Body Dysmorphic Disorder (BDD)

A distressing preoccupation with perceived flaws in physical appearance

Core Diagnostic Criteria (DSM-5):

  • Preoccupation with ≥1 perceived defect or flaw in appearance that appears slight or unobservable to others
  • Repetitive behaviors (mirror checking, excessive grooming) or mental acts (comparing appearance) in response to concerns
  • Clinically significant distress/impairment in functioning
  • Not better explained by eating disorder concerns

Clinical Features:

  • Most common preoccupations: Skin (73%), hair (56%), nose (37%), eyes (20%)
  • Compulsive behaviors:
    • Camouflaging (with clothes/makeup)
    • Mirror checking/avoidance
    • Seeking reassurance
    • Skin picking
    • Excessive exercise
  • Insight levels (similar to OCD):
    • Good (knows beliefs may be exaggerated)
    • Poor (convinced beliefs are accurate)
    • Delusional (absolute certainty)

Epidemiology:

  • Prevalence: 1.7-2.9% general population
  • Onset: Adolescence (mean 16-17 years)
  • Gender: Slightly more common in females
  • High suicide risk: 25-30% lifetime suicide attempts

Neurobiological Basis:

  • Abnormal visual processing (hyperfocus on details vs. holistic view)
  • Serotonin and dopamine dysregulation
  • Overactivation in orbitofrontal cortex and amygdala

Differential Diagnosis:

  • Normal appearance concerns (not time-consuming/distressing)
  • Eating disorders (focus on weight/body shape)
  • Social anxiety (fear of judgment, not appearance focus)
  • Delusional disorder (complete conviction)
  • OCD (broader range of obsessions)

Evidence-Based Treatment:

1. Psychotherapy:

  • CBT (gold standard):
    • Cognitive restructuring of distorted beliefs
    • Exposure (e.g., going out without camouflage)
    • Response prevention (mirror checking avoidance)
  • Enhancement strategies:
    • Motivational interviewing (for poor insight)
    • Perceptual retraining (viewing whole face/body)

2. Pharmacotherapy:

  • First-line: SSRIs (higher doses than for depression)
    • Fluoxetine (60-80mg/day)
    • Sertraline (150-200mg/day)
  • Augmentation strategies:
    • Atypical antipsychotics (for delusional variant)
    • Clomipramine (for treatment-resistant cases)

3. Advanced Interventions:

  • Deep brain stimulation (for refractory cases)
  • Cosmetic procedure refusal protocols

Clinical Management Pearls:

  • Avoid validating perceived flaws
  • Address comorbid depression/suicide risk
  • Collaborate with dermatologists/plastic surgeons (high rates of seeking procedures)
  • Use the Body Dysmorphic Disorder Examination (BDDE) for monitoring

Prognosis:

  • Chronic course without treatment
  • 50-80% improve with CBT/SSRIs
  • Poorer outcomes with:
    • Delusional beliefs
    • Comorbid personality disorders
    • Late treatment initiation

Patient Resources:

  • IOCDF Foundation (iocdf.org)
  • The Broken Mirror (book by Katharine Phillips)
  • BDD Foundation (bddfoundation.org)