Lori Riddle-Walker MFT, Treating OCD and Related Disorders, San Diego

A. Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person’s concern is markedly excessive.

B. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

C. The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in Anorexia Nervosa).

Diagnostic Features

The essential feature of Body Dysmorphic Disorder (historically known as dysmorphophobia) is a preoccupation with a defect in appearance (Criterion A). The defect is either imagined, or, if a slight physical anomaly is present, the individual’s concern is markedly excessive (Criterion A). The preoccupation must cause significant distress or impairment in social, occupational, or other important areas of functioning (Criterion B). The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in Anorexia Nervosa) (Criterion C).

Complaints commonly involve imagined or slight flaws of the face or head such as hair thinning, acne, wrinkles, scars, vascular markings, paleness or redness of the complexion, swelling, facial asymmetry or disproportion, or excessive facial hair. Other common preoccupations include the shape, size, or some other aspect of the nose, eyes, eyelids, eyebrows, ears, mouth, lips, teeth, jaw, chin, cheeks, or head. However, any other body part may be the focus of concern (e.g., the genitals, breasts, buttocks, abdomen, arms, hands, feet, legs, hips, shoulders, spine, larger body regions, overall body size, or body build and muscularity). The preoccupation may simultaneously focus on several body parts. Although the complaint is often specific (e.g., a “crooked” lip or a “bumpy” nose), it is sometimes vague (e.g., a “falling” face or “inadequately firm” eyes). Because of embarrassment over their concerns or for other reasons, some individuals with Body Dysmorphic Disorder avoid describing their “defects” in detail and may instead refer only to their general ugliness.

Most individuals with this disorder experience marked distress over their supposed deformity, often describing their preoccupations as “intensely painful,””tormenting,” or “devastating.” Most find their preoccupations difficult to control, and they may make little or no attempt to resist them. As a result, they often spend hours a day thinking about their “defect,” to the point where these thoughts may dominate their lives. Significant impairment in many areas of functioning generally occurs. Feelings of self-consciousness about their “defect” may lead to avoidance of work, school, or public situations.

Associated Features and Disorders

Frequent checking of the defect, either directly or in a reflecting surface (e.g., mirrors, store windows, car bumpers, watch faces) can consume many hours a day. Some individuals use special lighting or magnifying glasses to scrutinize their “defect.” There may be excessive grooming behavior (e.g., excessive hair combing, hair removal, ritualized makeup application, or skin picking). Although the usual intent of checking and grooming is to diminish anxiety, be reassured about one’s appearance, or temporarily improve one’s appearance, these behaviors often intensify the preoccupation and associated anxiety. Consequently, some individuals avoid mirrors, sometimes covering them or removing them from their environment. Others alternate between periods of excessive mirror checking and avoidance. Other behaviors aimed at improving the “defect” include excessive exercise (e.g., weight lifting), dieting, and frequent changing of clothes. There may be frequent requests for reassurance about the “defect,” but such reassurance leads to only temporary, if any, relief. Individuals with the disorder may also frequently compare their “ugly” body part with that of others. They may try to camouflage the “defect” (e.g., growing a beard to cover imagined facial scars, wearing a hat to hide imagined hair loss, stuffing their shorts to enhance a “small” penis). Some individuals may be excessively preoccupied with fears that the “ugly” body part will malfunction or is extremely fragile and in constant danger of being damaged. Insight about the perceived defect is often poor, and some individuals are delusional; that is, they are completely convinced that their view of the defect is accurate and undistorted, and they cannot be convinced otherwise. Ideas and delusions of reference related to the imagined defect are also common; that is, individuals with this disorder often think that others may be (or are) taking special notice of their supposed flaw, perhaps talking about it or mocking it.

Avoidance of usual activities may lead to extreme social isolation. In some cases, individuals may leave their homes only at night, when they cannot be seen, or become housebound, sometimes for years. Individuals with this disorder may drop out of school, avoid job interviews, work at jobs below their capacity, or not work at all. They may have few friends, avoid dating and other social interactions, have marital difficulties, or get divorced because of their symptoms. The distress and dysfunction associated with this disorder, although variable, can lead to repeated hospitalization and to suicidal ideation, suicide attempts, and completed suicide. Individuals with Body Dysmorphic Disorder often pursue and receive general medical (often dermatological), dental, or surgical treatments to rectify their imagined or slight defects. Occasionally, individuals may resort to extreme measures (e.g., self-surgery) to correct their perceived flaws.

Such treatment may cause the disorder to worsen, leading to intensified or new preoccupations, which may in turn lead to further unsuccessful procedures, so that individuals may eventually possess “synthetic” noses, ears, breasts, hips, or other body parts, which they are still dissatisfied with. Body Dysmorphic Disorder may be associated with Major Depressive Disorder, Delusional Disorder, Social Phobia, and Obsessive-Compulsive Disorder.

Specific Culture and Gender Features

Cultural concerns about physical appearance and the importance of proper physical self-presentation may influence or amplify preoccupations about an imagined physical deformity. Body Dysmorphic Disorder may be equally common in women and in men in outpatient mental health settings.

Prevalence

The prevalence of Body Dysmorphic Disorder in the community is unknown. In clinical mental health settings, reported rates of Body Dysmorphic Disorder in individuals with Anxiety or Depressive Disorders range from under 5% to approximately 40%. In cosmetic surgery and dermatology settings, reported rates of Body Dysmorphic Disorder range from 6% to 15%.

Course

Body Dysmorphic Disorder usually begins during adolescence but can begin during childhood. However, the disorder may not be diagnosed for many years, often because individuals with the disorder are reluctant to reveal their symptoms. The onset may be either gradual or abrupt. The disorder often has a fairly continuous course, with few symptom-free intervals, although the intensity of symptoms may wax and wane over time. The part of the body on which concern is focused may remain the same or may change.