Section Learning Objectives

• Describe how body dysmorphic disorder presents itself.
• Describe the epidemiology of body dysmorphic.
• Indicate which disorders are commonly comorbid with body dysmorphic disorder.
• Indicate what factors are implicated in the etiology of body dysmorphic disorder.
• Describe the treatment for body dysmorphic disorder.

5.2.1 Clinical Description

Body Dysmorphic Disorder (BDD) is another obsessive-compulsive related disorder, however, the focus of these obsessions is on a perceived defect or flaw in physical appearance. A key feature of these obsessions with defects or flaws is that they are not observable to others or appear very slight to others. An individual who has a congenital facial defect or a burn victim who is concerned about scars are not examples of an individual with BDD. The obsessions related to one’s appearance can run the spectrum from feeling “unattractive” to “looking hideous.” While any part of the body can be a concern for an individual with BDD, the most commonly reported areas are skin (e.g., acne, wrinkles, skin color), hair (e.g., thinning hair or excessive body hair), or nose (e.g., size, shape).

The distressing nature of the obsessions regarding one’s body often drives individuals with BDD to engage in compulsive behaviors that take up a considerable amount of time. For example, an individual may repeatedly compare their body to other people’s bodies in the general public, repeatedly look at themself in the mirror, and/or engage in excessive grooming which includes using make-up to modify their appearance. Some individuals with BDD will go as far as having numerous plastic surgeries in an attempt to improve their appearance. The problem is plastic surgery does not usually resolve the issue; after all the physical defect or flaw is not observable to others. While most of us engage in some of these behaviors, to meet the diagnostic criteria for BDD, one must experience significant distress and/or display significant impairment in social, occupational, or other areas of functioning. Indeed, nearly all individuals with BDD have impairments in psychosocial functioning that range from moderate (e.g., avoiding some social situations) to severe (e.g., being housebound).

5.2.1.1  Muscle Dysmorphia. 

While muscle dysmorphia is not a formal diagnosis, it is a common type of BDD, that occurs almost exclusively in males.  Muscle dysmorphia refers to the belief that one’s body is too small, or lacks an appropriate amount of muscle definition despite having a normal-looking or muscular body (Ahmed, Cook, Genen & Schwartz, 2014). While the severity of BDD between individuals with and without muscle dysmorphia appears to be the same, some studies have found higher substance use (i.e. steroid use), poorer quality of life, and increased reports of suicide attempts in those with muscle dysmorphia (Pope, Pope, Menard, Fay Olivardia, & Philips, 2005).

5.2.2 Epidemiology

The point prevalence rate for BDD among U.S. adults is 2.4% (APA, 2022). Internationally, this rate drops to 1.7% –2.9% (APA, 2022). Despite the difference between the national and international prevalence rates, the symptoms across cultures are similar, although in some collectivist cultures (e.g., Japan) concerns may emphasize the fear of offending others because of their perceived defect (APA, 2022).

Gender-based prevalence rates indicate a fairly balanced sex ratio (2.5% females; 2.2% males; APA, 2013). While the diagnosis rates may be different, general symptoms of BDD appear to be the same across genders with one exception: males tend to report genital preoccupations, while females are more likely to present with a comorbid eating disorder.

5.2.3 Comorbidity

While research on BDD is still in its infancy, initial studies suggest that major depressive disorder is the most common comorbid psychological disorder (APA, 2013). Major depressive disorder typically occurs after the onset of BDD. Additionally, there are some reports of social anxiety, OCD, and substance-use disorders (likely related to muscle enhancement; APA, 2022).

5.2.4 Etiology

Initial studies exploring genetic factors for BDD indicate a hereditary influence as the prevalence of BDD is elevated in first-degree relatives of people with BDD. Interestingly, the prevalence of BDD is also heightened in first-degree relatives of individuals with OCD (suggesting a shared genetic influence for these disorders).

However, environmental factors appear to play a larger role in the development of BDD than OCD (Ahmed, et al., 2014; Lervolino et al., 2009). Specifically, it is believed that negative life experiences such as teasing in childhood, negative social evaluations about one’s body, and even childhood neglect and abuse contribute to BDD. Cognitive research has further discovered that people with BDD tend to have an attentional bias towards beauty and attractiveness, selectively attending to words related to beauty and attractiveness. Cognitive theories have also proposed that individuals with BDD have dysfunctional beliefs that their worth is inherently tied to their attractiveness and hold attractiveness as one of their primary core values. These beliefs are further reinforced by our society, which overly values and emphasizes beauty.

5.2.5 Treatment

Seeing as though there are strong similarities between OCD and BDD, it should not come as a surprise that the only two effective treatments for BDD are those that are effective in OCD. Exposure and response prevention has been successful in treating symptoms of BDD, as clients are repeatedly exposed to their body imperfections/obsessions and prevented from engaging in compulsions (e.g., mirror checking) used to reduce their anxiety (Veale, Gournay, et al., 1996; Wilhelm, Otto, Lohr, & Deckersbach, 1999).

The other treatment option, psychopharmacology, has also been shown to reduce symptoms in individuals diagnosed with BDD. Similar to OCD, medications such as clomipramine (a tricyclic antidepressant) and some SSRIs are generally prescribed. While these are effective in reducing BDD symptoms, once the medication is discontinued, symptoms resume nearly immediately, suggesting this is not an effective long-term treatment option for those with BDD.

Treatment of BDD appears to be difficult, with one study finding that only 9% of clients had full remission at a 1-year follow-up, and 21% reported partial remission (Phillips, Pagano, Menard & Stout, 2006). A more recent finding reported more promising findings with 76% of participants reporting full remission over an 8-year period (Bjornsson, Dyck, et al., 2011).

5.2.5.1 Plastic surgery and medical treatments

It should not come as a surprise that many individuals with BDD seek out plastic surgery to attempt to correct their perceived defects. Phillips and colleagues (2001) evaluated treatments of clients with BDD and found that 76.4% reported some form of plastic surgery or medical treatment, with dermatology treatment the most reported (45%) followed by plastic surgery (23%). The problem with this type of treatment is that the individual is rarely satisfied with the outcome of the procedure, thus leading them to seek out additional surgeries on the same defect (Phillips, et al., 2001). Therefore, it is important that medical professionals thoroughly screen patients for BDD before completing any type of medical treatment.