Body Dysmorphic Disorder: A Distorted Lens

Body dysmorphic disorder (BDD) is a common condition, affecting 0.7% to 2.4% of the general population.¹ The rates are higher in clinical settings, including dermatology (9% to 12%), cosmetic surgery (3% to 57%), adult psychiatric inpatients (11% to 13%), and adolescent inpatients (up to 15%).^1,2 BDD has childhood or adolescent onset in approximately 17% of individuals^1,3 and tends to be more prevalent in women than in men, (2.5% vs 2.2%), although its presentation differs between the genders.^4,5 (Table 1)

Table 1. Typical Gender Predominance of BDD

Symptom	Male	Female
Body part	Body build Genitalia Thinning hair Musculature	Breasts Buttocks Excessive hair Nose Skin Stomach Teeth Thighs Weight
Behavior	Substance use disorder Weight lifting	Camouflaging techniques Eating disorder Skin picking

Hunt TJ, et al. Am Fam Physician. 2008 Jul 15;78(2):217-22.

BDD is currently classified as one of the obsessive-compulsive disorders (OCD).⁶ Diagnostic criteria are listed in Table 2. Common comorbidities include obsessive-compulsive disorder (8% to 37%), social phobia (11% to 13%), trichotillomania (26%), and atypical major depressive disorder (42%).¹ There is considerable overlap between symptoms of BDD and those of other disorders. Approaches to differential diagnosis can be found in Table 3.

Table 2. DSM-5 Diagnostic Criteria for Body Dysmorphic Disorder

The individual is preoccupied with 1 or more perceived defects or flaws in physical appearance that are not observable by or appear slight to others At some point during the course of the disorder, the individual has performed repetitive behaviors (eg, mirror checking, excessive grooming, skin picking, or reassurance seeking) or mental acts (eg, comparing his or her appearance with that of others) in response to the appearance concerns The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning The appearance preoccupation cannot be better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder

BDD diagnosis includes 2 specifiers to identify meaningful subgroups Muscle dysmorphia: The individual is preoccupied with concerns that that his or her body build is too small or insufficiently muscular. Insight specifier: Degree of insight regarding BDD beliefs “With good or fair insight” “With poor insight” “With absent insight/delusional beliefs.”

American Psychiatric Association. Obsessive-Compulsive and Related Disorders. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. 5th ed. (DSM-5) Arlington, VA: American Psychiatric Association; 2013.

Table 3. Differential Diagnosis of Body Dysmorphic Disorder

Condition	When to Diagnose BDD
Obsessive-compulsive disorder (OCD)	Preoccupations and repetitive behaviors focus on appearance (including symmetry concerns)
OCD: Social anxiety disorder (social phobia)	Social anxiety and social avoidance are due to shame about perceived appearance flaws
Major depressive disorder (MDD)	Appearance-related preoccupation and excessive compulsive repetitive behaviors
Excoriation (skin-picking disorder)	Skin picking is intended to improve perceived defects in the appearance of one’s skin
Generalized anxiety disorder (GAD)	Worry focuses on perceived appearance flaws
Schizophrenia and schizoaffective disorder	Psychotic symptoms (ie, delusional beliefs) focus on appearance defects or BDD-related delusions of reference
Eating disorder	Concern on the part of a normal-weight person about being fat or overweight; does not meet diagnostic criteria for an eating disorder
Trichotillomania (hair-pulling disorder)	Hair tweezing, plucking, pulling, or other types of hair removal are intended to improve perceived defects in the appearance of body or facial hair
Agoraphobia	Avoidance of situations because of fears that others will see the person’s perceived appearance defects

Phillips KA. Diagnosis and Clinical Assessment in BDD. International OCD Foundation (IOCDF), 2016. Available at: https://bdd.iocdf.org/professionals/diagnosis/. Accessed: May 9, 2016.

The most frequent body parts of concern are skin (73%), hair (56%), and nose (37%), although some patients are preoccupied with as many as 5 to 7 different body parts and others with their overall appearance.¹ BDD is associated with impairment in academic, employment, social, and relationship arenas, increased substance abuse, and high suicide rates. It is also associated with increased violent behavior, sometimes following dissatisfaction with the results of cosmetic procedures. “The behaviors associated with BDD diminish quality of life and create tremendous interference,” Jennifer Greenberg, PsyD, told Psychiatry Advisor.

Underrecognized and Underdiagnosed in Psychiatric Settings

Although BDD is common, it is frequently underdiagnosed.⁷ “BDD does not get as much focus as it should in clinical or research settings,” observed Greenberg, who is an instructor in the Department of Psychiatry, Harvard Medical School. Unlike other anxiety disorders such as OCD, “it is rarely spontaneously disclosed to providers due to extreme shame,” said Hilary Weingarden MA, Fellow, Department of Psychology, OCD and Related Disorders Program, Massachusetts General Hospital. Moreover, individuals with BDD “often do not know that they are dealing with a psychiatric disorder because they perceive their appearance to be objectively defective and flawed,” Weingarden told Psychiatry Advisor.  For this reason, BDD is sometimes described as a “disorder of imagined ugliness.”

Etiology of BDD

The etiology of BDD is complex, involving multiple biological, psychological, and socio-environmental factors. Findings of family studies reveal high heritability and that individuals with BDD have serotonergic abnormalities. Early childhood experiences, such as bullying or trauma, may reinforce maladaptive beliefs. However, even “positive” messages about appearance can contribute to BDD, Greenberg noted. For example, “a child who has been continually praised for her ‘cute little button nose’ may feel acceptable only if she maintains that appearance and may become distressed when her nose changes.”