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Body dysmorphic disorder (BDD) (sometimes informally called “body dysmorphia”) is a condition in which a person has an obsessive preoccupation with their physical appearance. These obsessions are triggered by perceived flaws in appearance.
The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) classifies body dysmorphic disorder (BDD) under the category of obsessive-compulsive and related disorders, alongside obsessive-compulsive disorder (OCD), hoarding disorder, and other conditions.
People with BDD usually experience an intense preoccupation with perceived defects in their physical appearance, defects that can sometimes be insignificant or unnoticeable to others. Individuals with BDD often exhibit repetitive and time-consuming behaviors (e.g., mirror checking, skin picking), and/or they constantly compare their appearance to others, which in turn may cause distress and have a negative impact on their social, personal, and professional lives. BDD is also linked with a high rate of suicidal thoughts and behaviors.
Although any part of the body can be a cause for concern in individuals with BDD, certain areas — like skin, hair, and nose — are more commonly affected. Furthermore, a specific subtype of BDD, muscle dysmorphia (MD), is characterized by preoccupation with the size and muscle composition of the entire body.
Depression is also frequently observed in people affected by BDD, either as a pre-existing condition or as a direct consequence of body dysmorphia. Clinicians must screen patients for conditions that share symptoms with BDD (e.g., OCD, social phobia, depression, eating disorders) and which may confound the diagnosis of body dysmorphia.
BDD is often overlooked and undiagnosed. Individuals who experience BDD are often overwhelmed with feelings of shame and embarrassment and find it challenging to reach out to mental health professionals and discuss their thoughts and preoccupations. Unless clinicians use specific screening tools, such as the *Body Dysmorphic Disorder Questionnaire (BDDQ) or the Body Image Disturbance Questionnaire (BIDQ), they may mistake BDD for other conditions such as depression, OCD, or social anxiety, which may result in delayed treatment.
Similar questionnaires, such as the Cosmetic Procedures Screening (COPS) for BDD, may also be used before surgical cosmetic procedures to determine whether a referral is necessary or after a procedure to measure improvements in BDD symptoms.
Additionally, the DSM provides specific criteria to assist clinicians in identifying cases of BDD. One criterion emphasizes the importance of differentiating between BDD and eating disorders, so if a patient’s primary concern revolves around their body weight, the possibility of an eating disorder should be considered instead.
Other diagnostic tools are designed to identify subgroups of body dysmorphic disorder (e.g., muscle dysmorphia) and to measure an individual’s level of insight regarding their perceived defects.
The main treatments currently used for body dysmorphic disorder include cognitive behavioral therapy (CBT) and medications from the serotonin reuptake inhibitors (SRIs) class. This class comprises selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine, sertraline, and citalopram, as well as nonselective SRI drugs such as clomipramine. Clinicians may also consider off-label use of other medications with known effectiveness in similar conditions (e.g., OCD). However, further research is needed to establish their efficacy specifically for treating BDD.
Given the frequent presence of comorbidities in individuals with BDD, treatment approaches may need to be adjusted accordingly. The use of SRIs in BDD treatment often aligns well with overlapping conditions, such as OCD or social anxiety. Similarly, CBT has shown improvements both in BDD symptoms and comorbid depression. However, for individuals with BDD and bipolar disorder, the administration of mood stabilizers may be necessary before initiating SRIs because the latter can potentially exacerbate bipolar symptoms. In cases in which anorexia nervosa and BDD coexist, anorexia should be addressed as a primary concern. This highlights the complexities involved in establishing the appropriate treatment for BDD.
CBT, the main psychological treatment for BDD, is used to address specific issues, such as repetitive behaviors, distorted perception patterns, and misinterpretation of others' emotions (e.g., feeling judged by others).
N-Acetylcysteine (NAC) has shown positive outcomes in the treatment of certain obsessive-compulsive and related disorders, such as OCD, nail biting, grooming disorder, skin picking, and trichotillomania (hair pulling). Although there are currently no specific studies assessing the effectiveness of NAC for treatment of BDD, clinicians have been prescribing it as an adjunct therapy alongside SRIs, yielding promising results. However, further research is needed to establish its safety, effectiveness, and appropriate dosage for BDD.
It is well known that nutrition and diet can impact brain health. However, there is currently a lack of nutritional studies specifically focused on BDD. As a result, there is limited knowledge regarding potential nutritional deficiencies and the related dietary adjustments that could be beneficial for individuals with BDD.
Although specific interventions for nutrition and diet in BDD are not yet available, research has shown that people with BDD are more likely to also have an unhealthy relationship with food, which may contribute to the presence of an eating disorder. It is important to note that eating disorders are distinct from BDD and can occur as a consequence or symptom of body dysmorphia. Furthermore, individuals with muscle dysmorphia often adhere to very strict diets that are typically high in protein and low in fats, and some individuals may also use supplements and/or anabolic steroids in an attempt to achieve their desired body shape more quickly. All of these unhealthy eating patterns can potentially result in nutritional deficiencies and correlated issues, which should be addressed alongside BDD signs and symptoms.
Online and smartphone-based cognitive behavioral therapy is currently being explored as a potential intervention for body dysmorphic disorder, and some studies have demonstrated improvements in symptoms. These technological approaches may particularly benefit individuals living in rural areas or those who are hesitant to engage in face-to-face interactions with physicians. However, further research is needed to compare the effectiveness of app-based CBT with traditional in-person CBTy.
Body dysmorphic disorder typically manifests during adolescence. It is not yet clear what exactly causes BDD, and it’s likely that multiple factors contribute to the development of the disorder.
Research suggests a genetic (and thus hereditary) component in BDD because individuals are more susceptible to the disorder if they have a family member affected by BDD or OCD. So far, only a few gene mutations have been identified as potentially contributing to the development of BDD, and these mutations are located on the gamma-aminobutyric acid (GABA)A-γ2 gene and the serotonin transporter gene.
Developmental factors (e.g., child emotional and/or physical abuse) and social factors (e.g., being bullied about a specific body flaw) may also contribute to the development of BDD, according to some studies.
Additionally, functional magnetic resonance imaging (fMRI) has been used to scan BDD subjects while they perform a photo match task. In these fMRI studies, participants with BDD showed altered activity in the right hemisphere of the brain, compared to participants without BDD, and hypoactivity in the visual cortical systems and occipital regions, which may affect visual perception and/or visuospatial processing. Another study also detected a dysfunction in the frontal-striatal circuits of the brain, which are responsible for the perception and manipulation of information, among other functions. Further studies on the brain morphometry of participants with BDD displayed some differences compared to control participants without BDD, but the results across studies were inconsistent, and more research is needed.
Furthermore, the involvement of the serotonin system in BDD is under investigation, with some studies showing that by modulating the serotonin response, BDD symptoms may be exacerbated or attenuated. However, a direct causal relationship between serotonin and BDD has yet to be established.