Body Dysmorphic Disorder
Clinical Features of Body Dysmorphic Disorder
Body Dysmorphic Disorder (BDD) involves the preoccupation with an imagined or slight defect in appearance. Preoccupation with the skin, hair, and nose are the most common, but any body area can be the focus of concern.
Patients with BDD often can be observed to pick their skin, check their appearance in the mirror frequently, or to try to camouflage their appearance with a hat or make-up. These patients often seek cosmetic surgery repeatedly, only to remain dissatisfied with their appearance.
In the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR; American Psychiatric Association, 2000), BDD is defined as a preoccupation with an imagined defect in appearance; if the person does have a slight physical flaw, the concern is excessive.
The appearance concern must be associated with considerable upset and/or impairment in functioning (including work and social functioning). In addition, the DSM reminds the reader that the body image concerns should not solely occur in the context of another psychiatric disorder (such as weight and shape concerns in anorexia nervosa).
BDD occurs somewhat more often among women than among men. Although most of its clinical features appear generally similar in both genders, some gender differences have been found (Phillips, Menard, & Fay, 2006). BDD usually begins during early adolescence, and appears to have a chronic and unremitting course unless it is appropriately treated.
Core BDD Symptoms
- Appearance Preoccupations
Patients with BDD are preoccupied with the idea that one or more aspects of their appearance are unattractive, deformed, defective, flawed, or “not right” . Some patients describe themselves as “unattractive,” whereas others use stronger words (e.g., “ugly,” “hideous,” “repulsive,” or “looking like a monster”). In reality, these body areas usually look normal. If an imperfection is present, it is slight and not anything that would typically be noticed at a conversational distance.
Preoccupations may focus on any area of the body. They commonly involve the face or head—most often the skin, hair, or nose. Patients may worry, for example, that their skin is terribly scarred, their hair is thinning, their teeth are not straight enough, or their nose is too big. They may be concerned that they are not muscular enough, their thighs are too fat, or their cheekbones are asymmetrical.
On average, over the course of their illness, patients are excessively preoccupied with about five or six different body areas; however, some obsess about only one area, whereas others obsess about virtually every body area. The appearance preoccupations have an obsessive quality, in that they occur frequently (an average of 3 – 8 hours a day) and are usually difficult to resist or control. The thoughts are very distressing and are associated with low self-esteem, rejection sensitivity, anxiety, and depression, as well as feelings of defectiveness, unworthiness, embarrassmentOpens in new window, and shameOpens in new window.
Nearly all patients perform behaviors (rituals) that are intended to examine, improve, or hide the perceived defect. Many of these behaviors (e.g., mirror checking and reassurance seeking) are considered compulsive, in that they are repetitive, time-consuming, and difficult to resist or control.
Others (e.g., camouflaging the perceived flaw with a hat, clothing, or makeup) may be conceptualized as safety behaviors that are intended to prevent a feared consequence (e.g., being ridiculed by others).
Table X-1 lists the most common BDD behaviors and the percentages of people with BDD who have been found to engage in these behaviors over their lifetimes.
|Table X-1. Common BDD Behaviors|
|Behavior||Percentage of people|
with the behavior
|Camouflaging (e.g., with body position/posture, clothing, makeup, hand, hair, or hat)||91%|
|Comparing body part with that of others/scrutinizing the appearance of others||88%|
|Checking appearance in mirrors and other reflecting surfaces||87%|
|Seeking surgery, dermatological, or other cosmetic treatment||72%|
|Excessive grooming (e.g., combing or styling hair, applying makeup, shaving, removing hair||59%|
|Questioning: seeking reassurance or attempting to convince others that the perceived defect is unattractive||54%|
|Touching the perceived defect||52%|
|Mirror avoidance (avoidance of all mirrors for at least several days in a row)||24%|
|Excessive weight lifting||18%|
|Note. Adapted with permission of the publisher from Philips, K. A. (1996; Revised and Expanded Edition, 2005). The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder. New York: Oxford University Press.|
One behavior included in Table X-1, skin picking, deserves special mention. More than one-third of individuals with BDD compulsively pick their skin to try to improve its appearance (Phillips & Taub, 1995).
Because this behavior is difficult to resist and may occur for hours a day, it may cause noticeable skin lesions, especially if implements such as needles or razor blades are used. Thus, unlike other patients with BDD, those who pick their skin may not look “normal” because the picking may cause skin lesions or scarring. In more extreme cases, this behavior can be life-threatening; for instance, one woman picked at her neck so forcibly that she exposed her carotid artery, requiring emergency surgery (O’Sullivan, Phillips, Keuthen, & Wilhelm, 1999).
During the assessment phase, you will need to ask patients carefully about BDD behaviors, because these will be targeted in treatment with response prevention (or habit reversal for skin picking or hair plucking).
BDD behaviors are varied and limitless; Table X-1 includes only the most common ones. One woman, for example, repeatedly tensed and relaxed her facial muscles to make less “limp,” and another frequently pushed on her eyeball to change their shape. To make his face look fuller, a man with BDD slept without a pillow, ate large amounts of food, and drank more than three gallons of water a day (Phillips, 1996, 2005). Thus, in addition to asking patients about whether they engage in any of the behaviors in Table X-1, you will need to ask whether they do any other things to check, fix, hide, or otherwise cope with their perceived flaws.
- Avoidance Behaviors
Nearly everyone with BDD avoids at least some social situations, as they typically feel very self-conscious and embarrassed about how they look in the presence of other people; they believe that others consider them unattractive, ugly, or disfigured.
A majority experience ideas or delusions of reference, believing that other people take special notice of them and single them out of the crowd in a negative way—for example, stare at them, talk about them, or laugh at them because of how they look.
As a result, many patients avoid social gatherings, dating, and/or sexual intimacy; places with lots of mirrors (e.g., stores); places where their bodies will be more exposed (e.g., the beach); or places with lots of people (e.g., shopping malls).
Some people avoid only certain situations, whereas others avoid virtually any situation where other people might see them. Many patients avoid work or school, because they feel too ugly to be seen or feel too depressed and distracted by their appearance obsessions or rituals to focus on the task at hand. About one-third of patients have been completely housebound for at least 1 week because of their BDD symptoms. (Phillips, 2000; Phillips, Menard, Fay, & Pagano, 2005).
Impairment in BDD
It is easy to trivialize BDD by confusing patient’s appearance concerns with vanity. However, BDD is very distressing and impairing. Although at levels of functioning vary, nearly all individuals with BDD experience impairment in social and occupational/academic functioning, often to a debilitating degree. They may avoid usual social and leisure activities, stop working, or drop out of school.
As noted above, they often avoid dating and other social interactions, and some may even become housebound. A high proportion of patients require psychiatric hospitalization (Phillips & Diaz, 1997).
On average, individuals with BDD appear to have poorer quality of life than either patients with clinical depression (major depression and/or dysthmia) or patients with a medical condition such as type II diabetes or a recent heart attack.
Poor Insights or Delusional Beliefs
Most patients with BDD have poor insight or have delusional BDD beliefs. That is, they do not recognize that the appearance of flaws they perceive are actually minimal or nonexistent. Very few untreated patients have good insight. They typically say things like “I’m pretty sure I’m about my nose—it really looks strange,” or “I’m certain I really do look deformed; otherwise, why would everyone be staring at me?”
They also tend to think that most other people share their view of the supposed defects. It’s usually hard to talk people with BDD out of their appearance beliefs. Whereas some patients realize that their appearance beliefs have a psychological or psychiatric cause, many do not; they simply think that their belifs are true.
Patients with poor insight or delusional beliefs can be more difficult to engage and work with in treatment. Although delusional and nondelusional patients have many similarities, the former appear to have a greater likelihood of attempting suicideOpens in new window, a higher rate of substance use disorders, poorer social functioning, and more severe BDD symptoms (Phillips, Menard, Pagano, Fay, & Stout, 2006).
Co-Occurring Mental Health Problems
Most patients with BDD have other mental disorders. Major depressive disorder is most common, with the largest studies reporting a current prevalence of 38 – 58% and a lifetime prevalence of 74 – 76% (Gunstad & Phillips, 2003; Phillips, Didie, & Menard, 2007).
In these studies, the BDD usually began before the depression, and the depressive symptoms often appeared to be secondary to the BDD. A longitudinal study found that improvement of BDD was often quickly followed by improvement of depression, and, conversely, that improvement of depression might also be quickly followed by improvement of BDD (Phillips & Stout, 2006).
Lifetime comorbidity of BDD with other disorders—including substance abuse or dependence (40%), social phobia (38%), and OCD (33%)—is also common. Other studies have reported lower comorbidity rates, which may reflect the treatment setting, referral sources, or other factors. Reported rates of a personality disorder in sizable samples of patients seen in psychiatric settings range from 40 to 72%, with avoidant personality disorderOpens in new window most common.
Suicidal Ideation and Suicide Attempts
An important consideration in treating patients with BDD is that suicidal ideation and suicide attempts are common. Lifetime rates of suicidal ideation are in the range of 78 – 81%, and 24 – 28% of patients have attempted suicide (Phillips, Coles, et al., 2005; Phillips & Diaz, 1997; Veale et al., 1996). The lifetime suicide attempt rate for BDD is an estimated 6 – 23 times higher than in the general U.S. population, and appears higher than for many other psychiatric disorders (Phillips, Coles, et al., 2005).
It is not known with certainty how many people with BDD commit suicide. However, completed suicides have been reported, and the suicide rate (though the data are limited) appears to be very high (Philips & Menard, 2006).
In a restrospective study of patients in two dermatology practices who were known to have committed suicide over 20 years, most had acne of BDD (Cotteril & Cunliffe, 1997). Furthermore, patients with BDD have many suicide risk factors, including (in addition to high rates of suicidal ideation and suicide attempts) psychiatric hospitalization; unemployment and/or disability; being single or divorced; poor social supports; and high rates of major depressive disorder, eating disorders, and substance use disorders.
Additional risk factors include high levels of anxiety and depression, feelings of shame and humiliation, and poor self-esteem. From a clinical perspective, patients’ often delusional belief that they look deformed causes distress and self-loathing. This distress is further fueled by time-consuming intrusive obsessions about the “defect,” as well as the belief that other people share their belief and even mock and ostracize them because of how they look.
Thus patients with BDD must be carefully monitored for suicidality. For patients with worrisome levels of suicidality, hospitalization may be required. Medication can also be considered in addition to CBT, as suicidal thinking often diminishes in patients who receive appropriate medication for BDD (Phillips, 2009; Phillips & Kelly, 2009).
Data from available studies indicate that cognitive-behavioral therapy (CBT)Opens in new window is often efficacious for BDD. Most published studies of CBT have included both cognitive therapy and behavioral components consisting mainly of exposure and response prevention to reduce social avoidance and compulsive behaviors (e.g., mirror checking). CBT has led to consistently good outcomes in studies of individual treatment, studies of group treatment, and one study that used both individual and group treatment. These studies are described briefly below.
CBT was conducted in an individual intensive format by Neziroglu, McKay, Todaro, and Yaryura-Tobias (1996), who provided 20 daily 90-minute sessions to patients with BDD over 1 month. The treatment included exposure to perceived physical defects and social situations; prevention of compulsive behaviors; and cognitive therapy aimed at challenging faulty appearance-related beliefs, perfectionism, and concerns about social acceptance and attractiveness. This treatment produced a 50% reduction in BDD symptoms for 12 of 17 patients.
Available data indicate that serotonin reuptake inhibitors (called SRIs or SSRIs) are often efficacious for BDD (Phillips, 2009). SRIs that are marketed in the United States at the time of this writing include escitalopram (Lexapro), citalopram (Celexa), fluoxetine (Prozac), fluvoxamine (Luvox), sertraline (Zoloft), paroxetine (Praxil), and clomipramine (Anafranil).
SRIs are currently recommended as the first-line medications for BDD. SRIs affect the neurotransmitter serotonin, which is one of the brain’s natural chemicals used to communicate between brain cells. Specifically, SRIs block the reabsorption (reuptake) of serotonin into the releasing nerve cells. This changes the serotonin balance in the brain, and more serotonin is made available to affect key brain areas.
Two randomized double-blind controlled studies of SRIs have been done. A randomized double-blind parallel-group study found that fluoxetine (Prozac) was more efficacious than placebo for BDD symptoms and psychological functioning (Philips, Albertini, & Rasmussen, 2002; Phillips & Rasmussen, 2004).
In a randomized double-blind crossover study, the SRI clomipramine (Anafranil) was more efficacious for BDD than the non-SRI tricyclic antidepressant desipramine (Hollander et al., 1999). This latter study is consistent with previous case series in indicating that SRI antidepressants may be more efficacious than non-SRI antidepressants for BDD.
Systemic, methodologically rigorous open-label with the SRIs fluvoxamine, citalopram, and escitalopram found that these SRIs are also often efficacious.
Among all six SRI studies, BDD response rates in intention-to-treat analyses (which included study dropouts, who may not have had adequate time to improve) ranged from 53 to 77%, and BDD symptoms significantly improved. Response rates were higher than this among those patients who completed the studies.
In addition to improving BDD symptoms, these medications also often significantly improved suicidal ideation, depressive symptoms, anxiety, anger/hostility, somatization, psychosocial functioning, and mental-health-related quality of life in patients with BDD. Of note, SRIs alone also appeared to be efficacious for patients who were completely convinced that they looked ugly or deformed (i.e., who had delusional BDD beliefs).
SRI doses that are needed for successful treatment of BDD are often higher than those typically needed for many other disorders, such as depression. Also, BDD may require a longer time to respond (sometimes as long as 12 – 14 weeks) than many other disorders require. If one SRI is not adequately helpful for BDD, another SRI may be. Alternatively, some patients improve when a different type of medication is added to an ineffective or partially effective SRI.
Surgical, Dermatological, and Other Cosmetic Treatments
A majority of patients with BDD seek and receive cosmetic treatment (e.g., surgical, dermatological, dental) for their BDD concerns. In fact, studies have found that 9 – 12% of patients in dermatology clinics and 3 – 53% in cosmetic surgery clinics have BDD.
Not surprisingly, they may request extensive procedures. Some patients even attempt their own surgery, as in the case of a patient who attempted to replace his nose cartilage with chicken cartilage in the desired shape (Phillips, 1996); another patient used a staple gun to do a facelift (Veale, 2000).
The outcomes of cosmetic treatments usually appear to be poor. In fact, they can lead to increased or new appearance preoccupations and multiple medical procedures without improvement. Occasionally, dissatisfied patients have committed suicide or become violent toward treating physicians (Cotteril, 1996; Phillips, 1991). Thus we do not recommend these treatmens for BDD. Our CBT-BDD includes a treatment module for patients who are receiving or considering cosmetic treatment.
- Pope, C., Pope, H., Menard, W., Fay, C., Olivardia, R., & Philips, K. (2005). Clinical features of muscle dysmorphia among males with body dysmorphic disorder. Body Image, 4, 385 – 400.
- Veale, D., & Riley, S. (2001). Mirror, mirror on the wall, who is the ugliest of them all? The psychopathology of mirror grazing in body dysmorphic disorder. Behavior Research and Therapy 39, 1381 – 1393.
- Woolfolk, R. L., & Allen, L. A. (2011). Somatoform and physical disorders. In D. H. Barlow, (ed.), The Oxford handbook of clinical psychology, (pp. 334 – 358). New York, NY: Oxford University Press.
- Wilhelm, Sabine. Cognitive-behavioral therapy for body dysmorphic disorder: a treatment manual/Sabine Wilhelm, Katharine A. Phillips, and Gail Steketee.