What Defines “Excessive” Concern with Appearance?

“Everyone has physical imperfections, and some people have noticeable ones — for example, a congenital deformity,” Greenberg observed. “We reserve BDD diagnosis for disproportionate preoccupation with a minor or nonexistent imperfection.” Individuals with BDD may think about their disliked body parts for as much as 3 to 8 hours a day, and 25% report thinking about them for more than 8 hours daily. This causes disruption in functioning at school or work, not going out with friends, spending a great deal of time, energy and money on trying to fix or hide some aspect of the appearance, engage in constant mirror-checking, and seeking cosmetic treatments, Greenberg said.

Detecting BDD in adolescence can be difficult because normal adolescents are typically concerned about body image, Greenberg said. “An adolescent with BDD is not just having a ‘bad hair day’ or normal self-consciousness,” she emphasized. “No matter how much reassurance friends and family members provide, it is never enough. This is an important clue in distinguishing between normal adolescent concerns and BDD.”

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Assessing Patients

“We have some work to do in psychiatry, when it comes to recognizing and diagnosing patients with BDD,” Greenberg remarked. “Unless you specifically ask about appearance concerns, you can easily miss it.”If a patient presents with depression and social issues, a simple question such as “Are you worried about how you look?” might open the door to a discussion, more targeted questions, or a formal assessment, Greenberg said.

An assessment tool used to screen for BDD is the Body Dysmorphic Disorder Questionnaire (BDDQ) — a brief, self-report screening measure available in adult and adolescent versions. The Yale-Brown Obsessive-Compulsive Scale Modified for Body Dysmorphic Disorder (BDD-YBOCS), a 12-item clinician-administered instrument, rates the current severity of BDD, and is also available in adult and adolescent versions. It is important to note that the BDD-YBOCS is a severity rather than a diagnostic tool.

Pharmacologic Treatments for BDD

While no medication is approved by the US Food and Drug Administration (FDA) for the specific indication of BDD, high doses of serotonin reuptake inhibitors (SRIs) have been well-researched and are recommended.5,13,14 An SRI should be taken for at least 12 weeks before determining whether it is efficacious.Successful SRI treatment usually results in less frequent and less intense preoccupation with appearance, decreased BDD-related distress, and improved control over BDD compulsions.1

Nonpharmacologic Interventions for BDD

Cognitive behavioral therapy (CBT), the most studied and established nonpharmacologic intervention,1,8 includes cognitive restructuring that focuses on altering appearance-related assumptions and beliefs as well as exposure and response prevention, Weingarden said. “In addition, perceptual/attention retraining helps patients to stand back from the mirror and describe their whole appearance in objective terms, not only focusing on certain specific areas.”

Cultural Considerations

The presentation and phenomenology of BDD differs between cultures and ethnicities.8,15 For example, Asians tend to report concern that their hair is “too straight” or their skin “too dark.”15 Among the Japanese, a similar syndrome called taijin kyofusho (fear of displeasing or embarrassing others) includes two subtypes: phobia of a deformed body and phobia of one’s own foul body odor.16 “It is important for clinicians to be aware of these presentations,” Weingarden stated.

Multidisciplinary Collaboration

Most patients with BDD (71% to 76%) seek cosmetic treatment for their perceived flaws. “Patients with BDD rarely present in psychiatric settings initially,” Weingarden noted. “Usually they are seen by dermatologists, plastic surgeons, or dentists.” Neelam A. Vashi, MD, Assistant Professor of Dermatology at the Boston University School of Medicine, stated that dermatologists must learn how to detect BDD. “I believe in multidisciplinary care for these patients,” she told Psychiatry Advisor. Moreover, “in my experience — and there is research to support this — most patients report no change or even have worse symptoms after cosmetic procedures. And those who do obtain relief typically transfer their appearance concern onto some other part of their body.” Greenberg agreed, adding that psychiatrists can play an important role in educating other specialists regarding “red flags” suggesting BDD in patients seeking cosmetic treatments.


“Rarely does a person with BDD come in and say, ‘I’m experiencing persistent appearance concerns and this is really disrupting my life,’” Weingarden noted. Psychiatrists play a key role in detecting BDD in patients who present with other complaints and providing targeted treatment for this common and devastating disorder.

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