Body Dysmorphic Disorder

Body dysmorphic disorder (BDD) is a psychiatric disorder characterized by a patient’s preoccupation with minor or imagined flaws in their physical appearance. The obsession over the perceived defect leads to compulsive behaviors to cover it up, either with cosmetic therapy or social avoidance. These patients have a high incidence of comorbid depression and anxiety and may benefit from psychotherapy, along with selective serotonin reuptake inhibitors (SSRIs).

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Epidemiology and Etiology

  • Worldwide prevalence: 2%–4%
  • Girls > boys
  • Onset typically in adolescence (65% by the age of 18 years)
  • 90% of patients have comorbid depression.
  • 70% have comorbid anxiety.
  • 30% have comorbid psychotic disorder.
  • Incidence is highest in dermatologic and cosmetic surgery patients.

Etiology

  • Etiology is unknown.
  • Predisposing factors thought to include:
    • Genetics: 43% heritability noted in monozygotic twins
    • Frontal lobe dysfunction → deficits in executive function → focus on specific details of body rather than entirety of appearance
    • History of neglect or abuse
  • Some studies suggest genetic predisposition along with OCD.

Clinical Presentation

General

  • Patients don’t usually disclose the preoccupation.
  • Patients have varying degrees of insight into symptoms and must be asked specifically.
  • Often present to dermatology or plastic surgery for correction of perceived imperfection
  • May present with:
    • Social anxiety and avoidance
    • Emotional distress
    • Poor psychosocial functioning and quality of life
    • Suicidal ideation and behavior:
      • 4 times more likely to develop ideas
      • 2 times more likely to carry it out
    • Aggressive behavior

Muscle dysmorphia

  • Subtype of body dysmorphic disorder (BDD)
  • Preoccupied with idea that body build is too small or insufficiently muscular
  • Commonly seen in men
  • Usually associated with steroid abuse

Comorbidities

  • Major depression
  • Social anxiety disorder
  • Personality disorders 
  • OCD
  • Eating disorders
  • Substance use disorders

Diagnosis

Patients exhibit:

  • Preoccupation with 1 or more perceived defects or flaws in physical appearance that are not observable or appear slight to others:
    • Thought is difficult to resist or control.
    • Occurs for an average of 3–8 hours/day
  • Repetitive behaviors or mental acts in response to concern with appearance:
    • Comparing features with those of others
    • Mirror checking
    • Excessive grooming
    • Seeking reassurance from others
    • Camouflaging
  • Clinically significant distress or impairment in social, occupational, or other areas of functioning due to preoccupation/compulsion
  • Meeting the diagnostic criteria for eating disorders supersedes a diagnosis of BDD.

Management and Prognosis

  • Psychoeducation is important, as many patients lack insight into the condition.
  • Treatment includes psychological and pharmacological interventions:
    • Psychological interventions:
      • CBT
      • Metacognitive therapy
      • Address co-morbidities.
    • Pharmacological interventions:
      • Selective serotonin reuptake inhibitors (SSRIs; fluoxetine)
      • Clomipramine

Prognosis

  • Chronic illness
  • Response to treatment requires ≤ 16 weeks of therapy.
  • Response rate of 50%–80% with pharmacological treatment
  • Relapses are common; maintenance SSRI therapy recommended.

Differential Diagnosis

  • Generalized anxiety disorder: marked by chronic, multiple worries that are irrational and uncontrollable. Associated with fatigue, low concentration, restlessness, irritability, and sleep disturbance. Symptoms last for more than 6 months and cause significant decline in functioning. Treatment includes psychotherapy and medications (e.g., SSRI or serotonin-norepinephrine reuptake inhibitor (SNRI) antidepressants). 
  • Social anxiety disorder: disorder or social phobia marked by fear and avoidance of social interactions due to concerns about embarrassment. Usually occurs in more than 1 social situation for more than 6 months and leads to a significant decline in function. Performance subtype occurs only in performance-related situations (e.g., giving a speech in front of others). Treatment includes CBT, antidepressants (SSRI, SNRI), and beta-blockers or benzodiazepines for performance-only subtype. 
  • OCD: characterized by obsessions (recurring senseless and intrusive thoughts, feelings, or sensations) that cause severe distress. Obsessions are neutralized partly by compulsions (repetitive actions), which are time-consuming and affect patient quality of life. Patients may experience either obsessions alone or a combination of obsessions and compulsions. Treatment is monotherapy with antidepressants, which may be augmented by CBT and antipsychotic medication.
  • Anorexia nervosa: eating disorder marked by self-imposed starvation and inappropriate dietary habits due to morbid fear of weight gain and disturbed perception of body shape and weight. Patients have strikingly low body weight (≤ 18.5 kg) and diverse physiological and psychological complications. Most commonly seen in adolescent girls. Treatment mainly consists of psychotherapy (CBT) and patient hospitalization for optimization of nutritional deficiencies.

References

  1. Veale D, Gledhill LJ, Christodoulou P, Hodsoll J. (2016). Body dysmorphic disorder in different settings: A systematic review and estimated weighted prevalence. Body Image. https://pubmed.ncbi.nlm.nih.gov/27498379/
  2. Enander J, Ivanov VZ, Mataix-Cols D, Kuja-Halkola R, Ljótsson B, Lundström S, Pérez-Vigil A, Monzani B, Lichtenstein P, Rück C. (2018). Prevalence and heritability of body dysmorphic symptoms in adolescents and young adults: A population-based nationwide twin study. Psychol Med. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6236441/
  3. Grant JE, Kim SW, Crow SJ. (2001). Prevalence and clinical features of body dysmorphic disorder in adolescent and adult psychiatric inpatients. J Clin Psychiatry. https://pubmed.ncbi.nlm.nih.gov/11488361/
  4. Phillipou A, Rossell SL, Wilding HE, Castle DJ. (2016). Randomised controlled trials of psychological & pharmacological treatments for body dysmorphic disorder: A systematic review. Psychiatry Res. https://pubmed.ncbi.nlm.nih.gov/27544783/
  5. Phillips KA, Keshaviah A, Dougherty DD, Stout RL, Menard W, Wilhelm S. (2016). Pharmacotherapy relapse prevention in body dysmorphic disorder: A double-blind, placebo-controlled trial. Am J Psychiatry. https://pubmed.ncbi.nlm.nih.gov/27056606/
  6. Gunstad J, Phillips KA. (2003). Axis I comorbidity in body dysmorphic disorder. Compr Psychiatry. https://pubmed.ncbi.nlm.nih.gov/12923704/

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