Dysmorphophobia [body dysmorphic disorder]

Body dysmorphic disorder (historically known as dysmorphophobia) belongs to the broader category of somatoform disorders, which are characterized by the presence of physical symptoms that are not justified by a general medical condition or by the effects of a substance or other mental disorder.

The hallmark of dysmorphophobia is preoccupation with a defect in physical appearance, which may be entirely imaginary or, if a real minor physical abnormality is present, the subject’s preoccupation is far beyond normal.

Complaints may easily be about minor or imagined defects of the face or head, such as thicker or thinner hair, acne, wrinkles, scars, vascular manifestations, pallor or redness, sweating, facial asymmetries or disproportion, or excessive hair.

Other common concerns of dysmorphic individuals relate to the shape, size, or other appearance of the nose, eyes, eyelids, eyebrows, ears, mouth, lips, teeth, jaw, chin, cheeks, or head. However, any other part of the body may be of concern (e.g., genitals, breasts, buttocks, abdomen, arms, hands, feet, legs, hips, shoulders, spine, larger body regions or overall body measurements, or body build and muscle mass). In dysmorphophobia, the preoccupation may involve multiple body parts at the same time.

This disorder is mainly observed in adolescents of both sexes and is closely related to the changes of puberty. When it affects adults, it is more complex, because with the end of adolescence, the person should acquire a sense of self-confidence such that he or she is able to relate harmoniously with others without being afflicted by inferiority complexes related to physical appearance, let alone obvious symptoms such as those of dysmorphophobia.

Most people with this disorder experience severe discomfort with their perceived deformity, often describing their concerns as “extremely painful,” “torturous,” or “devastating. Most find their concerns difficult to control and make little or no attempt to resist them.

As a result, dysmorphophobes often spend many hours a day thinking about their “defect” and how to fix it (sometimes resorting to cosmetic surgery or self-manipulation that can make it worse), to the point that these thoughts can dominate their lives. Feelings of shame about their “defect” may lead to avoidance of work, school, or social situations.

These people with body dysmorphic disorder engage in compulsions to examine, improve, or hide the perceived defect. For example, they tend to check themselves in mirrors or other reflective surfaces, show excessive concern for their appearance, tend to comb or wash their hair repeatedly, make constant comparisons with the physical appearance of others, seek reassurance, or try to convince others of their defect.

Dysmorphophobia can be effectively treated with cognitive-behavioral psychotherapy, which borrows many techniques from those used to treat obsessive-compulsive disorder, with which there are various similarities. Medication is rarely effective, at least in the absence of comorbidity with major depression.


Body dysmorphic disorder typically has a chronic course if not adequately treated and tends to be associated with moderate to severe disability. (Phillips KA, et al., 2013). In adults, the presence of the disorder tends to promote greater social difficulties, manifested in higher rates of unemployment and greater social isolation.

In adolescents, the presence of dysmorphophobia also predicts school dropout, poorer academic performance, and social isolation. In addition, feelings of guilt and shame associated with body dysmorphic disorder help explain the high rates of suicidal ideation and suicide attempts in these patients (Angelakis I et al., 2016).

Epidemiology of Body Dysmorphic Disorder

Body dysmorphic disorder typically begins in adolescence, with an average age of onset of 17 years, and in many cases remains undiagnosed. The prevalence of the disorder is approximately 2% in the general population. However, it increases to 5% in the college-aged population (Bohne A, et al., 2002).

In the psychiatric population, the prevalence increases and body dysmorphic disorder affects 6% to 7%. In addition, the prevalence of BDD is estimated to be 13% in those requiring cosmetic surgery and 20% in those requiring rhinoplasty.

Dysmorphophobia occurs in both sexes with a slightly higher prevalence in women (2.5%) than in men (2.2%) (Koran LM., 2008).

Psychiatric comorbidities

The disorder can often occur in comorbidity with other psychiatric disorders. The most common comorbid disorders include major depressive disorder, anxiety disorders, obsessive-compulsive disorder, substance abuse disorders, and eating disorders.

Symptoms of Body Dysmorphic Disorder

As described above, the defining symptom of body dysmorphic disorder is a constant preoccupation with some completely absent or minimal body defects.

Body dysmorphic disorder can affect any part of the body, although most concerns focus on certain facial features (Phillips KA et al, 2006), such as

  • Hair
  • Nose
  • Skin
  • Eyes
  • Teeth
  • Lips

These concerns are often accompanied by compulsive behaviors designed to reduce, even temporarily, the sense of discomfort and distress. Some of the behavioral symptoms of body dysmorphic disorder include:

  • constantly looking in the mirror or avoiding mirrors altogether
  • using strategies to hide perceived physical defects, such as excessive use of cosmetics or covering them with clothing or accessories (e.g., sunglasses)
  • avoiding social situations and isolating themselves at home
  • seeking constant reassurance about their physical imperfections.

Bigorexia or reverse anorexia

In some cases, the disorder may affect body image as a whole, as in the case of muscular dysphoria, also known as bigorexia or reverse anorexia, in which one perceives one’s body as too thin, insufficiently muscular, and slender, despite the fact that the individual often has strong muscles and a toned body (Phillipou A et al., 2015).

Bigorexia is a disorder that predominantly affects men and leads these individuals to exhausting compulsive workouts, strict adherence to a diet with meticulous attention to the composition of food intake, exaggerated use of protein supplements and, in some cases, the use of anabolic steroids.

Despite these efforts, body dissatisfaction persists.

Diagnosis of Body Dysmorphic Disorder

The diagnosis of BDD requires an initial assessment of the patient’s medical history with a thorough evaluation of psychological status and psychopathological history.

Some typical features of patients with body dysmorphic disorder are:

  • the presence of suicidal ideation,
  • sometimes delusional thoughts
  • comorbidity with other psychiatric disorders, and
  • a history of previous cosmetic interventions aimed at reducing perceived physical defects (Phillips K.A. ., 2017).

Body dysmorphic disorder is often underdiagnosed in clinical practice. In fact, patients tend not to disclose these symptoms to their clinicians due to shame or lack of awareness that these symptoms can be clinically treated (Mufaddel A et al., 2013).

Diagnosis according to DSM-5

The DSM-5 places body dysmorphic disorder in the Obsessive Compulsive Disorder chapter and defines its diagnostic criteria (APA, 2013):

  • The individual manifests a preoccupation with one or more physical defects that are unobservable or appear mild to others.
  • The individual engages in a series of repetitive behaviors aimed at seeking reassurance (e.g., repeatedly looking in the mirror) or spending a great deal of time comparing oneself to others in response to concerns about one’s appearance.
  • These concerns cause the individual significant distress and problems in social, emotional, relational, or other important areas of life functioning.
  • Worries about one’s appearance are no better explained by concerns about weight and body shape in an individual with an eating disorder.

In addition, when making a diagnosis, the clinician is asked to report the patient’s level of awareness (or insight). With good insight, the patient recognizes that the thoughts associated with the disorder are exaggerated and that the physical defect is probably not as severe as perceived.

With poor insight, the patient believes what he or she perceives and struggles to question the plausibility of his or her concerns. When insight is completely absent, thinking has delusional characteristics and there is no way to question these irrational beliefs.

Causes of Body Dysmorphic Disorder

It is not yet clear what causes Body Dysmorphic Disorder, although the development of BDD is often associated with stressful life events such as violence, abuse, and trauma (Buhlmann U, et al., 2012).

Specifically, those who develop body dysmorphic disorder most often report childhood exposure to:

  • emotional and physical neglect by parents,
  • sexual abuse
  • being teased by peers
  • being bullied.

Some recent studies have shown a link between teasing about one’s physical appearance at a young age and BDD, especially when it is perpetrated by peers of the opposite sex (Webb HJ., 2015).

Body Dysmorphic Disorder and anorexia nervosa

Body dysmorphic disorder shares some characteristics with anorexia nervosa. Indeed, in both types of patients, there is an alteration in the perception of the body or a part of it.

But while BDD tends to focus on a single detail of the body, anorexia nervosa tends to affect the entire body image.

Both disorders also tend to begin in adolescence and share the same comorbidities. In addition, it is not uncommon for the two disorders to co-occur in the same patient.

In fact, it is estimated that approximately 32% of patients with a body dysmorphic disorder will develop an eating disorder in their lifetime (Ruffolo et al., 2006), just as those with anorexia nervosa have a 25-39% chance of developing BDD.

Differences between Body Dysmorphic Disorder and anorexia nervosa

Despite the many similarities, there are significant differences between the two disorders.

  1. The first difference is the gender distribution. Anorexia nervosa is much more prevalent in females, in contrast to BDD, where the male/female ratio is much less skewed.
  2. In addition, those with dysmorphophobia tend to have lower self-esteem and greater inhibition and avoidance of social activities than those with anorexia nervosa.
  3. Finally, body weight in individuals with body dysmorphic disorder tends to be in the normal range, unlike those with anorexia who have significantly low body weight.

Neurofunctional differences

From a neuroscientific perspective, recent studies using neuroimaging techniques such as fMRI (functional magnetic resonance imaging) have examined the brain responses of patients with BDD and patients with anorexia nervosa while viewing human faces.

These studies showed functional changes in the face processing area (called the facial fusiform area, or FFA) only in patients with body dysmorphic disorder.

This confirms clinical observations showing that patients with BDD often exhibit altered perception of facial details, whereas in anorexia the disparate phenomena mainly affect the hips, thighs, and abdomen and the body image as a whole.

Neurofunctional similarities

However, similarities have also been found between BDD and anorexia nervosa. Indeed, in both types of patients, reduced connectivity was observed between the areas that process faces, the insula and the central opercular cortex.

The insula, in particular, is an area of the brain that is important for recognizing emotional stimuli, analyzing interoceptive information (i.e., information coming from the skin and inside the body), and signaling physiological states of the body.

According to some authors, this reduced connectivity between face-processing areas and the insula could lead to integration deficits between face perception and body awareness. These integration deficits could therefore promote the development of disinhibitory symptoms in both anorexia nervosa and body dysmorphic disorder. (Moody et al., 2015)

Treatment of Body Dysmorphic Disorder

Treatment for body dysmorphic disorder generally involves a combination of cognitive behavioral therapy and medication. In particular, SSRI antidepressants have been shown to produce significant improvements in quality of life and suicidal ideation in patients with BDD (Hong et al., 2019).

The use of antidepressants in the treatment of body dysmorphic disorder often requires higher doses of medication than in the treatment of other psychiatric disorders (Phillips KA et al., 2017).

Cognitive behavioral psychotherapy

The psychotherapy recommended by NICE for the treatment of body dysmorphic disorder is cognitive behavioral psychotherapy, which has been shown to be effective in 50-80% of cases when combined with medication.

Treatment is based primarily on psychoeducation, modification of dysfunctional thoughts about one’s body, and a general focus on the patient’s psychological well-being.

Therapy focuses not only on irrational concerns about one’s appearance, but also on the controlling (e.g., compulsive mirror use) and avoiding (e.g., limiting social life) behaviors typical of this disorder.

Treatment strategies for dysmorphophobia

Among the techniques used in the CBT approach to the treatment of dysmorphophobia is mirror exposure. Several cognitive-behavioral oriented individual psychotherapy pathways are described in the literature that include at least one session of mirror exposure (Fang, Schwartz & Wilhelm, 2016).

Cognitive-behavioral group psychotherapy protocols involving in-home personal mirror exposure have also been described (Rosen et al., 1995).

Transcranial magnetic stimulation

Recently, alternative therapeutic strategies based on neurostimulation such as transcranial magnetic stimulation (rTMS) and bilateral deep brain stimulation have been developed.

In particular, transcranial magnetic stimulation is currently an FDA-approved treatment for major depression and shows encouraging results in the treatment of obsessive-compulsive disorder, including body dysmorphic disorder (Ma ZR., 2014).

Treatment of dysmorphophobia

Treatment of dysmorphophobia is generally provided on an outpatient basis. Often in a team that includes the psychiatrist and psychotherapist and does not require an inpatient pathway.

However, if comorbid disorders such as major depressive disorder are present and particularly disabling, the use of an inpatient pathway may be indicated to address both the mood disorder and dysmorphophobia.

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