally (for example, at work, in their family, or with friends) because they are so concerned about the perceived flaws in their appearance

If people's only concern is body shape and weight and their eating behavior is abnormal, an eating disorder may be the more accurate diagnosis; if their only concern is the appearance of their physical sex characteristics or other physical characteristics that reflect their sex at birth, a diagnosis of gender dysphoria may be considered.

Treatment

  • Certain antidepressants

  • Cognitive-behavioral therapy

Treatment with certain antidepressants—specifically selective serotonin reuptake inhibitors or clomipramine (a tricyclic antidepressant)—is often effective in people with body dysmorphic disorder. High doses are often needed.

Cognitive-behavioral therapy that specifically focuses on the symptoms of body dysmorphic disorder may also be effective. For this therapy, practitioners help people develop more accurate and helpful beliefs about their appearance. Practitioners also help people to stop engaging in their excessive repetitive behaviors, such as checking themselves in a mirror and picking at their skin. They also help people participate in and feel more comfortable in social situations.

Habit reversal therapy is used to lessen the repetitive skin picking or hair plucking that people with body dysmorphic disorder may do in an attempt to minimize or remove perceived defects in the skin (such as blemishes) or hair (such as excess facial hair).

Because many people with this disorder do not recognize that they have a body image problem, rather than an actual appearance problem, doctors may need to use motivational techniques to help people participate in these treatments.

Many experts believe that combining drug therapy and cognitive-behavioral therapy is best for severe cases.

More Information

The following is an English-language resource that may be useful. Please note that THE MANUAL is not responsible for the content of this resource.

Drugs Mentioned In This Article

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DELATESTRYL
ANAFRANIL
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