Body Dysmorphic Disorder

Symptoms of body dysmorphic disorder may develop gradually or abruptly. Although intensity may vary, the disorder is thought usually to be chronic unless patients are appropriately treated.

Concerns commonly involve the face or head but may involve any body part or parts and may change from one part to another over time. For example, patients may be concerned about perceived thinning hair, acne, wrinkles, scars, vascular markings, color of their complexion, or excessive facial or body hair. Or they may focus on the shape or size of the nose, eyes, ears, mouth, breasts, buttocks, legs, or other body part. Men (and rarely women) may have a form of the disorder called muscle dysmorphia, which involves preoccupation with the idea that their body is not sufficiently lean and muscular. Patients may describe the disliked body parts as looking ugly, unattractive, deformed, hideous, or monstrous.

Patients usually spend many hours a day worrying about their perceived defects and often mistakenly believe that people take special note of or mock them because of these perceived defects. Most check themselves often in mirrors, others avoid mirrors, and still others alternate between the 2 behaviors.

Other common compulsive behaviors include comparing their appearance with that of other people, excessive grooming, skin picking (to remove or fix perceived skin defects), hair pulling or plucking, reassurance seeking (about the perceived defects), and clothes changing. Most try to camouflage their perceived defects—eg, by growing a beard to hide perceived scars or by wearing a hat to cover slightly thinning hair. Many undergo dermatologic, dental, surgical, or other cosmetic treatment to correct their perceived defects, but such treatment is usually unsuccessful and may intensify their preoccupation. Men with muscle dysmorphia may use anabolic-androgenic steroids and various supplements to build muscle and/or lose fat, which can be dangerous.

Because people with body dysmorphic disorder feel self-conscious about their appearance, they may avoid going out in public. For most, social, occupational, academic, and other aspects of functioning are impaired—often substantially—because of their concerns about appearance. Some leave their homes only at night; others, not at all. Social isolation, depression, psychiatric hospitalization, and suicidal behavior are common. In very severe cases, body dysmorphic disorder is incapacitating.

The degree of insight varies, but it is usually poor or absent. That is, most patients genuinely believe that the disliked body part probably (poor insight) or definitely (absent insight or delusional beliefs) looks abnormal, ugly, or unattractive.

Over their lifetime, about 80% of people with body dysmorphic disorder experience suicidal ideation, and about one quarter to nearly 30% attempt suicide (see Suicidal Behavior). Body dysmorphic disorder is characterized by significantly higher levels of suicidality than other psychiatric disorders (1, 2)

• Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) criteria

Because many patients are too embarrassed and ashamed to reveal their symptoms, body dysmorphic disorder may go undiagnosed for years. It is distinguished from normal concerns about appearance because the preoccupations are time-consuming and cause significant distress, impairment in functioning, or both.

Diagnosis of body dysmorphic disorder is based on history. If the only concern is body shape and weight and eating behavior is abnormal, an eating disorder may be the more accurate diagnosis; if the only concern is the appearance of physical sex characteristics, a diagnosis of gender dysphoria may be considered.

Diagnostic criteria for body dysmorphic disorder include the following:

• Preoccupation with one or more perceived defects in appearance that are not observable or appear only slight to others

• Performance of repetitive behaviors (eg, mirror checking, excessive grooming) in response to the appearance concerns at some point during the disorder

• The preoccupation causes significant distress or impairs social, occupational or other areas of functioning

• Cognitive-behavioral therapy

SSRIsN

Cognitive-behavioral therapy that is tailored to the specific symptoms of body dysmorphic disorder is the psychotherapy of choice. Cognitive approaches (eg, cognitive restructuring) and exposure and ritual prevention are essential elements of therapy. Clinicians encourage patients to gradually face situations they fear or avoid (which are usually social situations) while refraining from performing their rituals, such as mirror checking, excessive grooming, and comparing their appearance with that of other people.

Cognitive-behavioral therapy also includes other elements such as perceptual retraining and habit reversal training for skin picking (excoriation) or hair pulling or plucking if present. Habit reversal training includes the following:

• Awareness training (eg, self-monitoring, identification of triggers for the behavior)

• Stimulus control (modifying situations—eg, avoiding triggers—to reduce the likelihood of initiating the behavior)

• Competing response training (teaching patients to substitute other behaviors, such as clenching their fist, knitting, or sitting on their hands, for the excessive behavior)

Because most patients have poor or absent insight, motivational techniques are often needed to increase their willingness to participate and stay in treatment.

Many experts believe that combining cognitive-behavioral therapy with medications is best for severe cases.

Cosmetic treatment is not recommended. It is almost always ineffective, and clinicians who provide such treatment may be at risk of legal or physical threats or behaviors by dissatisfied patients.