Body Dysmorphic Disorder

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 any number of parts and may change from one part to another over time. For example, patients may be concerned about 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.

Patients usually spend many hours a day worrying about their perceived defects and often mistakenly believe that people take special note of 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 compulsive behaviors include comparing their appearance with that of other people, excessive grooming, skin picking Excoriation (Skin-Picking) Disorder Excoriation disorder is characterized by recurrent picking of one's skin resulting in skin lesions. Patients with excoriation disorder repeatedly pick at or scratch their skin; the picking is... read more (to remove or fix perceived skin defects), hair pulling or plucking Trichotillomania Trichotillomania is characterized by recurrent pulling out of one's hair resulting in hair loss. Patients with trichotillomania repeatedly pull or pluck out their hair for noncosmetic reasons... read more , reassurance seeking (about the perceived defects), and clothes changing. 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. 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 androgen supplements, which can be dangerous.

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 appearance. Some leave their homes only at night; others, not at all. Social isolation, depression, hospitalization, and suicidal behavior are common. In very severe cases, body dysmorphic disorder is incapacitating.

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

Over their lifetime, about 80% of people with body dysmorphic disorder experience suicidal ideation, and about one quarter to nearly 30% attempt suicide (see Suicidal Behavior Suicidal Behavior Suicide is death caused by an intentional act of self-harm that is designed to be lethal. Suicidal behavior encompasses a spectrum of behavior from suicide attempt and preparatory behaviors... read more ). Body dysmorphic disorder is characterized by significantly higher levels of suicidality than other psychiatric disorders (1 Signs and symptoms reference Body dysmorphic disorder is characterized by preoccupation with ≥ 1 perceived defects in physical appearance that are not apparent or appear only slight to other people. The preoccupation with... read more ) at high risk of suicide.

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, impairment in functioning, or both.

Diagnosis of body dysmorphic disorder is based on history. If the only concern is body shape and weight and eating behavior is abnormal, an eating disorder Anorexia Nervosa Anorexia nervosa is characterized by a relentless pursuit of thinness, a morbid fear of obesity, a distorted body image, and restriction of intake relative to requirements, leading to a significantly... read more may be the more accurate diagnosis; if the only concern is the appearance of physical sex characteristics, a diagnosis of gender dysphoria Gender Dysphoria Sex and gender are not the same thing. Sex refers to a person's biologic status: male, female, or intersex. Sexual identity refers to the sex to which a person is sexually attracted (if any)... read more may be considered.

Diagnostic criteria for body dysmorphic disorder include the following:

SSRIs Selective Serotonin Reuptake Inhibitors (SSRIs) Several drug classes and drugs can be used to treat depression: Selective serotonin reuptake inhibitors (SSRIs) Serotonin modulators (5-HT2 blockers) Serotonin-norepinephrine reuptake inhibitors... read more and clomipramine (a tricyclic antidepressant with potent serotonergic effects), are often very effective in patients with body dysmorphic disorder. 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 drugs may benefit from addition of augmenting medication such as an atypical neuroleptic (eg, aripiprazole), buspirone, or a glutamate modulator (eg, N-acetylcysteine).

Cognitive-behavioral therapy that is tailored to the specific symptoms of body dysmorphic disorder is currently the psychotherapy of choice. 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 while refraining from performing their rituals.

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

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

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