Body dysmorphic disorder

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Body dysmorphic disorder
Classification and external resources
Specialty Psychiatry
ICD-10 F45.2
ICD-9-CM 300.7
DiseasesDB 33723
eMedicine med/3124
Patient UK Body dysmorphic disorder

Body dysmorphic disorder (BDD), also termed body dysmorphia or dysmorphic syndrome, but originally termed dysmorphophobia, is a mental disorder characterized by an obsessive preoccupation that some aspect of one's own appearance is severely flawed and warrants exceptional measures to hide or fix it.[1] In BDD's delusional variant, the flaw is imagined.[2] If the flaw is actual, its importance is severely exaggerated.[2] Either way, one's thoughts about it are pervasive and intrusive, occupying up to several hours a day. The DSM-5 categorizes BDD in the obsessive–compulsive spectrum, and distinguishes it from anorexia nervosa.

A fairly common mental disorder, affecting some 1.7% to 2.4% of the population, BDD usually starts during adolescence, and affects men and women roughly equally.[2] (The BDD subtype muscle dysmorphia, concerned with perceived smallness, is rare among females.)[3] Besides thinking about it, one repetitively checks and compares the perceived flaw, and can adopt unusual routines to avoid social contact that exposes it.[2] Fearing the stigma of vanity, one usually hides the preoccupation itself.[2] Commonly unsuspected even by psychiatrists, BDD has been severely underdiagnosed.[2] Severely impairing quality of life via educational and occupational dysfunction and social isolation, BDD involves especially high rates of suicide and suicidal ideation.[2]


In 1886, Enrico Morselli reported a disorder that he termed dysmorphophobia.[4] In 1980, the American Psychiatric Association recognized the disorder in the third edition of its DSM—the Diagnostic and Statistical Manual of Mental Disorders—while identifying it as a somatoform disorder. The manual's 1987 revision switched the term to body dysmorphic disorder. Published in 1994, DSMs fourth edition defines BDD as a preoccupation with an imagined or trivial defect in appearance, a preoccupation causing clinically significant distress or dysfunction—socially, occupationally, or educationally—and not better explained as another disorder, such as anorexia nervosa.[5] Published in 2013, the DSM-5 shifts BDD to a new category, obsessive–compulsive spectrum, adds operational criteria, such as repetitive behaviors or mental acts, and notes the subtype muscle dysmorphia: perceiving one's body as too small or insufficiently muscular or lean.


Whereas vanity concerns preoccupation with aggrandizing the appearance, BDD is compulsion to merely normalize the appearance.[2] While associating with perfectionism, BDD also reflects negative body image, [6] and shares features with obsessive-compulsive disorder (OCD),[7] but manifests greater levels of depression and social avoidance.[1] BDD is often associated with social anxiety disorder.[8]

In BDD, the perceived bodily defect can be at virtually any area, yet is usually the nose, skin, or hair.[2] Attempts at self-treatment can paradoxically create lesions where none previously existed.[2] BDD often drives a quest to obtain dermatological treatment or cosmetic surgery, which interventions typically do not resolve the distress.[2] Sometimes deluded in believing that persons are covertly pointing out their flaws.

Most generally, one experiencing BDD ruminates over the perceived bodily defect up to several hours daily, uses either social avoidance or camouflaging with cosmestics or apparel, repetitively checks the appearance, compares it to that of other persons, and might often seek verbal reassurances.[2][1] BDD's severity can wax and wane, and flareups tend to yield absences from school, work, or socializing, sometimes leading to protracted social isolation, with some becoming housebound for extended periods.[2] Severely impairing quality of life, BDD typically involves distress exceeding that of either major depressive disorder or type-2 diabetes, and rates of suicidal ideation and attempts are especially elevated.[2]


As with most psychiatric diagnoses, BDD causation is unknown. Most likely, it is the result of an interaction of multiple factors, including genetic, developmental, psychological, and social learning factors.[9] Though twin studies into BDD are few, one estimated its heritability at 43%, and its heritability overlaps with obsessive-compulsive disorder (OCD).[10] Other factors include the personality trait introversion,[11] childhood abuse and neglect,[9][12] and a heightened aesthetic sensitivity.[9]


Estimates of prevalence and gender distribution have varied widely via discrepancies in diagnosis and reporting.[1] In American psychiatry, BDD gained diagnostic criteria in the DSM-IV, but clinicians' knowledge of it, especially among general practitioners, is constricted.[13] Meanwhile, the shame that persons feel about having the bodily concern, and fearing the stigma of vanity, hinders recognition.[2][14] BDD is sometimes mistaken for major depressive disorder or social phobia.[15] BDD is severely under-diagnosed even in psychiatric patients.[16] Correct diagnosis calls for specialized questioning and correlation with emotional distress or social dysfunction.[16] Estimates place the Body Dysmorphic Disorder Questionnaire's specificity at 92.5% and its sensitivity at 100%.[17]


BDD's delusional variant does not respond to treatment with antipsychotic drugs, but instead with some antidepressant drugs: the selective serotonin reuptake inhibitors (SSRIs).[2] The gold-standard psychological intervention for BDD is cognitive-behavioral therapy (CBT).[18] [19][20][21] The main techniques in CBT for BDD are exposure and response prevention. Exposure means helping the patient confront situations that provoke irrational fear (such as going out in public with the perceived physical defect exposed); response prevention means resisting urges to ask for reassurance, use excessive makeup to conceal the perceived defect, or repeatedly check one's appearance in the mirror.


Neuroimaging[22] suggest weaker connection between the amygdala (involved in basic emotions) and the orbitofrontal cortex (involved in regulation of emotional arousal).[23] Cognitive-behavioral therapy may improve connections between the orbitofrontal cortex and the amygdala.[23][not in citation given]


  1. ^ a b c d Cororve, Michelle; Gleaves, David (August 2001). "Body dysmorphic disorder: A review of conceptualizations, assessment, and treatment strategies". Clinical Psychology Review 21 (6): 949–970. doi:10.1016/s0272-7358(00)00075-1. 
  2. ^ a b c d e f g h i j k l m n o p Bjornsson AS, Didie ER & Phillips KA (2010). "Body dysmorphic disorder". Dialogues Clin Neurosci 12 (2): 221–32. PMC 3181960. PMID 20623926. 
  3. ^ Timothy M Baghurst, "Muscle dysmorphia", in Justine J Reel, ed, Eating Disorders: An Encyclopedia of Causes, Treatment, and Prevention (Santa Barbara CA, 2013), p 287.
  4. ^ Hunt TJ, Thienhaus O & Ellwood A (July 2008). "The mirror lies: Body dysmorphic disorder". American Family Physician 78 (2): 217–22. PMID 18697504. 
  5. ^ Diagnostic and Statistical Manual of Mental Disorders (Fourth text revision ed.). American Psychiatric Association, Washington DC. 2000. pp. 507–10. 
  6. ^ Hartmann, A. "A comparison of self-esteem and perfectionism in anorexia nervosa and body dysmorphic disorder". The journal of nervous and mental disease. 
  7. ^ Fornaro M, Gabrielli F, Albano C; et al. (2009). "Obsessive-compulsive disorder and related disorders: A comprehensive survey". Annals of General Psychiatry 8: 13. doi:10.1186/1744-859X-8-13. PMC 2686696. PMID 19450269. 
  8. ^ Angela Fang & Stefan G Hofmann, "Relationship between social anxiety disorder and body bysmorphic disorder", Clinical Psychology Review, 2010 Dec;30(8):1040–1048.
  9. ^ a b c Feusner, J.D.; Neziroglu, F; Wilhelm, S.; Mancusi, L.; Bohon, C. (2010). "What causes BDD: Research findings and a proposed model". Psychiatric Annals 40 (7): 349–355. doi:10.3928/00485713-20100701-08. 
  10. ^ Browne, Heidi A.; Gair, Shannon L.; Scharf, Jeremiah M.; Grice, Dorothy E. (2014-01-01). "Genetics of obsessive-Compulsive Disorder and Related Disorders". Psychiatric Clinics of North America 37 (3). doi:10.1016/j.psc.2014.06.002. PMC 4143777. PMID 25150565. 
  11. ^ Veale D, "Body dysmorphic disorder", British Medical Journal, 2004;80(940):67-71.
  12. ^ Didie E, Tortolani C, Pope C, Menard W, Fay C & Phillips K, "Childhood abuse and neglect in body dysmorphic disorder", Child Abuse and Neglect, 2006;30:1105–1115.
  13. ^ Katharine A Phillips. The Broken Mirror. Oxford University Press, 1996. p. 39. 
  14. ^ Prazeres AM, Nascimento AL, Fontenelle LF (2013). "Cognitive-behavioral therapy for body dysmorphic disorder: A review of its efficacy". Neuropsychiatric Disease Treatment 9: 307–16. doi:10.2147/NDT.S41074. PMC 3589080. PMID 23467711. 
  15. ^ Katharine A Phillips. The Broken Mirror. Oxford University Press, 1996. p. 47. 
  16. ^ a b Phillips, Katherine; Castle, David (November 3, 2001). British Medical Journal 323: 1015–1016.  Missing or empty |title= (help)
  17. ^ Grant, Jon; Won Kim, Suck; Crow, Scott (2001). "Prevalence and Clinical Features of Body Dysmorphic Disorder in Adolescent and Adult Psychiatric Inpatients.". J Clin Psychiatry: 527-522. 
  18. ^ Wilhelm, Phillips, Didie, Buhlmann, Greenberg, Fama, Keshavia, & Steketee, 2014, "Modular Cognitive-Behavioral Therapy for Body Dysmorphic Disorder: A Randomized Controlled Trial", Behavior Therapy
  19. ^ Veale, "Cognitive-behavioural therapy for body dysmorphic disorder", 2001.
  20. ^ Ipser JC, Sander C & Stein DJ, "Pharmacotherapy and psychotherapy for body dysmorphic disorder", Cochrane Database of Systematic Reviews, 2009;1.
  21. ^ Williams J, Hadjistavropoulos T & Sharpe D, "A meta-analysis of psychological and pharmacological treatments for body dysmorphic disorder", Behaviour Research and Therapy, 2006;44(1):99–111.
  22. ^ Buchanan BG, Rossell SL & Castle DJ, "Body dysmorphic disorder: A review of nosology, cognition and neurobiology", Neuropsychiatry, 2011;1:71-80.
  23. ^ a b Buchanan B, Rossell S, Maller J, Toh W, Brennan S & Castle D, "Brain connectivity in body dysmorphic disorder compared with controls: A diffusion tensor imaging study", Psychological Medicine, 2013, pp 1–9.

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