Body Dysmorphic Disorder

Key Takeaways

• Body dysmorphic disorder is a mental health condition marked by an obsessive and intrusive fixation on perceived flaws in physical appearance, causing significant distress.

• Individuals with BDD present with symptoms of repetitive behavior, such as constantly checking the mirror or taking selfies, excessive grooming and weightlifting, attempting to hide the perceived defects with makeup or clothing, and skinpicking.

• Treatment for body dysmorphic disorder typically involves cognitive behavioral therapy and medication, with hospitalization recommended in cases of suicidal thoughts or attempts.

Understanding Body Dysmorphia

Body dysmorphic disorder (BDD) is a mental disorder classified in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) as an obsessive focus on perceived flaws or defects in physical appearance. Typically, these flaws do not exist or appear minor to others, although in certain cases, people with BDD may fixate on physical aspects in line with societal norms. ^[1]

Individuals with BDD may struggle with all-consuming, uncontrollable thoughts regarding their perceived imperfections, with ruminations typically lasting between three and eight hours per day. Some individuals with the disorder are fixated on a single physical feature, while others are preoccupied with multiple areas (averaging between five and seven different “flaws”). ^[1]

Any physical feature can be perceived as a horrific defect by a person with BDD. Common features of concern include the hair, skin, nose, breasts, stomach, and eyes. Men more often fixate on perceived issues such as balding or genital size, while women tend to fixate on body fat distribution, particularly in areas such as the legs, buttocks, breasts, hips, and waist. ^[1]

Classified within the “obsessive-compulsive and related disorders” chapter of the DSM-5, the condition leads to distressing repetitive behaviors, such as excessive mirror checking, hiding perceived flaws with makeup or clothing (camouflaging), excessive weightlifting, excessive grooming, skin picking, or obsessively comparing one's physical image to others. ^[1]

BDD and Cosmetic Procedures

The overwhelming belief held by individuals with BDD is that they are unattractive, deformed, or repulsive. This leads to significant emotional turmoil and can cause noticeable impairment in important areas of functioning. In light of the distress experienced by individuals with BDD, many pursue cosmetic procedures in an attempt to correct what they perceive as flawed. ^[1]

Sometimes, instead of seeking mental health care to address their false beliefs or distorted self-image, individuals with body dysmorphic disorder will visit beauticians, dermatologists, botox practitioners, and plastic surgeons. However, research has revealed that people with BDD tend to be strongly dissatisfied with the results. ^[2]

Furthermore, studies have found that even after a satisfactory cosmetic procedure, the symptoms of body dysmorphia can worsen, with individuals seeking further cosmetic procedures or redirecting their obsession to another area of their appearance. ^{[2] [3]}

How Common Is It?

According to a 2025 meta-analysis, around 13% to 21% of the global population is estimated to have body dysmorphic disorder across all ages and genders, although the condition remains underrecognized. BDD was found to be more common in females than males and is most prevalent among plastic surgery clients, followed by psychiatric and dermatology patients. ^{[1] [4]}

Furthermore, emerging research suggests that social media may play a role in fueling body dysmorphic disorder and increasing interest in cosmetic surgery (particularly among women and singles). Findings reveal that participants who spent 4 to 7 hours a day on Instagram and Snapchat were 10 % more likely to have BDD than those who spent less than an hour. ^[2]

Although this small-scale study focused on 1483 Saudi adults during a specific period (rather than tracking participants over time, or analyzing multiple studies for the global population), these findings indicate a link between social media usage and the potential for a growing prevalence of body dysmorphic disorder among social networking users.

Symptoms of Body Dysmorphia

Body dysmorphic disorder affects how individuals see themselves and others, often resulting in significant disruption to daily life. One of the key symptoms that differentiates BDD from commonplace self-image concerns is the presence of repetitive behaviors, performed in an attempt to ease the intense distress caused by appearance-related thoughts. ^[1]

Preoccupation with Perceived Physical Flaw/s

People with BDD are intensely preoccupied with perceived flaws in their appearance that may not be observable to others. These perceived defects may morph from one feature to another over time. While some individuals focus on one specific body part, others worry about multiple areas, which commonly include: ^[1]

• Skin (complexion, acne, wrinkles, pigmentation, veins, etc.)

• Hair (loss of volume or baldness)

• Nose

• Stomach

• Breast

• Eyes

• Muscles

• Genitals

• Legs

• Hips

• Buttocks

• Waist

Awareness of body dysmorphic disorder can vary, with some individuals realizing that the perceptions surrounding their “imperfections” are excessive, and others believing their judgment is likely accurate, while others are convinced that they are flawed. The more certain the beliefs, the greater the distress and disruption they may cause. ^[1]

Significant Distress and Impaired Functionality

A persistent, overwhelming belief that one’s appearance is flawed (regardless of reality) leads to emotional turmoil and can significantly disrupt a person’s ability to function. This is largely due to the incredibly time-consuming fixation surrounding perceived flaws, often leading to repetitive behaviors. Additional signs of distress and impaired functionality include: ^[1]

• Feeling convinced that others are judging or mocking one’s appearance

• Frequently comparing one’s looks to others

• Regularly asking others for reassurance about one's looks

• Struggling with perfectionism, especially regarding one’s appearance

• Avoiding social interactions due to appearance-related distress

• Pursuing cosmetic procedures but feeling little to no satisfaction afterward

• Accumulating debt as a result of undergoing cosmetic treatments

• Unable to focus at work or school, or an inability to remain present in relationships

• Difficulty interpreting the emotions of others from facial expressions (more likely to perceive neutral faces as angry)

• Challenges with executive functioning in the brain may affect impulse control, planning, and decision-making

• Anxiety

• Panic attacks (in a small percentage of cases)

• Depression

• Self-harm

• Suicidal thoughts or behaviors

Repetitive Behaviors

Individuals with body dysmorphic disorder often engage in repetitive behaviors (also referred to as compulsions or rituals) to cope with the intense psychological distress caused by their persistent, distressing thoughts related to appearance. Many individuals with BDD engage in these behaviors at some point during their condition: ^[1]

• Hiding certain body parts with clothing

• Camouflaging perceived flaws with makeup, accessories, or tattoos

• Frequent mirror checking or avoidance of mirrors altogether (or constantly checking one’s appearance with a smartphone or in window reflections)

• Excessive grooming (e.g., reapplying makeup throughout the day)

• Compulsive skin picking

• Changing outfits repeatedly due to dissatisfaction

• Over-exercising in an effort to build muscle or lose weight

• Closely inspecting the area of concern

• Constantly seeking reassurance from others regarding one’s perceived flaw

Other rituals are internal and invisible to others, such as: ^[1]

• Pervasively comparing one’s appearance to others

• Counting or repeating mental statements

• Attempting to mentally reassure oneself that one’s appearance is acceptable

BDD in Children

A recent UK study of over 7,600 children and adolescents found that around 1 in 100 young people have body dysmorphic disorder. The condition is rare in children under the age of 12 but more common in teenagers, especially among females, with around 3 in 100 adolescent women struggling with the disorder, compared to less than 1 in 100 males. ^[5]

Despite the rise in social media, which has affected the prevalence of body dysmorphic disorder, BDD is often missed or not treated properly in children and teenagers. Research over the past decade has helped to understand the disorder better, including the fact that it usually starts during the teenage years. ^[5]

The majority of young people with BDD are concerned about more than one aspect of their appearance. In an attempt to manage these concerns, they often spend a lot of time checking mirrors, hiding perceived flaws, or trying to fix them. They may also avoid certain situations (especially social events or brightly lit places) where they feel more exposed. ^[5]

In light of findings that show a strong link between the onset of body dysmorphic disorder and social media use, it is recommended to limit time spent using apps such as Instagram or TikTok during the developmental years. Additionally, educating children and adolescents about unrealistic beauty standards and promoting body positivity in the home may help prevent BDD.

Causes of Body Dysmorphia

There is a limited number of high-quality studies examining the underlying causes of body dysmorphic disorder, and those that exist are small in scale. However, while the exact cause of the condition remains unknown, current findings suggest that BDD is linked to biological, psychological, environmental, and social factors, including digital media: ^{[1] [2]}

Biological Factors

Brain scans show that body dysmorphic disorder involves changes in the brain, but it is not clear if these changes cause the disorder or are a result of it. Additionally, research has shown a link between BDD and genetics, with one study showing that a specific gene appears more often in people with the disorder, and twin studies suggesting that around 43% of BDD may be inherited. ^[1]

Psychological Contributors

People with body dysmorphic disorder may struggle with perfectionism, leading them to constantly compare their appearance to others and develop a distorted body image. When an individual’s body image becomes distorted, they are nearly six times more likely to experience severe symptoms of BDD than those with a more accurate view of their appearance. ^[2]

Environmental Influences

A history of abuse, negative childhood experiences (such as lower levels of parental care or neglect), and taunting may contribute to the onset of body dysmorphic disorder. These experiences can lead to low self-esteem and insecurity, with 69% of individuals with BDD reporting that they were mocked or bullied during childhood. ^[2]

Social Media and BDD

Research states that body dysmorphic disorder and the widespread use of digital communication often occur together. According to existing data, frequent use of social media could be a major risk factor for developing BDD. Constant exposure to edited and idealized images online can contribute to insecurities and a distorted perception of one's body. ^[2]

Researchers believe that exposure to social media can contribute to body dissatisfaction and low self-esteem by encouraging self-objectification and comparison (particularly in women). Furthermore, it has been shown that females who frequently shared selfies on social media had higher body dissatisfaction, overevaluated their size, and were more likely to adopt the notion of a thin ideal. ^[2]

Recent studies have found that selfies are a major contributor to the rise in plastic surgery among young people. Research indicates that photo filters, which enhance physical features, can influence individuals to pursue cosmetic procedures, a phenomenon known as “Snapchat dysmorphia,” where plastic surgery patients request to resemble their filtered images. ^[2]

Conditions Linked with Body Dysmorphia

Body dysmorphic disorder frequently occurs alongside other mental health conditions. Additionally, the disorder also shares symptoms with a number of other psychiatric disorders that can make it difficult for clinicians to diagnose the condition accurately. ^[1]

Commonly Co-Occurring Disorders

• Anxiety disorders: Highly prevalent amongst individuals with BDD, with social anxiety being particularly common due to fears about appearance and judgment.

• Major depression: Widespread in those living with body dysmorphic disorder, often stemming from persistent feelings of inadequacy and hopelessness.

• Psychotic disorders: Appear at higher rates in BDD individuals, sometimes involving delusional beliefs about perceived flaws.

• Bipolar disorder: Frequently co-occurs with BDD, where mood instability can further complicate body image concerns.

• Personality disorders: Personality disorders share patterns of distorted self-perception along with emotional dysregulation.

• Substance use disorder: Commonly develops in individuals with BDD as they attempt to escape emotional turmoil or cope with overwhelming social fears.

Disorders With Overlapping Symptoms

• Skin picking disorder: Similar to BDD but involves skin-picking behaviors without a fixation on improving perceived flaws.

• Trichotillomania (hair-pulling disorder): Involves compulsive hair-pulling, and is part of the OCD-related disorders group, but BDD is diagnosed when there is a focus on perceived defects.

• Isolated dysmorphic concern: A perceived concern about one's body, differing from BDD in that there are no symptoms of repetitive behavior.

• Obsessive-compulsive disorder (OCD): Similar to BDD but distinct in that OCD manifests as intrusive thoughts or obsessions unrelated to appearance.

• Gender dysphoria: Incongruence between experienced gender and gender assigned at birth, causing distress and impairment in social or occupational functioning.

• Eating disorders: These include anorexia nervosa and bulimia nervosa, where symptoms of BDD and eating disorders overlap as a distorted body image.

• Major depressive disorder: Many people with BDD have symptoms that mirror depression, such as a low mood, sleep changes, and appetite disturbances.

• Social anxiety disorder: Characterized by the fear of being judged by others, but social anxiety symptoms relate to behavior and speech, while BDD focuses on appearance.

• Delusional disorder: People with severe BDD may have delusional (false) beliefs about their appearance, though the preoccupation in BDD is not always delusional.

Risks and Complications

Body dysmorphic disorder can significantly impact social relationships, emotional processing, and performance at work or school, resulting in a poorer quality of life. Severe BDD can lead to total social isolation, choosing to leave the workforce or drop out of school, and, in some cases, becoming housebound for years in order to avoid being seen. ^{[1] [6]}

Approximately 40% of individuals with body dysmorphic disorder have been hospitalized for psychiatric reasons, with more than 25% attributing at least one hospitalization primarily to BDD. In light of the severe psychological strain caused by the disorder, many people with BDD also develop other mental health conditions, with nearly 75% also struggling with major depression. ^{[1] [6]}

Research suggests that suicidality is more prevalent in individuals with body dysmorphic disorder compared to those with various other psychiatric disorders. Suicidal thoughts are widespread, affecting between 50% to 80% of those with BDD, and around 26% of people living with the condition attempt suicide. ^{[1] [6]}

This is likely due to feelings of worthlessness and hopelessness surrounding perceived “deformities”, stemming from a belief that it is not possible to fix these “flaws”, as well as beliefs that others reject them due to their looks, and that they experience social isolation and mockery as a result of their appearance. ^[6]

Suicide Hotlines

If you or someone you care about is experiencing suicidal thoughts or plans, it is important to seek help immediately. The suicide and crisis hotline for the United States of America is 988, and you can find more suicide hotlines for veterans, youth, and Spanish-speaking people living in the States here.

You can also find suicide hotline numbers worldwide through this link. If your country is not listed, you can easily search for "suicide hotline" + "your country" to get immediate help. Remember, individuals with suicidal thoughts linked to BDD may not recognize that their beliefs are irrational, and in some cases, hospitalization might be necessary.

Getting a Diagnosis for Body Dysmorphia

Being diagnosed with body dysmorphic disorder involves a physical examination, which can be conducted by non-psychiatric doctors, as well as a comprehensive mental health evaluation, which may be administered in mental health settings such as a hospital, institution, or a psychologist's or psychiatrist’s office. ^[1]

Due to many symptoms of body dysmorphic disorder overlapping with those of other psychiatric disorders, it is common for BDD to be misdiagnosed or missed entirely. To further complicate the matter, many individuals living with the disorder do not wish to draw attention to their perceived flaws and may only mention them upon questioning. ^[1]

That said, there are a few signs that may indicate the presence of body dysmorphic disorder to qualified mental health professionals. In addition to the official DSM-5 diagnostic criteria, these include uncontrollable compulsive behaviors observed during an appointment, and a history of unsatisfactory cosmetic procedures, along with the pursuit of unnecessary aesthetic treatments. ^[1]

Additionally, during an assessment or care, a healthcare professional may discover a belief held by the person with BDD surrounding their perceived flaw.. Furthermore, upon examination of the concerning feature, the provider observes whether the flaw is either non-existent or non-consequential. ^[1]

The Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-5) lists the following diagnostic criteria for body dysmorphic disorder: ^[1]

• Individuals are intensely focused on one or more perceived flaws in their appearance, which are either unnoticeable or barely noticeable to others.

• The individual engages in repeated behaviors in response to these concerns.

• The fixation leads to significant emotional distress or disrupts important areas of daily life, such as work, school, or relationships.

• The appearance-related concerns are not better explained by an eating disorder.

If a person’s main concern is that their muscles or physique appear too small, the diagnosis is specified as “body dysmorphic disorder with muscle dysmorphia”. When panic attacks are also present and linked to these appearance-related concerns, the diagnosis is classified as “body dysmorphic disorder with panic attacks”. ^[1]

Additionally, in rare cases, individuals are preoccupied with physical flaws that are genuinely noticeable to others. If all other DSM-5 criteria for BDD are met, then the person is diagnosed with “body dysmorphic-like disorder with actual flaws,” which falls into the "other specified obsessive-compulsive and related disorder” section of the manual. ^[1]

What Assessments are Used?

Individuals who are suspected of having body dysmorphic disorder should undergo a comprehensive psychiatric assessment. The main objectives of this initial evaluation are to gather detailed background information related to the presenting concerns and perform a thorough mental status examination (MSE). ^[1]

Additionally, clinicians may potentially administer self-report questionnaires such as the body dysmorphic disorder questionnaire (BDDQ) or the body image disturbance questionnaire (BIDQ). These questionnaires rely on a patient’s honesty to obtain accurate information that may affect the diagnosis. ^[1]

Mental Status Examination (MSE)

The MSE includes targeted interview questions that explore each of the DSM-5 diagnostic criteria for body dysmorphic disorder. This assessment evaluates a patient's psychological functioning during a clinical interview and includes observations and questions related to appearance, behavior, mood, thought content, perception, cognition, and insight. ^[1]

Body Dysmorphic Disorder Questionnaire (BDDQ)

The BDDQ is another self-report tool used to screen individuals for symptoms of body dysmorphic disorder. This questionnaire has shown high accuracy in identifying BDD individuals, with a sensitivity of 100%, meaning it correctly identifies all individuals with the disorder, and a specificity of 90.3%, meaning it accurately excludes those without the disorder. ^{[1] [4]}

Body Image Disturbance Questionnaire (BIDQ)

The BIDQ is a self-report questionnaire designed to assess the severity of body image distortions in individuals suspected of having body dysmorphic disorder. It evaluates the level of distress a person experiences related to their physical appearance, focusing on how intensely they are preoccupied with perceived flaws. ^[1]

Risks of Self-Diagnosis

With the growing popularity of social media, photographic filters, and cosmetic procedures in recent years, almost everyone struggles with a negative self-image from time to time. Add to this the growing awareness surrounding mental health, and it can be tempting for some to self-diagnose as having body dysmorphic disorder.

However, while the pursuit of beauty is a natural human instinct, an overwhelming obsession with correcting non-existent "defects" is a serious mental health disorder. Although BDD exists on a spectrum, the disorder is only clinically diagnosed when it presents as compulsive behaviors and significantly time-consuming ruminations that affect a person’s ability to function. ^[1]

It is unwise to rely on Google or AI to self-diagnose body dysmorphic disorder, as BDD is far more complex and nuanced than a list of symptoms or diagnostic criteria, which overlap with other psychiatric conditions. It is imperative to seek a diagnosis from a qualified health professional capable of differentiating between disorders.

Psychologists and psychiatrists have the skills to identify additional symptoms (or disorders) that could be missed by individuals attempting to self-diagnose. Accurate diagnosis supports individuals in getting treatment for body dysmorphic disorder and potential co-occurring conditions. Without support, the condition may worsen, causing further distress and dysfunction.

Treatment Options

Assessing an individual with body dysmorphic disorder’s level of awareness regarding their illness (insight) is crucial in determining the appropriate treatment approach. Those with good or fair insight acknowledge that their beliefs about their “flaws” are likely inaccurate, while individuals with poor insight tend to believe their thoughts are true. ^[1]

In cases of absent insight or delusional beliefs, individuals maintain their perceptions despite contrary evidence. That said, most people with BDD who receive treatment (including medication, psychotherapy, or both) generally begin to feel better within 4 to 16 weeks, with between 50% and 80% showing improvements during that timeframe. ^[1]

It is important to keep in mind that ongoing maintenance treatment is recommended to prevent recurrence of symptoms, though the optimal duration for this remains unclear. Additionally, it is imperative to consider the consequences of cosmetic interventions, as they rarely address the underlying psychological issues and may lead to increased financial and emotional distress. ^[1]

Medication

Medication is typically the most accessible treatment option for individuals with BDD, with therapy being the next most commonly available approach. While there are no FDA-approved medications for body dysmorphic disorder, pharmaceuticals that effectively treat obsessive-compulsive disorders are often used, as BDD shares clinical features with OCD. ^[1]

Selective serotonin reuptake inhibitors (SSRIs) and clomipramine, a tricyclic antidepressant (TCA), are considered first-line medication options for body dysmorphic disorder, especially when combined with therapy. These medications have been found to help reduce body image obsessions and compulsive behaviors, while also treating commonly co-occurring conditions like depression and anxiety. ^[1]

Evidence for other medications is limited, however, the following may be prescribed in specific cases: ^[1]

• Buspirone (anxiolytic)

• Memantine (a glutamate modulator used in combination with SSRIs)

• Second-generation antipsychotics (as adjuncts to SSRIs)

• Venlafaxine (some success in small studies)

• Bupropion augmentation (occasional case reports of benefit)

Therapy

Therapy plays an important role in treating body dysmorphic disorder, with two primary approaches best suited to address the disorder’s unique challenges. Cognitive behavioral therapy (CBT) is the primary treatment, while motivational interviewing can also be helpful in severe cases. ^[1]

Cognitive Behavioral Therapy (CBT)

CBT is the first-line therapeutic approach for body dysmorphic disorder. Specialized CBT tailored for BDD focuses on identifying and challenging distorted thoughts and beliefs about appearance. Techniques may include psychoeducation, stress management, relaxation exercises, and developing coping skills. ^[1]

Motivational Interviewing

Motivational interviewing may be helpful in severe cases, particularly when patients are ambivalent about starting treatment. This communication style focuses on building internal motivation for psychological transformation through empathetic, non-confrontational conversation. It is especially useful when a person feels unsure about whether they want to change. ^[1]

Hospitalization for Safety

Inpatient care may be necessary for individuals experiencing suicidal thoughts or who have made recent suicide attempts to ensure safety and stabilization. A structured hospital setting provides continuous monitoring, the management of acute symptoms, and the development of a comprehensive treatment plan before the individual transitions to outpatient support. ^[1]

Living with Body Dysmorphia

Living with untreated body dysmorphic disorder can severely disrupt daily functioning and be deeply distressing. Individuals with BDD struggle with all-consuming thoughts surrounding their perceived flaws, which lead to time-consuming repetitive behaviors such as excessive grooming, mirror checking, or constantly seeking reassurance from others. ^[1]

Additionally, people with BDD often misread facial expressions, interpreting neutral looks as hostile, and may experience difficulties with planning, decision-making, and impulse control. These challenges can affect an individual's performance at work or school, impact relationships, and isolate those affected. ^[1]

Many people with body dysmorphic disorder turn to cosmetic procedures to find relief, but these interventions rarely help and can exacerbate symptoms. When BDD is not treated, an individual may choose unhelpful coping strategies, like substances, which may lead to substance use disorder or other psychiatric conditions as the BDD worsens. ^[1]

Fortunately, the prognosis for those with BDD who seek treatment is exceptionally good. Cognitive behavioral therapy and medication are highly effective, with the majority of individuals who receive these treatments experiencing significant relief. In fact, more than half of individuals with BDD respond well to treatment, meaning that recovery is not only possible, but likely. ^[1]

Final Thoughts

Body dysmorphic disorder is a serious mental health condition with a growing prevalence marked by intense preoccupation with perceived appearance flaws that seem minor or non-existent to others. The condition leads to substantial distress and functional impairment, with BDD individuals spending between 3 and 8 hours a day ruminating about the “defect/s”.

There is a strong link between body dysmorphic disorder and unnecessary cosmetic procedures, with individuals who undergo these treatments often feeling unsatisfied and experiencing a worsening of the condition. Recognizing the symptoms of BDD and seeking professional help is essential for accurate diagnosis and management.

The good news is that treatment (primarily involving cognitive behavioral therapy and medication) offers a positive prognosis for many individuals with the disorder, ultimately improving the quality of life and reducing the serious risks associated with this often under-recognized disorder.