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What is Body Dysmorphia: Symptoms, Causes, and Treatment
Written by: Raylene Hungate RD/N, LD/N on August 16, 2021
Body Dismorphic Disorder (BDD) or dysmorphophobia affects about 1.7% to 2.4% of the population, which is about 1 in 50 people.1
BDD most often develops in adolescents and young adults, 12-13 years old. Interestingly, it affects men and women almost equally.1
Unfortunately, it can take 10 years or more before a diagnosis is made or treatment is suggested and provided.6
Body Dysmorphia Definition
Body dysmorphic disorder (BDD) is a disabling psychiatric disorder characterized by excessive and persistent preoccupation with perceived defects or flaws in appearance, which are unnoticeable to others, and associated with repetitive behaviors.4
What is Body Dysmorphic Disorder? (According to the DSM-5)
BDD is a preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others.5
In the DSM-5, BDD is now classified under the Obsessive-Compulsive and Related Disorders chapter. This is due to BDD and OCD commonly being diagnosed together.4
During the progression of this disorder, individuals will spend significant amounts of time engaging in repetitive behaviors or mental acts.
These signs of body dysmorphia are key features of the disorder and may include:5
- Mirror checking
- Excessive grooming or hygiene
- Skin picking
- Reassurance seeking
Individuals may also compare themselves physically with others in response to concerns surrounding appearance.5
Lastly, the DSM-5 includes two specifiers when identifying BDD. First, the insight specifier aids clinicians in identifying delusional dysmorphic beliefs. Second, the muscle dysmorphia specifier helps to identify those preoccupied with body build.4
Body Dysmorphic Disorder ICD-10 Code
BDD is underdiagnosed and undertreated in an age when insurance coverage for treatment is possible.
Practitioners can use ICD-10-CM Code F45.22 to bill for the specific diagnosis of BDD3 through insurance.
When medically coding, make sure to use proper terminology. The recommended term to include for BDD would be Dysmorphophobia.3
Body Dysmorphic Statistics
BDD most commonly starts in adolescence and is often unnoticed. Body dysmorphic disorder statistics highlight the prevalence of BDD, who is at risk, and where assessments can be applied for diagnosis.
Here are just a few staggering body dysmorphic statistics:4,6
- BDD affects about 1.9% of the adult population
- BDD affects about 1.7-2.2% of adolescents
- In adult psychiatric outpatients, about 5.8% suffer from BDD
- In adult psychiatric inpatients, about 7.4% suffer from BDD
- In adolescent psychiatric patients, about 6.7-14.3%
- In general cosmetic surgery, up to at least 20% suffer from BDD
- In cosmetic dentistry, about 5.2%
- In dermatology outpatients, 11.3%
On average, people suffering from BDD are preoccupied with 5-7 different body parts during their lifetime.6 If more awareness can be formed around those at risk, then improvements can be made in assessing for and diagnosing BDD.
Who Gets Body Dysmorphic Disorder?
The proportion of adults living with BDD in the United States is 2.4%, with men and women affected equally.7 It commonly begins in adolescence at the time when people are most sensitive about their appearance, but many sufferers live with it for years before seeking help for fear that they will be considered vain.8 Body dysmorphia and its link to eating disorders are similar in this regard.
What is more, BDD is often underdiagnosed, partly because patients tend to talk to healthcare professionals about other related symptoms such as anxiety or depression rather than revealing their underlying concern. Children can get BDD too, but they are often unable to articulate their problems; instead, signs that they are ill can include refusing to attend school and making plans for suicide.
Types of Body Dysmorphia
Body dysmorphia can affect anyone and may present differently based on an individual’s preoccupation. Muscle dysmorphia and BDD by Proxy (BDDBP) are two common subtypes of BDD.
Muscle Dysmorphia
Muscle Dysmorphia is a subtype of BDD involving preoccupation with the entire body. Muscle Dysmorphia is present when an individual is preoccupied with their body build being either too small or having inadequate muscle definition.5
This type of body dysmorphia can be present even if an individual is preoccupied with other body areas. Important to note that those suffering from muscle dysmorphia usually struggle with additional perceived flaws or defects.5
BDD by Proxy (BDDBP)
BDDPD refers to body dysmorphia with the primary preoccupation fixated on perceived imperfections of another person.2
Similar to BDD, individuals spend time repeating rituals to “fix” another person’s appearance in an attempt to alleviate distress.2
This may have a profound impact on someone’s ability to function and interact socially.2
Body Dysmorphia Symptoms & Diagnosis
To diagnose BDD, there must be an awareness of body dysmorphia symptoms.
Common signs of body dysmorphia may include:4,6
- Fixation with the body, primarily face/head, particularly skin, nose, and hair
- Excessive grooming or hygiene routines
- Extreme exercise habits
- Seeking reassurance from others regarding physical appearance
- Change in eating patterns and behaviors
- Repetitive mirror checking
- Skin picking
- Hair pulling
Individuals with BDD may spend about 3-8 hours per day preoccupied with perceived defects or flaws.6 Although 25% of those with BDD will spend more than 8 hours per day focused on perceived flaws.6
Also, BDD diagnosis may be overlooked due to an already present mental illness. Common co-occurring conditions include major depressive disorder, social phobia, obsessive compulsive disorder (OCD), and substance misuse disorders.6
What Are the Effects of Body Dysmorphic Disorder?
Preoccupations resulting from BDD are intrusive and unwanted.6 The effects of body dysmorphic disorder may include:4,6
- Social withdrawal
- Isolating from intimate relationships
- Reduced academic performance
- Dropping out of school
- Unemployment
- Increased distress, shame, disgust, anxiety and depression
- Development of co-occurring mental health conditions
- Increased risk of suicidal ideation and suicide attempts
- Increased risk of substance abuse
- Development of eating disorders
- Development of nutritional deficiencies
- Increased risk of health complications and hospitalizations
What Causes Body Dysmorphic Disorder?
No single factor can be identified as the cause of BDD. BDD is thought to be the result of several interacting factors, including various biological factors and environmental stressors.
Biological Causes of Body Dysmorphic Disorder
The causes of body dysmorphia disorder are unclear; however, some potential biological causes include:1
- Genetic predisposition
- Family history of mental illnesses
- Neurobiological factors (i.e., malfunctioning of serotonin in the brain)
- Having additional diagnosed mental health illnesses (depression, OCD, anxiety, etc.)
Psychological Factors
In addition to biological factors, BDD may be influenced by psychological factors that drive attitudes, beliefs, learned behaviors, perceptions, and motivations. Some factors include:4
- Childhood abuse
- Parents or loved ones that are fixated on physical appearance
- Peer teasing
- Peer victimization
- Personality traits, such as perfectionism
- Cultural beliefs
- Beauty ideals
Psychological factors often lead to fear that people are noticing, judging, or talking about perceived defects or flaws.6 This may fuel behaviors and ultimately lead to deterioration of quality of life.
Why Getting Surgery Doesn’t Work
When surgery goes ahead, it is frequently perceived to be unsuccessful, while in cases where satisfaction is achieved, 50% of people with BDD have been shown to develop a preoccupation with a previously unaffected body part.8 People with BDD are at high risk for depression and suicide and have been shown to have a greater degree of distress than people with depression, diabetes, or bipolar disorder.9
They tend to avoid social situations because they do not want others to see and judge them, and because their perceived defect causes them to be afraid of dating or intimacy.8
They may employ unhelpful strategies to help them endure such situations, such as drinking alcohol to excess, or they may become housebound. As a result, attempts to follow a course of study or engage in paid employment are frequently disrupted.
All of these factors may lead to interpersonal difficulties with family members who cannot understand the extent of the disability that the person with BDD faces.8
Living with BDD can make even everyday, normal activities challenging and overwhelming, creating an overall poor quality of life. Individuals with BDD are also at increased susceptibility for suicide, with research surveys finding that approximately 80% of individuals with BDD reporting suicidal ideation, and about one quarter having attempted suicide.9
Another behavior experienced among some individuals with BDD includes violent behavior, with approximately one-third of people with BDD reporting violence related to their symptoms.
Body Dysmorphia Treatment
Addressing how to help someone with body dysmorphia starts with an assessment for BDD. It is the first step in body dysmorphia treatment. The utilization of a screening tool, such as the BDD Questionnaire, may aid in detection in various settings, including psychiatric, general medicine, and cosmetic procedures.6
After assessing for and diagnosing BDD, treatment can start. The preferred treatment for BDD is cognitive behavioral therapy (CBT).
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In those suffering from BDD, insight related to appearance beliefs may be poor or even nonexistent [6]. Studies have found delusional beliefs can range from 32-38% in those with BDD.6
The inability to have good insight prevents individuals from even entertaining the possibility that their beliefs may not be true.6
CBT helps patients uncover alternative explanations for their preoccupations. Through CBT, patients also work to reduce self-focused attention or rituals and reduce ruminations or self-defeating coping mechanisms.6
This form of therapy will support and guide patients through gradual exposures to challenge fears and to start practicing new adaptive coping mechanisms.6
Ambivalence to treatment, especially after starting exposure-based treatment, is very common. It is important for healthcare professionals, including therapists, dietitians, and psychiatrists, to support patients through motivational interviewing.
The incorporation of serotonin reuptake inhibitor (SRI) medication has been suggested in addition to CBT.6 In some cases, the addition of SRI medication has been shown to enhance outcomes.6
Some studies have also found that the incorporation of an SRI has improved BDD and associated symptoms in about 63-83% of patients.6
Body Dysmorphic Disorder: How to Treat Those Who are Suffering
Kevin Wandler, MD is the Chief Medical Officer of Advanced Recovery
Systems and Jessica Setnick, MS, RD, CEDRD, Remuda Ranch Senior Fellow and author of Pocket Guide to Eating Disorders
Resources
- What is Body Dysmorphic Disorder? (n.d.). Anxiety & Depression Association of America. Retrieved June 30, 2021.
- Greenberg JL, Mothi SS, & Wilhelm S. (2016). Cognitive-Behavioral Therapy for Body Dysmorphic Disorder by Proxy. Behavior Therapy; 47(4):515–526.
- ICD-10-CM Code F45.22 – Body dysmorphic disorder. (n.d.). ICD.CODES. Retrieved June 30, 2021.
- Krebs G, Fernández De La Cruz L, & Mataix-Cols D. (2017). Recent advances in understanding and managing body dysmorphic disorder. Evidence Based Mental Health; 20(3):71–75.
- Substance Abuse and Mental Health Services Administration. (2016). DSM-5 Changes: Implications for Child Serious Emotional Disturbance. CBHSQ Methodology Report. Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, Rockville, MD
- Veale D, & Singh A. (2019). Understanding and treating body dysmorphic disorder. Indian Journal of Psychiatry; 61(7):131.
- Koran LM, Abujaoude E, Large MD, Serpe RT. (2008). The prevalence of body dysmorphic disorder in the United States adult population. CNS Spectrums; 13(4):316-22.
- Veale D. Body dysmorphic disorder. (2004). Postgraduate Medical Journal; 80(940):67-71.
- Phillips KA. (2000). Quality of life for patients with body dysmorphic disorder. The Journal of Nervous and Mental Disease; 188(3):170-5.
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