Body Dysmorphic Disorder: Symptoms, Causes & Treatment

What Is Body Dysmorphic Disorder?

Body Dysmorphic Disorder (BDD) is a mental health condition characterized by obsessive preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others. People with BDD spend at least one hour per day thinking about their perceived flaws and engage in repetitive behaviors like mirror checking or excessive grooming.

Body Dysmorphic Disorder, sometimes called dysmorphophobia or body dysmorphia, is classified as an Obsessive-Compulsive and Related Disorder in the DSM-5. The name itself comes from the Greek word "dysmorphia," meaning abnormality of shape. However, it's crucial to understand that BDD is not about actual physical abnormalities—it's about the perception and emotional response to appearance that becomes distorted and overwhelming.

Living with BDD means experiencing a profound disconnection between how you see yourself and how others perceive you. While friends and family may see nothing wrong with your appearance, or notice only minor imperfections that don't warrant concern, you may be convinced that a particular feature is horribly disfigured, ugly, or abnormal. This isn't a matter of low self-esteem or fishing for compliments—it's a genuine perceptual distortion combined with intense emotional distress.

The condition shares many features with Obsessive-Compulsive Disorder (OCD), including intrusive, unwanted thoughts (obsessions about appearance) and repetitive behaviors performed to reduce anxiety (compulsions like checking mirrors or seeking reassurance). Research has shown that BDD and OCD share similar patterns of brain activity, genetic factors, and respond to similar treatments. Approximately 30% of people with BDD also meet criteria for OCD.

Areas of concern in BDD

While BDD can focus on any body part, certain areas are more commonly affected. It's important to note that the perceived flaw may be completely invisible to others, or may be a minor imperfection that the person magnifies to extreme proportions. Common areas of focus include:

• Skin: Perceived acne, scars, wrinkles, paleness, or uneven skin tone
• Facial features: Nose shape or size, eyes, lips, ears, chin, or facial symmetry
• Hair: Thinning hair, excessive body hair, or hair texture and style
• Body shape: Weight, muscle mass, breast size, or genital appearance
• Specific features: Teeth, veins, hands, or any other body part

Many people with BDD focus on multiple areas, and the focus may shift over time. Even if one perceived flaw is "fixed" through cosmetic procedures, attention typically shifts to another area or the person remains dissatisfied with the results.

Muscle dysmorphia

A specific form of BDD, sometimes called "bigorexia" or "reverse anorexia," involves preoccupation with the idea that one's body is too small or insufficiently muscular. This form is more common in males and can lead to excessive exercise, strict dieting, and steroid abuse. Despite often having very muscular physiques, those affected perceive themselves as small or weak.

What Are the Symptoms of Body Dysmorphic Disorder?

BDD symptoms include spending at least one hour daily preoccupied with perceived appearance flaws, engaging in repetitive behaviors like mirror checking or excessive grooming, avoiding social situations due to appearance concerns, and experiencing significant distress or impairment in daily functioning. Warning signs include frequent reassurance-seeking about appearance and feeling unable to control thoughts about perceived defects.

Recognizing BDD can be challenging because many people feel ashamed to discuss their concerns, fearing they'll be seen as vain or superficial. However, BDD is a serious mental health condition with specific diagnostic criteria. Understanding these symptoms is the first step toward getting help.

The core symptom of BDD is preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear only slight to others. This preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. The appearance concerns are not better explained by concerns with body fat or weight in someone who meets criteria for an eating disorder.

Cognitive symptoms

The mental aspects of BDD are often the most distressing. People with BDD experience intrusive, unwanted thoughts about their appearance that can be extremely difficult to control or dismiss. These cognitive symptoms include:

• Persistent preoccupation: Spending at least one hour per day thinking about perceived flaws, though many spend 3-8 hours or more
• Negative self-referential thinking: Believing that others are taking special notice of your perceived defect, staring, or making fun of you
• Difficulty accepting reassurance: When others say you look fine, being unable to believe them or feeling they're just being kind
• Comparing: Constantly comparing your appearance to others, often concluding you're inferior
• Magnification: Perceiving minor features as grotesque or severely disfigured

Behavioral symptoms

BDD drives a range of repetitive behaviors that people feel compelled to perform, often in an attempt to reduce anxiety or "fix" the perceived problem. Common behavioral symptoms include:

• Mirror checking: Frequently examining appearance in mirrors, or alternatively, avoiding mirrors entirely
• Excessive grooming: Spending excessive time on hair, makeup, or other grooming activities
• Camouflaging: Using makeup, clothing, hats, or body positioning to hide perceived flaws
• Skin picking: Picking at skin to try to improve perceived blemishes, often causing actual damage
• Reassurance seeking: Repeatedly asking others about your appearance
• Seeking cosmetic treatments: Pursuing dermatological or surgical procedures

Social and functional impact

BDD significantly impairs quality of life and functioning. The condition can lead to social isolation, difficulty maintaining relationships, problems at work or school, and in severe cases, inability to leave the house. Many people with BDD experience:

• Social avoidance: Declining invitations, avoiding dating, or refusing to be photographed
• Occupational impairment: Difficulty concentrating at work, frequent absences, or unemployment
• Relationship difficulties: Strain on family relationships and romantic partnerships
• Financial problems: Spending significant money on cosmetic procedures, products, or treatments

What Causes Body Dysmorphic Disorder?

BDD develops from a combination of biological factors (genetics, brain differences in visual processing), psychological factors (perfectionism, negative body image, low self-esteem), and environmental factors (childhood teasing, bullying, emphasis on appearance, trauma). There is no single cause, but multiple risk factors interact to create vulnerability to the condition.

Understanding what causes BDD is complex because, like most mental health conditions, it results from multiple interacting factors rather than a single cause. Research has identified biological, psychological, and environmental contributors that together create vulnerability to developing the disorder.

Biological factors

Brain imaging studies have revealed that people with BDD show differences in how they process visual information. Specifically, there appears to be an imbalance between detailed, piecemeal processing (focusing on tiny details) and holistic processing (seeing the big picture). This may contribute to the tendency to fixate on minor imperfections while losing sight of overall appearance.

Genetic factors also play a role. Studies show that BDD runs in families, and having a first-degree relative with BDD or OCD increases your risk of developing BDD. The heritability of BDD is estimated to be similar to that of other psychiatric disorders, suggesting a significant genetic component.

Neurochemistry, particularly the serotonin system, appears to be involved. This is supported by the effectiveness of SSRI medications in treating BDD. There may also be involvement of other neurotransmitter systems and brain structures, including the amygdala (involved in emotional processing) and the orbitofrontal cortex (involved in decision-making and self-image).

Psychological factors

Certain psychological characteristics and thinking patterns increase vulnerability to BDD:

• Perfectionism: Setting impossibly high standards and being highly critical of perceived failures
• Negative self-image: Already having low self-esteem or negative beliefs about oneself
• Attentional biases: A tendency to selectively focus on negative aspects of appearance
• Interpretation biases: Interpreting neutral or ambiguous situations negatively (e.g., thinking someone's glance means they noticed your "flaw")

Environmental and social factors

Life experiences and social environment significantly influence the development of BDD. Research has identified several environmental risk factors:

• Childhood experiences: Being teased, bullied, or criticized about appearance during formative years
• Family emphasis on appearance: Growing up in an environment where physical appearance was highly valued or frequently discussed
• Trauma: Experiencing abuse, neglect, or other traumatic events
• Media and social pressure: Exposure to unrealistic beauty standards in media and social media
• Cultural factors: Living in a culture that places high value on physical appearance

How Is Body Dysmorphic Disorder Diagnosed?

BDD is diagnosed through clinical assessment by a mental health professional who evaluates whether you meet DSM-5 criteria: preoccupation with perceived appearance flaws not observable to others, repetitive behaviors related to appearance concerns, and significant distress or impairment. Specialized questionnaires like the BDD-YBOCS help assess severity.

Diagnosing BDD requires a thorough clinical evaluation by a qualified mental health professional, typically a psychiatrist or psychologist. There is no blood test or brain scan that can diagnose BDD—diagnosis is based on careful assessment of symptoms, behaviors, and their impact on functioning.

The diagnostic process usually involves a clinical interview where the healthcare provider asks about your appearance concerns, how much time you spend thinking about them, what behaviors you engage in, and how these concerns affect your daily life. Many people feel embarrassed discussing these concerns, but being open and honest is essential for accurate diagnosis.

DSM-5 diagnostic criteria

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), BDD is diagnosed when the following criteria are met:

1. Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear only slight to others
2. At some point during the course of the disorder, the individual has performed repetitive behaviors (mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (comparing appearance with others) in response to the appearance concerns
3. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
4. The appearance preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder

Assessment tools

Several validated assessment instruments help clinicians evaluate BDD symptoms and severity:

• BDD-YBOCS (Yale-Brown Obsessive Compulsive Scale Modified for BDD): The gold standard for assessing BDD severity
• BDDQ (Body Dysmorphic Disorder Questionnaire): A screening tool to identify potential BDD
• BDD-SS (Body Dysmorphic Disorder Symptom Scale): Measures various aspects of BDD symptoms

Challenges in diagnosis

BDD often goes undiagnosed for many years. On average, people with BDD seek help from numerous healthcare providers over many years before receiving the correct diagnosis. Several factors contribute to this diagnostic delay:

• Shame and secrecy: Many people feel too embarrassed to discuss their appearance concerns
• Seeking cosmetic rather than psychiatric help: People often consult dermatologists or plastic surgeons rather than mental health professionals
• Lack of awareness: Many people don't know BDD is a recognized condition
• Clinician unfamiliarity: Some healthcare providers may not be familiar with BDD or may dismiss concerns as vanity

What Treatment Is Available for Body Dysmorphic Disorder?

The most effective treatments for BDD are Cognitive Behavioral Therapy (CBT) specifically adapted for BDD, which has 50-80% response rates, and SSRI medications at higher doses than typically used for depression. Combining therapy and medication often provides the best results. Cosmetic procedures are not recommended as they rarely improve symptoms.

The good news is that BDD is a treatable condition. With proper treatment, most people experience significant improvement in their symptoms and quality of life. The two main evidence-based treatments are cognitive behavioral therapy specifically designed for BDD and medication, typically SSRI antidepressants.

Cognitive Behavioral Therapy (CBT) for BDD

CBT is considered the first-line psychological treatment for BDD. The therapy specifically designed for BDD typically includes several key components that address both the thought patterns and behaviors that maintain the disorder:

Psychoeducation: Learning about BDD helps you understand that your condition is a recognized mental health disorder and that your perception of your appearance is distorted. This knowledge alone can begin to reduce shame and provide hope for recovery.

Cognitive restructuring: This involves identifying and challenging the distorted thoughts about your appearance. You learn to recognize cognitive errors like magnification (making small things seem huge), mind-reading (assuming others notice and judge your appearance), and emotional reasoning (feeling ugly therefore believing you must be ugly).

Exposure and response prevention (ERP): This behavioral component involves gradually exposing yourself to situations you've been avoiding (like going out in public without camouflage) while resisting the urge to engage in safety behaviors (like checking mirrors or seeking reassurance). Over time, this reduces anxiety and breaks the cycle of avoidance.

Behavioral experiments: Testing out beliefs in the real world to gather evidence about whether your fears are accurate. For example, going to a social event with minimal makeup to test whether people actually notice or react negatively.

CBT for BDD typically involves weekly sessions over 12-22 weeks, though some people may need longer treatment. Online CBT programs specifically designed for BDD have also shown effectiveness and may be more accessible for some people.

Medication treatment

SSRI (Selective Serotonin Reuptake Inhibitor) medications are the medication of choice for BDD. Importantly, higher doses are typically needed for BDD than for depression. Research has shown that many people with BDD require the maximum approved doses of SSRIs to achieve optimal response.

SSRIs that have been studied for BDD include fluoxetine, fluvoxamine, escitalopram, and sertraline. Response to medication typically takes 12-16 weeks, which is longer than the response time for depression. This means it's important to give the medication adequate time to work before concluding it's not effective.

For people who don't respond adequately to SSRIs alone, augmentation strategies may be considered, such as adding an atypical antipsychotic medication. However, these decisions should be made in consultation with a psychiatrist experienced in treating BDD.

Combining treatment approaches

For many people with BDD, combining CBT and medication provides the best outcomes, particularly for those with moderate to severe symptoms. The medication may help reduce the intensity of symptoms enough to engage more fully in CBT, while the therapy provides tools for managing symptoms long-term.

What Can You Do to Help Yourself with BDD?

Self-help strategies for BDD include learning about the condition, gradually reducing time spent on appearance-related behaviors, practicing exposure to feared situations, limiting social media use, talking to trusted people about your struggles, and seeking professional treatment. Remember that BDD is a medical condition, not a character flaw.

While professional treatment is important for BDD, there are also things you can do to help yourself. These strategies work best alongside professional treatment rather than as a replacement for it.

Acknowledge the problem

The first step is recognizing that your concerns about your appearance may be due to BDD rather than actual physical defects. This can be difficult because the condition makes the perceived flaws feel very real. Learning about BDD—reading articles like this one, watching educational videos, or reading books about the condition—can help you understand that what you're experiencing is a recognized mental health condition that affects how you perceive yourself.

It's common to feel shame about BDD, but understanding that it's a medical condition, not vanity or weakness, can help reduce that shame. Many people with BDD have kept their struggles secret for years. Breaking that silence, even just acknowledging the problem to yourself, is an important step toward recovery.

Reduce safety behaviors

Safety behaviors are the things you do to cope with your appearance anxiety—like excessive mirror checking, wearing heavy makeup, or constantly adjusting your clothing. While these behaviors provide short-term relief, they actually maintain the problem in the long run.

Try to gradually reduce the time you spend on these behaviors. This might mean setting a time limit for getting ready in the morning, covering mirrors for parts of the day, or resisting the urge to ask others about your appearance. This can be challenging, but each time you resist a safety behavior, you're taking a step toward recovery.

Talk to someone you trust

Isolation is common with BDD, and keeping your struggles secret can make them feel more overwhelming. Consider talking to someone you trust—a friend, family member, or partner—about what you're experiencing. You don't have to share every detail, but simply saying "I struggle with concerns about my appearance that are really affecting my life" can be a relief and open the door to support.

If you're having thoughts of suicide or self-harm, it's especially important to reach out to someone. These thoughts are common in BDD and are a sign that you need additional support.

Limit social media and appearance triggers

Social media can worsen BDD symptoms by providing endless opportunities for comparison and exposure to filtered, unrealistic images. Consider reducing your social media use, unfollowing accounts that make you feel worse about yourself, or taking breaks from platforms entirely. Similarly, try to limit other triggers like fashion magazines or TV shows focused on appearance.

Focus on values beyond appearance

BDD can make appearance feel like the most important thing in life. Try to reconnect with other values and activities that are important to you. What did you enjoy before BDD took over? What matters to you besides how you look? Gradually re-engaging with these areas of life can help restore a more balanced perspective.

How Can You Support Someone with Body Dysmorphic Disorder?

Support someone with BDD by learning about the condition, encouraging professional treatment, avoiding reassurance about appearance (which paradoxically maintains the problem), being patient with their struggles, and taking care of your own wellbeing. Remember that BDD is a medical condition that requires professional treatment.

If someone you care about has BDD, you may feel helpless, frustrated, or unsure how to help. Understanding the condition and knowing effective ways to support them can make a significant difference.

Understand that BDD is a medical condition

The most important thing is to understand that BDD is a recognized mental health condition, not vanity, attention-seeking, or a choice. The person with BDD is not being difficult or shallow—they are experiencing genuine distress due to a disorder that affects how they perceive themselves. Their perception of their appearance is genuinely distorted, which can be hard to understand if you can't see what they see.

Encourage professional treatment

One of the most helpful things you can do is encourage the person to seek professional help. You can offer to help them find a therapist, accompany them to appointments, or simply provide support as they begin treatment. Remember that treatment works—most people with BDD improve significantly with proper care.

The reassurance trap

It's natural to want to reassure someone with BDD that they look fine or that their perceived flaw isn't noticeable. However, research shows that this reassurance actually maintains the problem. The person may feel momentarily relieved but will soon need more reassurance, creating an endless cycle.

Instead of providing reassurance about appearance, try saying something like: "I understand you're worried about how you look, but I don't think my answer will help you feel better in the long run. I care about you and want to support you in finding real help for this." This acknowledges their distress while not feeding the reassurance-seeking behavior.

Take care of yourself

Supporting someone with BDD can be emotionally draining. It's important to maintain your own wellbeing, set boundaries when needed, and seek support for yourself if you're struggling. Consider joining a support group for family members of people with mental health conditions, or speaking with a therapist yourself.

When Should You Seek Professional Help?

Seek professional help if appearance concerns occupy more than an hour daily, cause significant distress, or interfere with work, relationships, or daily activities. Seek immediate help if you have thoughts of self-harm or suicide. Contact a mental health professional, your primary care doctor, or an emergency service if in crisis.

If you recognize yourself in this article, seeking professional help is the most important step you can take. BDD is unlikely to improve on its own and often worsens without treatment. The earlier you get help, the better the outcomes tend to be.

Signs it's time to seek help

• You spend an hour or more per day thinking about your perceived appearance flaws
• Appearance concerns are causing significant emotional distress
• You're avoiding social situations, work, or activities because of how you feel about your appearance
• You're engaging in repetitive behaviors like mirror checking, excessive grooming, or reassurance seeking
• You've had cosmetic procedures that didn't reduce your concerns
• Your appearance concerns are affecting your relationships
• You're experiencing depression, anxiety, or thoughts of self-harm

How to access treatment

Start by speaking with your primary care doctor, who can provide an initial assessment and refer you to a mental health specialist. You can also contact a psychiatrist or psychologist directly. When seeking treatment, look for providers who have experience with BDD or OCD-related disorders, as specialized expertise leads to better outcomes.

Be honest during your appointment about your appearance concerns, behaviors, and how much time you spend on these issues. Many people downplay their symptoms due to embarrassment, but accurate information helps ensure you get the right diagnosis and treatment.