Body dysmorphic disorder

Body dysmorphic disorder (BDD) is characterized by distressing or impairing preoccupation with nonexistent or slight defects in one's physical appearance. To try to alleviate the distress caused by the appearance preoccupations, patients perform repetitive behaviors, such as excessive mirror checking, grooming, or reassurance seeking.

BDD is associated with marked functional impairment and very poor quality of life. Suicidality is common. A majority of people with BDD seek and receive cosmetic procedures for their perceived appearance flaws.

BDD is diagnosed by asking the patient questions about BDD symptoms and determining whether diagnostic criteria are met.

Selective serotonin-reuptake inhibitors (SSRIs) and the tricyclic antidepressant clomipramine are first-line pharmacotherapy. Cognitive behavioral therapy that is specifically tailored to the unique symptoms of BDD is the first-line psychotherapy. Monitor patients for suicidal ideation and behavior during treatment.

Treatment requires at least several weeks, or even several months, before it might start to work. An adequate treatment trial takes many months.

BDD is typically chronic unless it is effectively treated. Appropriate treatment results in high response and remission rates.

BDD consists of preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear only slight to others.[1]American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 5th ed., text revision, (DSM-5-TR). Washington, DC: American Psychiatric Publishing; 2022.​ The preoccupation triggers repetitive behaviors (also referred to as compulsions or rituals), such as excessively checking the perceived flaws in mirrors or other reflecting surfaces, excessive grooming, skin picking, or seeking reassurance about one's appearance.[1]American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 5th ed., text revision, (DSM-5-TR). Washington, DC: American Psychiatric Publishing; 2022. These repetitive behaviors sometimes consist of mental acts, such as comparing one's appearance with that of other people.[1]American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 5th ed., text revision, (DSM-5-TR). Washington, DC: American Psychiatric Publishing; 2022. The preoccupations cause clinically significant distress or clinically significant impairment in functioning (for example, work, academic, social, or role functioning) – usually both.[1]American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 5th ed., text revision, (DSM-5-TR). Washington, DC: American Psychiatric Publishing; 2022. If appearance preoccupations focus on perceived excessive weight or “fat” body areas (such as stomach or thighs), and if the individual has an eating disorder diagnosis, these concerns count towards the eating disorder diagnosis rather than a diagnosis of BDD.[1]American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 5th ed., text revision, (DSM-5-TR). Washington, DC: American Psychiatric Publishing; 2022.

In recent years, a broad range of colloquial terms have been used for constructs with similarities to BDD. These terms include body dysmorphia, skin dysmorphia, acne dysmorphia, and penile dysmorphia. In both the medical literature and the popular press, these terms are often not precisely defined or operationalized, and many scientific studies do not use validated screening or diagnostic measures for BDD. The meaning of these terms and constructs is therefore often unclear. These terms often overlap significantly with BDD and may even be synonymous with the disorder BDD (depending on how they are used). However, they may instead refer to more normative, nonpathologic, non-BDD body image concerns and dissatisfaction.