What is body dysmorphic disorder

Body dysmorphic disorder is a common mental illness that leads people to become obsessed with parts of their bodies and how they appear to other people.

Body dysmorphic disorder is a condition characterised by an individual’s excessive and persistent preoccupation with perceived defects or flaws in appearance or minor faults in their appearance, which others do not notice. These perceived flaws are unobservable or appear only slight to others, but nevertheless give rise to significant distress and impairment in the sufferer ¹. Body dysmorphic disorder sufferers can become preoccupied with any aspect of their appearance, but the face and facial features – such as the size and shape of the nose, lips or ears, or the skin or complexion – are the most common cause of worry for people with body dysmorphic disorder ². But any body part – including the arms and legs, buttocks and hair – can become the focus.

To meet diagnostic criteria for body dysmorphic disorder, the appearance preoccupation cannot be better explained by concerns with body fat or weight in an individual who fulfils diagnostic criteria for an eating disorder ¹. Diagnostic criteria for body dysmorphic disorder also specify that at some point during the course of illness, the individual will have performed repetitive behaviors (e.g, mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (eg, comparing his or her appearance with that of others) in response to their appearance concerns ¹.

People with body dysmorphic disorder can feel emotions such as shame or disgust concerning a part or parts of their body and how they imagine they appear to other people.

The disorder generally starts in adolescence, but often goes unnoticed and is severely underdiagnosed.

If you have body dysmorphic disorder, you feel a part of your body is unusual or deformed, so that you feel ashamed, distressed or depressed.

These feelings may affect your wellbeing and prevent you from living a normal life.

There is a high prevalence of the condition amongst cosmetic surgery patients, although individuals with body dysmorphic disorder who change their appearance through cosmetic surgery are rarely satisfied with the results.

In a recent systematic review, the weighted prevalence of body dysmorphic disorder was estimated to be 1.9% in community samples of adults and 5.8%–7.4% in psychiatric settings, highlighting the importance of clinical vigilance for the disorder ³. Comparable rates have been found for adolescents, with prevalence estimates ranging from 1.7%–2.2% ³ in the community and 6.7%–14.3% in psychiatric inpatient settings ³. Body dysmorphic disorder has been shown to be more common in older adolescents ⁴, consistent with reports that the mean age of onset is around 16 years ⁵. No study to date has examined the prevalence of body dysmorphic disorder in young people under the age of 12 years, thus it remains unclear how common body dysmorphic disorder is in childhood. Furthermore, the majority of community-based prevalence studies have been conducted within Europe and North America, and it is therefore unknown whether rates vary across different cultures. Such knowledge would assist in identifying at risk populations, enabling focused efforts to promote diagnosis and treatment.

With respect to sex differences in prevalence, findings have been inconsistent, with some studies suggesting that body dysmorphic disorder is more common in females and others indicating equivalent prevalence rates in both genders. These discrepancies may reflect methodological differences across studies including variation in the study setting, with higher female to male ratios typically found in community compared with clinical settings. In this vein, there is some suggestion that subclinical body dysmorphic disorder symptoms are more common in females but that the prevalence of diagnosable body dysmorphic disorder is equivalent in both sexes ⁴. The features of body dysmorphic disorder are broadly similar in males and females, but evidence suggests that males are more likely to be preoccupied with their genitals and thinning hair, while females are more likely to be preoccupied with hips, breasts, legs and excessive body hair ⁶. Thus, clinicians should be aware of potential differences in the clinical presentation of body dysmorphic disorder in males and females.

Medication or psychotherapy can often help treat body dysmorphic disorder, so talk to your doctor if you think you have the condition.

Left untreated, body dysmorphic disorder typically persists and causes marked functional impairment in multiple domains.

Body dysmorphic disorder prognosis

Body dysmorphic disorder typically follows a chronic course ⁷ and is associated with marked functional impairment across multiple domains. Among adults, body dysmorphic disorder results in high rates of occupational impairment, unemployment, social dysfunction and social isolation ². Similarly, body dysmorphic disorder in youth is associated with major functional impairment, including reduced academic performance, social withdrawal and dropping out of school ⁸. High comorbidity, for example with major depressive disorder, social anxiety disorder and obsessive–compulsive disorder (OCD), is frequently reported. body dysmorphic disorder has also been associated with strikingly high rates of suicidality; reported rates of suicidal ideation range from 17%–77%, while rates of suicide attempts range from 3%–63% ⁹.

Body dysmorphic disorder complications

People with body dysmorphic disorder often stay at home, avoid social situations and miss work or school because of their feelings about their body.

Many people who have the disorder also have or develop obsessive compulsive disorder (OCD) or an eating disorder such as anorexia nervosa.

Some become so anxious or depressed that they use drugs, have suicidal thoughts or attempt suicide.

Complications that may be caused by or associated with body dysmorphic disorder include, for example:

• Major depression or other mood disorders
• Suicidal thoughts or behavior
• Anxiety disorders
• Health problems from behaviors such as skin picking
• Obsessive-compulsive disorder
• Eating disorders
• Substance abuse.

Body dysmorphic disorder causes

It is not fully understood what causes body dysmorphic disorder.

Like many other mental illnesses, body dysmorphic disorder may result from a combination of causes, such as:

• Brain differences. Abnormalities in brain structure or neurochemistry may play a role in causing body dysmorphic disorder.
• Genes. Some studies show that body dysmorphic disorder is more common in people whose blood relatives also have this condition or obsessive-compulsive disorder.
• Environment. Your environment, life experiences and culture may contribute to body dysmorphic disorder, especially if they involve negative social evaluations about your body or self-image, or even childhood neglect or abuse.

Results of twin studies indicate that genetic factors account for approximately 42%–44% of the variance in body dysmorphic disorder-like symptoms, with the remaining variance being account for by non-shared environmental influences ¹⁰.

Genome-wide association studies have yet to be conducted in body dysmorphic disorder and thus no specific risk genes have been identified to date. The specific aspects of the environment that contribute to the development of body dysmorphic disorder also remain unknown. Research on environmental risk factors in body dysmorphic disorder is sparse and most studies have serious methodological limitations, including an over-reliance on cross-sectional and retrospective designs, lack of multiple-informant assessment methods and inadequate control of potential confounding variables such as comorbidity and genetic factors. Nevertheless, a range of environmental factors have been suggested to influence the development of body dysmorphic disorder, including childhood abuse, peer teasing and peer victimization. Studies have shown that adults with body dysmorphic disorder report high levels of childhood maltreatment, with up to 79% of patients reporting abuse ¹¹. Furthermore, retrospectively reported rates of abuse are elevated in patients with body dysmorphic disorder compared with healthy controls ¹² and patients with obsessive-compulsive disorder (OCD) ¹³, although the cross-sectional nature of these studies prevents any interference regarding causality. Bullying has also been shown to be associated with body dysmorphic disorder ¹⁴. Several recent studies have shown associations between self-reported appearance-related teasing and body dysmorphic disorder symptoms in analogue samples ¹⁵ and clinical samples ¹⁶, particularly when the teasing is by members of the opposite sex. In one of the only longitudinal studies of environmental risk factors in body dysmorphic disorder, peer victimization in school students (as reported by the peer group) was prospectively associated with the development of body dysmorphic disorder symptoms 12 months later ¹⁷, in line with suggestions that experiences of bullying may play a causal role in body dysmorphic disorder. Although further research is clearly needed, understanding the role of environmental risk factors could have important implications for the prevention and early intervention in body dysmorphic disorder.

Genetics may play a part, but so might factors such as:

• teasing or verbal abuse concerning appearance
• an overemphasis on appearance among family or friends
• sexual abuse and related feelings of worthlessness.

Some people with body dysmorphic disorder also have mental illness in their family.

Risk factors for body dysmorphic disorder

Certain factors seem to increase the risk of developing or triggering body dysmorphic disorder, including:

• Having blood relatives with body dysmorphic disorder or obsessive-compulsive disorder
• Negative life experiences, such as childhood teasing and trauma
• Certain personality traits, such as perfectionism
• Societal pressure or expectations of beauty
• Having another psychiatric disorder, such as anxiety or depression.

Body dysmorphic disorder prevention

There’s no known way to prevent body dysmorphic disorder. However, because body dysmorphic disorder often starts in the early teenage years, identifying the disorder early and starting treatment may be of some benefit.

Long-term maintenance treatment also may help prevent a relapse of body dysmorphic disorder symptoms.

Body dysmorphic disorder symptoms

Symptoms of body dysmorphic disorder include a person:

• strongly (but incorrectly) believing they have a physical defect that makes them ugly or deformed
• being extremely preoccupied with a perceived flaw in appearance that to others can’t be seen or appears minor
• belief that others take special notice of your appearance in a negative way or mock you
• engaging in behaviors aimed at fixing or hiding the perceived flaw that are difficult to resist or control, such as frequently checking the mirror, grooming or skin picking
• wearing a lot of make-up or growing a beard as cover
• spending a lot of time grooming
• constantly comparing their appearance to others
• severely limiting their food intake
• exercising excessively
• undergoing cosmetic surgery related to their false beliefs
• compulsively picking at their skin
• inflicting self-harm
• always seeking reassurance about your appearance from others
• having perfectionist tendencies
• seeking frequent cosmetic procedures with little satisfaction
• avoiding social situations
• being so preoccupied with appearance that it causes major distress or problems in your social life, work, school or other areas of functioning

You may obsess over one or more parts of your body. The feature that you focus on may change over time. The most common features people obsess about include:

• Face, such as nose, complexion, wrinkles, acne and other blemishes
• Hair, such as appearance, thinning and baldness
• Skin and vein appearance
• Breast size
• Muscle size and tone
• Genitalia

Insight about body dysmorphic disorder varies. You may recognize that your beliefs about your perceived flaws may not be true, or think that they probably are true, or be absolutely convinced that they’re true.

Body dysmorphic disorder typically starts in the early teenage years and it affects both males and females. An obsession that body build is too small or not muscular enough (muscle dysmorphia) occurs almost exclusively in males.

Body dysmorphic disorder diagnosis

If you think you may have body dysmorphic disorder, you should talk to your doctor.

Your doctor will probably ask questions to confirm your condition and how serious it is, and talk about whether you should seek help from a psychologist or other specialist.

A physical exam and lab tests may help diagnose body dysmorphic disorder or other conditions.

You should try to talk honestly about your feelings to help your doctor diagnose your illness and work out the best treatment.

Diagnosis of body dysmorphic disorder is typically based on:

• A psychological evaluation that assesses risk factors and thoughts, feelings, and behaviors related to negative self-image
• Personal, social, family and medical history
• Symptoms listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association

Body dysmorphic disorder treatment

Body dysmorphic disorder is difficult to treat without professional help. It doesn’t usually get better on its own and can get worse.

Medication or working with a psychologist, or both, can help.

A psychologist may suggest cognitive behavioral therapy (CBT).

Physical activity and exercise can help manage depression, stress and anxiety.

Cognitive behavioral therapy

Cognitive behavioral therapy for body dysmorphic disorder focuses on:

• Helping you learn how negative thoughts, emotional reactions and behaviors maintain problems over time
• Challenging automatic negative thoughts about your body image and learning a more flexible and realistic way of thinking
• Learning alternate ways to handle urges or rituals to help reduce mirror checking or reassurance seeking
• Teaching you other behaviors to improve your mental health

You and your therapist can talk about your goals for therapy and develop a personalized treatment plan to learn and strengthen coping skills.

In clinical trials, cognitive behavioral therapy (CBT) for body dysmorphic disorder typically involves 12–22 weekly sessions ¹⁸, with a key therapeutic strategy being exposure with response prevention. Exposure with response prevention involves the gradually confronting of feared situations (e.g, bright lights, mirrors, social situations) and resisting the urge to perform safety-seeking behaviors (e.g, camouflaging, applying excessive make-up, focusing attention internally) to neutralize distress, with the goal of achieving anxiety habituation. Additional strategies that have been used in cognitive behavioral therapy (CBT) for body dysmorphic disorder include psychoeducation, motivational enhancement techniques, cognitive restructuring, mirror retraining and attention training ¹⁹.

Medications

Although there are no medications specifically approved by the Food and Drug Administration (FDA) to treat body dysmorphic disorder, medications used to treat other mental disorders, such as depression, can be effective.

• Selective serotonin reuptake inhibitors (SSRIs). Because body dysmorphic disorder is thought to be caused in part by problems related to the brain chemical serotonin, SSRIs may be prescribed. SSRIs appear to be more effective for body dysmorphic disorder than other antidepressants and may help control your obsessions and repetitive behaviors.
• Other medications. In some cases, you may benefit from taking other medications in addition to an SSRI, depending on your symptoms.

Hospitalization

In some cases, your body dysmorphic disorder symptoms may be so severe that you require psychiatric hospitalization. This is generally recommended only when you aren’t able to keep up with day-to-day responsibilities or when you’re in immediate danger of harming yourself.

Lifestyle and home remedies

Body dysmorphic disorder warrants treatment from a mental health professional. But you can do some things to build on your treatment plan, such as:

• Stick to your treatment plan. Don’t skip therapy sessions, even if you don’t feel like going. Even if you’re feeling well, resist any temptation to skip your medications. If you stop, symptoms may come back. You could also experience withdrawal-like symptoms from stopping a medication too suddenly.
• Learn about your disorder. Education about body dysmorphic disorder can empower you and motivate you to stick to your treatment plan.
• Pay attention to warning signs. Work with your doctor or therapist to learn what might trigger your symptoms. Make a plan so you know what to do if symptoms return. Contact your doctor or therapist if you notice any changes in symptoms or how you feel.
• Practice learned strategies. At home, practice the skills you learn during therapy so they become stronger habits.
• Avoid drugs and alcohol. Alcohol and recreational drugs can worsen symptoms or interact with medications.
• Get active. Physical activity and exercise can help manage many symptoms, such as depression, stress and anxiety. Consider walking, jogging, swimming, gardening or taking up another form of physical activity you enjoy. However, avoid excessive exercise as a way to fix a perceived flaw.

Coping and support

Talk with your doctor or therapist about improving your coping skills, and ways to focus on identifying, monitoring and changing the negative thoughts and behaviors about your appearance.

Consider these tips to help cope with body dysmorphic disorder:

• Write in a journal. This can help you better identify negative thoughts, emotions and behaviors.
• Don’t become isolated. Try to participate in normal activities and regularly get together with friends and family who can act as healthy supports.
• Take care of yourself. Eat healthy, stay physically active and get sufficient sleep.
• Read reputable self-help books. Consider talking about them to your doctor or therapist.
• Join a support group. Connect with others facing similar challenges.
• Stay focused on your goals. Recovery is an ongoing process. Stay motivated by keeping your recovery goals in mind.
• Learn relaxation and stress management. Try stress-reduction techniques such as meditation, yoga or tai chi.
• Don’t make important decisions when you’re feeling despair or distress. You may not be thinking clearly and may regret your decisions later.

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