For many individuals, Body Dysmorphic Disorder (BDD) may be a new term. Although this dysmorphic syndrome took time to gain public awareness, it has actually been around for over a century. Body dysmorphic disorder was first described in 1886 by a psychiatrist who described patients who experienced “sudden fears of deformity and painful desperation.” Although knowledge around body dysmorphic disorder has grown considerably over the years, clinicians continually strive to gain a more thorough understanding of its’ prevalence, symptoms, and effective treatments.
Symptoms of Body Dysmorphic Disorder
Body dysmorphic disorder is a type of “Obsessive-Compulsive and Related Disorders” (6) and therefore possesses qualities closely related to obsessive-compulsive disorder (OCD). Although the age of onset may vary in patients with body dysmorphic disorder, the dominant characteristic of the disorder remains consistent. The primary feature of BDD consists of repetitive behaviors (such as mirror checking, excessing grooming, reassurance seeking, or comparisons with others) in response to an imagined defect in appearance (2). Preoccupation may involve thinking about the perceived defect an average of 3-8 hours per day (7).
One of the variants of body dysmorphic disorder is “with muscle dysmorphia,” which many eating disorder researchers believe is actually the male version of anorexia and should belong in the feeding and eating disorders. In this condition, the individual is preoccupied with the idea that their body is not muscular enough.
Impact on Functioning
BDD causes significant distress, and often times, impairment in essential areas of functioning. Individuals who struggle with body dysmorphic disorder not only use ritualistic behaviors (8) as a way to control the perceived defect, but frequently require ongoing reassurance from others and spend an inordinate amount of time focusing on the superficial defect.
Body dysmorphic disorder also poses a substantial threat to the social and occupational functioning of those suffering with this dysmorphic syndrome. The obsessive focus on the perceived flaw(s) understandably produces insecurities. For example, individuals with this disorder tend to believe they are the focus of attention when entering a room, and often anticipate rejection by others. This can result in extreme anxiety (2). Likewise, the anxiety and insecurities manifest in recurrent reassurance seeking from others about their appearance, retention of which is short-lived. Individuals with body dysmorphic disorder frequently seek out needless dermatological, cosmetic, or dental procedures which often do not resolve the perceived defects and contribute to excessive health care costs (3).
Assessing Insight in Body Dysmorphic Disorder
For clinicians, a significant challenge of working with patients diagnosed with BDD is the lack of insight they possess. These individuals are often so obsessed with the perceived flaw that they are overcome by the belief that they are truly deformed or repulsive (6). This irrational belief can make it difficult for patients to accept the diagnosis of BDD, thus denying any sort of treatment, whether it is therapy or medication. This lack of insight plays a large role in BDD patients seeking cosmetic treatments.
Onset and Prevalence
The typical age of onset for body dysmorphic disorder is usually between ages twelve to seventeen (2). Considerable research shows the onset of this dysmorphic syndrome may be associated with bullying or abuse during childhood or adolescence (9).
BDD affects approximately 1-2% of the U.S. population (5). Yet, because this disorder often goes undiagnosed, the number of affected individuals is potentially much higher. Body dysmorphic disorder is under recognized and therefore often goes undiagnosed as many who struggle with BDD fear their concerns will be deemed superficial or insignificant (7). In addition, these individuals tend to experience high levels of shame around the perceived flaws, which become a deterrent to seeking treatment.
There is evidence for the benefit of cognitive behavioral therapy (CBT) in the treatment of body dysmorphic disorder, as well as anti-depressants, similar to the treatment of obsessive-compulsive disorder (9). Essential to the effectiveness of CBT is the individual’s willingness to change and ability (with a clinician’s help) to identify negative self-talk, challenge the negativity, and change (or restructure) the thoughts. With this dysmorphic syndrome, CBT must include exposure therapy where various social situations are presented, and the individual is encouraged to expose his or her perceived flaws (10). These exercises can aid in reducing the negative thought patterns and destructive behaviors while providing assurance that the perceived flaws are insignificant, most importantly to others around them.
Differentiation from an Eating Disorder
It is widely known that many individuals who suffer from an eating disorder also struggle with some level of body disatisfaction. Yet, understanding that individuals diagnosed with BDD do not always have an eating disorder, makes appreciating the difference vital. If the preoccupation is fully accounted for by the eating disorder, the additional diagnosis of body dysmorphic disorder is unnecessary.
Individuals with body dysmorphic disorder suffer from a distorted body image, a preoccupation with physical appearance, and repetitive behaviors used to compensate for perceived flaws or imperfections. However, if the preoccupation with appearance is focused exclusively on weight concerns, it is pertinent that the clinician determines if these concerns are not better explained by an eating disorder. If the person’s sole appearance concern is focused on weight, and the symptoms meet diagnostic criteria for an eating disorder, then he or she should be further assessed for an eating disorder (8). There are various diagnostic measures that assist clinicians with this differentiation, and the diagnosis of body dysmorphic disorder altogether.
Listed below are a couple of reliable tests to assess for body dysmorphic disorder:
- BDD Diagnostic Module: This is a concise measure, requiring clinician administration. It is used to measure abnormal and distorted body views in both youth and adults.
- Body Dysmorphic Disorder Examination (BDDE): This interview is more extensive, but has shown to be less effective in diagnosing patients with more severe levels of body dysmorphic symptoms. There is also a self-report option, but it has yet to be tested for reliability.(6)
Written by Jenna Jarrold – 2015
1. Allen Frances, Avram H. Mack, Ruth Ross, and Michael B. First (2000) The DSM-IV Classification and Psychopharmacology
2. American Psychiatric Association. (2013). Highlights of changes from DSM-IV-TR to DSM-5 (PDF). Retrieved August 22, 2015.
3. Greenberg,J.L., and Wilhelm, S. ( 2014) Treatment for body dysmorphic disorder. International OCD Foundation. Retrieved August 20, 2015, from http://www.ocfoundation.org/eo_bdd.asp
4. Hill, M. J. (2006). Body dysmorphic disorder: Implications for practice. Dermatology Nursing, 18(1), 13
5. Mackley CL. Body dysmorphic disorder. Dermatol Surg. 2005 May. 31(5):553-8
6. Phillips, K. (2005) The broken mirror: Understanding and treating body dysmorphic disorder. Oxford University Press
7. Phillips, K. A., Wilhelm, S., & Stein, D. (2010). Body Dysmorphic Disorder: Some Key Issues for DSM-V. Depression and Anxiety; 27(6), 573-591.
8. Phillips K.A. Body dysmorphic disorder: the distress of imagined ugliness. Am J Psychiatry. 1991 Sep. 148(9):1138-49.
9. Veale, D. (2004). Body dysmorphic disorder. Postgrad Medical Journal. 80:67-71
10. Wilhelm S, Otto MW, Lohr B. (1999). Cognitive behavior group therapy for body dysmorphic disorder: A case series. Behaviour Restorative Therapy, 37, 71-75.