body dysmorphic disorder

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Body Dysmorphic Disorder



Body dysmorphic disorder (BDD) is defined by DSM-IV-TR as a condition marked by excessive pre-occupation with an imaginary or minor defect in a facial feature or localized part of the body. The diagnostic criteria specify that the condition must be sufficiently severe to cause a decline in the patient's social, occupational, or educational functioning. The most common cause of this decline is the time lost in obsessing about the "defect"—one study found that 68 percent of patients in a sample of adolescents diagnosed with BDD spent three or more hours every day thinking about the body part or facial feature of concern. DSM-IV assigns BDD to the larger category of somatoform disorders, which are disorders characterized by physical complaints that appear to be medical in origin but that cannot be explained in terms of a physical disease, the results of substance abuse, or by another mental disorder.
The earliest known case of BDD in the medical literature was reported by an Italian physician named Enrique Morselli in 1886, but the disorder was not defined as a formal diagnostic category until DSM-III-R in 1987. The World Health Organization (WHO) did not add BDD to the International Classification of Diseases (ICD) until 1992. The word dysmorphic comes from two Greek words that mean "bad" or "ugly" and "shape" or "form." BDD was previously known as dysmorphophobia.


BDD is characterized by an unusual degree of worry or concern about a specific part of the face or body, rather than the general size or shape of the body. It is distinguished from anorexia nervosa and bulimia nervosa in that patients with eating disorders are preoccupied with their overall weight and body shape. As many as 50 percent of patients diagnosed with BDD undergo plastic surgery to correct their perceived physical defects.
Since the publication of DSM-IV in 1994, some psychiatrists have suggested that there is a subtype of BDD, namely muscle dysmorphia. Muscle dysmorphia is marked by excessive concern with one's muscularity and/or fitness. Persons with muscle dysmorphia spend unusual amounts of time working out in gyms or exercising rather than dieting obsessively or seeking plastic surgery. DSM-IV-TR added references to concern about body build and excessive weight lifting to DSM-IV's description of BDD in order to cover muscle dysmorphia.
BDD and muscle dysmorphia can both be described as disorders resulting from the patient's distorted body image. Body image refers to a person's mental picture of his or her outward appearance, including size, shape, and form. It has two major components: how the person perceives their physical appearance, and how they feel about their body. Significant distortions in self-perception can lead to intense dissatisfaction with one's body and dysfunctional behaviors aimed at improving one's appearance. Some patients with BDD are aware that their concerns are excessive, but others do not have this degree of insight; about 50 percent of patients diagnosed with BDD also meet the criteria for a delusional disorder.
The usual age of onset of BDD is late childhood or early adolescence; the average age of patients diagnosed with the disorder is 17. BDD has a high rate of comorbidity, which means that people diagnosed with the disorder are highly likely to have been diagnosed with another psychiatric disorder—most commonly major depression, social phobia, or obsessive-compulsive disorder (OCD). About 29% of patients with BDD eventually try to commit suicide.
BDD is thought to affect 1-2 percent of the general population in the United States and Canada, although some doctors think that it is underdiagnosed because it coexists so often with depression and other disorders. In addition, patients are often ashamed of grooming rituals and other behaviors associated with BDD, and may avoid telling their doctor about them. BDD is thought to affect men and women equally; however, there are no reliable data as of the early 2000s regarding racial or ethnic differences in the incidence of the disorder.

Causes and symptoms


The causes of BDD fall into two major categories, neurobiological and psychosocial.
NEUROBIOLOGICAL CAUSES. Research indicates that patients diagnosed with BDD have serotonin levels that are lower than normal. Serotonin is a neurotransmitter—a chemical produced by the brain that helps to transmit nerve impulses across the junctions between nerve cells. Low serotonin levels are associated with depression and other mood disorders.
PSYCHOSOCIAL CAUSES. Another important factor in the development of BDD is the influence of the mass media in developed countries, particularly the role of advertising in spreading images of physically "perfect" men and women. Impressionable children and adolescents absorb the message that anything short of physical perfection is unacceptable. They may then develop distorted perceptions of their own faces and bodies.

Key terms

Body image — A term that refers to a person s inner picture of his or her outward appearance. It has two components: perceptions of the appearance of one's body, and emotional responses to those perceptions.
Delusion — A false belief that is resistant to reason or contrary to actual fact. Common delusions include delusions of persecution, delusions about one s importance (sometimes called delusions of grandeur), or delusions of being controlled by others. In BDD, the delusion is related to the patient's perception of his or her body.
Displacement — A psychological process in which feelings originating from one source are expressed outwardly in terms of concern or preoccupation with an issue or problem that the patient considers more acceptable. In some BDD patients, obsession about the body includes displaced feelings, often related to a history of childhood abuse.
Muscle dysmorphia — A subtype of BDD, described as excessive preoccupation with muscularity and body building to the point of interference with social, educational, or occupational functioning.
Serotonin — A chemical produced by the brain that functions as a neurotransmitter. Low serotonin levels are associated with mood disorders, particularly depression. Medications known as selective serotonin reuptake inhibitors (SSRIs) are used to treat BDD and other disorders characterized by depressed mood.
Somatoform disorders — A group of psychiatric disorders in the DSM-IV-TR classification that are characterized by external physical symptoms or complaints. BDD is classified as a somatoform disorder.
A young person's family of origin also has a powerful influence on his or her vulnerability to BDD. Children whose parents are themselves obsessed with appearance, dieting, and/or body building, or who are highly critical of their children's looks, are at greater risk of developing BDD.
An additional factor in some young people is a history of childhood trauma or abuse. Buried feelings about the abuse or traumatic incident may emerge in the form of obsession about a part of the face or body. This "reassignment" of emotions from the unacknowledged true cause to another issue is called displacement. For example, an adolescent who frequently felt overwhelmed in childhood by physically abusive parents may develop a preoccupation at the high school level with muscular strength and power.


The central symptom of BDD is excessive concern with a specific facial feature or body part. Research indicates that the features most likely to be the focus of the patient's attention are (in order of frequency) complexion flaws (acne, blemishes, scars, wrinkles); hair (on the head or the body, too much or too little); and facial features (size, shape, or lack of symmetry). The patient's concerns may, however, involve other body parts, and may shift over time from one feature to another.
Other symptoms of body dysmorphic disorder include:
  • Ritualistic behavior. Ritualistic behavior refers to actions that the patient performs to manage anxiety and that take up excessive amounts of his or her time. Patients are typically upset if someone or something interferes with or interrupts their ritual. Ritualistic behaviors in BDD may include exercise or makeup routines, assuming specific poses or postures in front of a mirror, etc.
  • Camouflaging the "problem" feature or body part with makeup, hats, or clothing. Camouflaging appears to be the single most common symptom among patients with BDD; it is reported by 94%.
  • Abnormal behavior around mirrors, car bumpers, large windows, or similar reflecting surfaces. A majority of patients diagnosed with BDD frequently check their appearance in mirrors or spend long periods of time doing so. A minority, however, react in the opposite fashion and avoid mirrors whenever possible.
  • Frequent requests for reassurance from others about their appearance.
  • Frequently comparing one's appearance to others.
  • Avoiding activities outside the home, including school and social events.


The diagnosis of BDD in children or adolescents is often made by physicians in family practice because they are more likely to have developed long-term relationships of trust with young people. At the adult level, it is often specialists in dermatology, cosmetic dentistry, or plastic surgery who may suspect that the patient suffers from BDD because of frequent requests for repeated or unnecessary procedures. Reported rates of BDD among dermatology and cosmetic surgery patients range between 6 and 15 percent. The diagnosis is made on the basis of the patient's history together with the physician's observations of the patient's overall mood and conversation patterns. People with BDD often come across to others as generally anxious and worried. In addition, the patient's dress or clothing styles may suggest a diagnosis of BDD. It is not unusual, however, for patients with BDD to take offense if their primary care doctor suggests referral to a psychiatrist.
Some physicians may use a self-report question-naire, such as the Multidimensional Body-Self Relations Questionnaire (MBSRQ) or the short form of the Situational Inventory of Body-Image Dysphoria (SIBID), to evaluate patients during an office visit.
There are no brain imaging studies or laboratory tests as of the early 2000s that can be used to diagnose BDD.


The standard course of treatment for body dysmorphic disorder is a combination of medications and psychotherapy. Surgical, dental, or dermatologic treatments have been found to be ineffective.
The medications most frequently prescribed for patients with BDD are the selective serotonin reuptake inhibitors, most commonly fluoxetine (Prozac) or sertraline (Zoloft). Other SSRIs that have been used with this group of patients include fluvoxamine (Luvox) and paroxetine (Paxil). In fact, it is the relatively high rate of positive responses to SSRIs among BDD patients that led to the hypothesis that the disorder has a neurobiological component related to serotonin levels in the body. An associated finding is that patients with BDD require higher dosages of SSRI medications than patients who are being treated for depression with these drugs.
The most effective approach to psychotherapy with BDD patients is cognitive-behavioral restructuring. Since the disorder is related to delusions about one's appearance, cognitive-oriented therapy that challenges inaccurate self-perceptions is more effective than purely supportive approaches. Thought-stopping and relaxation techniques also work well with BDD patients when they are combined with cognitive restructuring.
Some doctors recommend couples therapy or family therapy in order to involve the patient s parents, spouse, or partner in his or her treatment. This approach may be particularly helpful if family members are critical of the patient s looks or are reinforcing his or her unrealistic body image.

Alternative treatment

Although no alternative or complementary form of treatment has been recommended specifically for BDD, such herbal remedies for depression as St. John's wort have been reported as helping some BDD patients. Aromatherapy appears to be a useful aid to relaxation techniques as well as a pleasurable physical experience for BDD patients. Yoga has helped some persons with BDD acquire more realistic perceptions of their bodies and to replace obsessions about external appearance with new respect for their body's inner structure and functioning.


As of early 2005, the prognosis of BDD is considered good for patients receiving appropriate treatment. On the other hand, researchers do not know enough about the lifetime course of body dysmorphic disorder to offer detailed statistics. DSM-IV-TR notes that the disorder "has a fairly continuous course, with few symptom-free intervals, although the intensity of symptoms may wax and wane over time."


Given the pervasive influence of the mass media in contemporary Western societies, the best preventive strategy involves challenging their unrealistic images of attractive people. Parents, teachers, primary health care professionals, and other adults who work with young people can point out and discuss the pitfalls of trying to look "perfect." In addition, parents or other adults can educate themselves about BDD and its symptoms, and pay attention to any warning signs in their children's dress or behavior.



"Body Dysmorphic Disorder," Section 15, Chapter 186 in The Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 2004.
Johnston, Joni E., Psy D. Appearance Obsession: Learning to Love the Way You Look. Deerfield Beach, FL: Health Communications, Inc., 1994.
Rodin, Judith, PhD. Body Traps: Breaking the Binds That Keep You from Feeling Good About Your Body. New York: William Morrow, 1992.


Arthur, Gary K., MD, and Kim Monnell, DO. "Body Dysmorphic Disorder." eMedicine, 3 September 2004.
Cafri, G., J. K. Thompson, L. Ricciardelli, et al. "Pursuit of the Muscular Ideal: Physical and Psychological Consequences and Putative Risk Factors." Clinical Psychology Review 25 (February 2005): 215-239.
Kirchner, Jeffrey T. "Treatment of Patients with Body Dysmorphic Disorder." American Family Physician 61 (March 2000): 1837-1843.
Slaughter, James R. "In Pursuit of Perfection: A Primary Care Physician's Guide to Body Dysmorphic Disorder." American Family Physician 60 (October 1999): 569-580.


American Psychiatric Association (APA). 1000 Wilson Boulevard, Suite 1825, Arlington, VA 22209-3901. (800) 368-5777 or (703) 907-7322. Fax: (703) 907-1091.


trunk (def. 1).
1. the largest and most important part of any organ.
2. any mass or collection of material.
acetone b's ketone bodies.
Babès-Ernst body metachromatic granule.
Barr body sex chromatin.
ciliary body see ciliary body.
fimbriate body corpus fimbriatum.


ketone b's see ketone bodies.
lamellar body keratinosome.
olivary body olive (def. 2).
paraaortic b's see para-aortic bodies.
pineal body see pineal body.
pituitary body pituitary gland.
polar b's
quadrigeminal b's corpora quadrigemina.
striate body corpus striatum.
wolffian body mesonephros.

bod·y dys·mor·phic dis·or·der

1. a psychosomatic (somatoform) disorder characterized by preoccupation with some imagined defect in appearance in a person who looks normal.
Synonym(s): dysmorphophobia

body dysmorphic disorder

A psychiatric disorder characterized by chronic and obsessive preoccupation with perceived defects in one's physical appearance that appear minor or are not visible to others and that are not related to fat or body weight.
A psychiatric condition in which the patient has a profound negative distortion of his/her body image, which may hinge on perceived craniofacial flaws or imperfections of physique, leading to compulsive checking of his/her appearance in the mirror, intense self-consciousness, social avoidance, isolation and depression

body dysmorphic disorder

Beauty hypochondria, dysmorphophobia Psychiatry A psychiatric condition in which the Pt has a profound negative distortion of his or her body image, which may hinge on a perceived craniofacial flaw; Pts with BDD have obsessive body-image concerns, leading to compulsive checking of appearance in the mirror, intense self-consciousness, social avoidance and isolation, and depression. See Body image. Cf Anorexia nervosa.

bod·y dys·mor·phic dis·or·der

(bod'ē dis-mōr'fik dis-ōr'dĕr)
1. A psychosomatic (somatoform) disorder characterized by preoccupation with some imagined defect in appearance in a person who looks normal.
2. A DSM diagnosis that is established when the specified criteria are met.
Synonym(s): dysmorphophobia.

bod·y dys·mor·phic dis·or·der

(bod'ē dis-mōr'fik dis-ōr'dĕr)
Psychosomatic disorder characterized by preoccupation with some imagined defect in appearance.
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ferred to as ness and is d to eating ing anorexia It is also referred to as imagined ugliness and is closely related to eating disorders including anorexia and bulimia.
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