Body Dysmorphic Disorder (BDD)

Symptoms of body dysmorphic disorder may develop gradually or abruptly. Although intensity may vary, the disorder is thought usually to be chronic unless patients are appropriately treated.

Concerns commonly involve the face or head but may involve any body part or parts and may change from one part to another over time. For example, patients may be concerned about perceived thinning hair, acne, wrinkles, scars, vascular markings, color of their complexion, or excessive facial or body hair. Or they may focus on the shape or size of the nose, eyes, ears, mouth, breasts, buttocks, legs, or other body part. Men (and rarely women) may have a form of the disorder called muscle dysmorphia, which involves preoccupation with the idea that their body is not sufficiently lean and muscular. Patients may describe the disliked body parts as looking ugly, unattractive, deformed, hideous, or monstrous (1).

Patients usually spend many hours a day worrying about their perceived defects and often mistakenly believe that people take special notice of them or mock them because of these perceived defects. Most check themselves often in mirrors, others avoid mirrors, and still others alternate between the 2 behaviors.

Other common repetitive (compulsive) behaviors include comparing their appearance with that of other people, excessive grooming, skin picking (to remove or fix perceived skin defects), hair pulling or plucking, reassurance seeking (about the perceived defects), and clothes changing (1). Most try to camouflage their perceived defects—eg, by growing a beard to hide perceived scars or by wearing a hat to cover slightly thinning hair (1). Many undergo dermatologic, dental, surgical, or other cosmetic treatment to correct their perceived defects, but such treatment is usually unsuccessful and may intensify their preoccupation. Men with muscle dysmorphia may use anabolic-androgenic steroids and various medications and supplements to build muscle and/or lose fat, a potentially dangerous practice.

Because people with body dysmorphic disorder feel self-conscious about their appearance, they may avoid going out in public. For most, social, occupational, academic, and other aspects of functioning are impaired—often substantially—because of their concerns about their physical appearance (1). Some leave their homes only at night; others, not at all. Social isolation, depression, psychiatric hospitalization, and suicidal behavior are common. In very severe cases, body dysmorphic disorder is incapacitating.

The degree of insight individuals have about their perceptions of their appearance varies, but it is usually poor or absent (1). That is, most patients genuinely believe that the disliked body part(s) probably (poor insight) or definitely (absent insight, or delusional beliefs) looks abnormal, ugly, or unattractive.

Body dysmorphic disorder is characterized by significantly higher levels of suicidality than many other psychiatric disorders (1–3). Over their lifetime, approximately 80% of people with body dysmorphic disorder experience suicidal ideation, and about one-third attempt suicide (see Suicidal Behavior) (4).

• Psychiatric assessment

Diagnosis of body dysmorphic disorder is based on history. Clinical criteria for diagnosis of BDD from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, Text Revision (DSM-5-TR) include the following (1):

• Preoccupation with at least 1 self-perceived defect in appearance that appears nonexistent or only slight to others

• Repetitive behaviors (eg, checking one's appearance in the mirror) in response to the concerns

• Significant distress and/or impairment of functioning

The preoccupation with appearance must not be due to a feeding/eating disorder. If the only concern is excessive weight or a belief that parts of one's body are too fat, and if eating behavior is abnormal, anorexia nervosa or bulimia nervosa may be the more accurate diagnosis. If the only concern is the appearance of physical sex characteristics and there is a marked incongruence between one's experienced/expressed gender and assigned gender, a diagnosis of gender dysphoria should be considered.

Because many patients are too embarrassed and ashamed to reveal their symptoms, body dysmorphic disorder may go undiagnosed for years. It is distinguished from normal concerns about appearance because the preoccupations are time-consuming and cause significant distress, significant impairment in functioning, or both.

The diagnosis of BDD may also include a specifier of the patient's level of insight (good or fair, poor, or absent/delusional beliefs), which is poor or absent in most patients (1). Muscle dysmorphia is specified if the preoccupation is of insufficient musculature or body build.

Other terms such as body dysmorphia, Zoom dysmorphia, skin dysmorphia, acne dysmorphia, penile dysmorphia, and smile dysmorphia do not have agreed-upon definitions, nor are they diagnoses in DSM-5-TR or ICD-11. It is also often unclear whether they refer to BDD or, instead, to normative body image dissatisfaction (2).

• Selective serotonin reuptake inhibitors (SSRIs) or clomipramine plus, in some cases, an augmenting medicationSelective serotonin reuptake inhibitors (SSRIs) or clomipramine plus, in some cases, an augmenting medication

• Cognitive-behavioral therapy

SSRIs or clomipramine (a tricyclic antidepressant with potent serotonergic effects) are often very effective in patients with body dysmorphic disorder (or clomipramine (a tricyclic antidepressant with potent serotonergic effects) are often very effective in patients with body dysmorphic disorder (1). An SSRI is typically preferred over clomipramine as initial pharmacologic therapy. Patients often require higher doses than are typically needed for depression and most anxiety disorders. Although data are limited, some patients who do not substantially improve with adequate trials of these medications may benefit from addition of augmenting medication such as an atypical neuroleptic (eg, aripiprazole), buspirone, or a glutamate modulator (eg, ). An SSRI is typically preferred over clomipramine as initial pharmacologic therapy. Patients often require higher doses than are typically needed for depression and most anxiety disorders. Although data are limited, some patients who do not substantially improve with adequate trials of these medications may benefit from addition of augmenting medication such as an atypical neuroleptic (eg, aripiprazole), buspirone, or a glutamate modulator (eg,N-acetylcysteine or memantine).-acetylcysteine or memantine).

Cognitive-behavioral therapy that is tailored to the specific symptoms of body dysmorphic disorder is the psychotherapy of choice (2). Cognitive approaches (eg, cognitive restructuring) and exposure and ritual prevention are essential elements of therapy. Clinicians encourage patients to gradually face situations they fear or avoid (which are usually social situations) while refraining from performing their rituals, such as mirror checking, excessive grooming, and comparing their appearance with that of other people.

Cognitive-behavioral therapy also includes other elements such as perceptual retraining and habit reversal training for skin picking (excoriation) or hair-pulling or plucking if present. Habit reversal training includes the following:

• Awareness training (eg, self-monitoring, identification of triggers for the behavior)

• Stimulus control (modifying situations—eg, avoiding triggers—to reduce the likelihood of initiating the behavior)

• Competing response training (teaching patients to substitute other behaviors—such as clenching their fist, knitting, or sitting on their hands—for the excessive behavior)

Because most patients have poor or absent insight, motivational techniques are often needed to increase their willingness to participate and stay in treatment.

Combining cognitive-behavioral therapy with medications is the approach typically used for severe cases.

Cosmetic treatment is not recommended (3). It is almost always ineffective, and clinicians who provide such treatment may be at risk of legal or physical threats or behaviors by dissatisfied patients.