Version May 2024
INTRODUCTION — Body dysmorphic disorder (BDD) is characterized by excessive preoccupation with nonexistent or slight defects in physical appearance, such that patients believe they look abnormal, unattractive, ugly, or deformed, when in reality they look normal. The preoccupation with perceived flaws leads to repetitive behaviors (eg, checking their appearance in mirrors), which are usually difficult to control and are not pleasurable. In addition, the appearance preoccupations cause clinically significant distress or impaired functioning. BDD is common but underrecognized, and it is often associated with suicidal ideation and behavior.
Patients with BDD may present to mental health professionals as well as other clinicians, such as dermatologists, plastic surgeons, otolaryngologists, primary care clinicians, pediatricians, gynecologists, and dentists. Most patients seek nonpsychiatric cosmetic treatment (most commonly dermatologic and surgical) for their perceived physical defects; this treatment appears to be ineffective for most patients and can be risky for clinicians to provide. By contrast, pharmacotherapy (selective serotonin reuptake inhibitors or clomipramine) and/or cognitive-behavioral therapy tailored specifically to BDD are often efficacious.
This topic reviews the epidemiology and pathogenesis of BDD. The clinical features, assessment, diagnosis, differential diagnosis, treatment, and prognosis of BDD are discussed separately.
●(See "Body dysmorphic disorder: Clinical features".)
●(See "Body dysmorphic disorder: Assessment, diagnosis, and differential diagnosis".)
●(See "Body dysmorphic disorder: General principles of treatment".)
●(See "Body dysmorphic disorder: Choosing treatment and prognosis".)
EPIDEMIOLOGY — The point prevalence of body dysmorphic disorder (BDD) in the general adult population across multiple countries is approximately 2 to 3 percent [1-6]. In clinical settings, the point prevalence is usually higher, ranging from approximately 3 to 40 percent, depending upon the study sample [7-10]. The mean age of onset is approximately 16 to 17 years, with onset before age 18 in two-thirds of cases [11]. Onset is usually gradual rather than abrupt [12].
General population — The estimated point prevalence of BDD in the general population, based upon community studies from Australia, China, Germany, Italy, Pakistan, Sweden, Turkey, and the United States, is as follows [1-6,13,14]:
●Adolescents – 2 to 5 percent
●College/university students – 3 percent
●Adults – 2 to 3 percent
Subsequent studies report even higher prevalence rates [15-17].
In nationwide, population-based epidemiologic studies in Western countries, the point prevalence of BDD is higher in younger adults than older adults, and higher in females than males (in a ratio of approximately 1:0.3 to 0.9).
Clinical settings — BDD is common in clinical settings; however, it usually goes undiagnosed [7]. In six studies, none of the patients identified as having BDD by researchers had the diagnosis recorded in their clinical records [8,9,18]. Thus, it is important to screen for BDD in clinical settings. (See "Body dysmorphic disorder: Assessment, diagnosis, and differential diagnosis", section on 'Screening instruments'.)
Psychiatric — The prevalence of BDD in psychiatric settings is as follows:
●Inpatients – A meta-analysis pooled four studies in adult psychiatric inpatients (total n = 788), who were diagnosed with anxiety, bipolar, depressive, psychotic, substance use, and other mental disorders. The point prevalence of comorbid BDD was approximately 7 percent [2].
●Outpatients – A meta-analysis of three studies in adult psychiatric outpatients (total n = 765) found that the point prevalence of BDD was approximately 6 percent [2]. BDD was often comorbid with other disorders, such as anxiety, depressive, and substance use disorders. Even higher rates of BDD are found in certain psychiatric subgroups, including patients with anxiety disorders, obsessive-compulsive disorder, atypical major depressive disorder, and eating disorders [1].
Cosmetic surgery — A meta-analysis of 11 studies in general cosmetic surgery clinics (total n = 2291 patients) found that the point prevalence of BDD was approximately 13 percent [2]. However, heterogeneity across studies was large. Although females outnumber males in most clinical settings, the prevalence of BDD in general cosmetic surgery settings was higher in males.
●Rhinoplasty – A meta-analysis of seven studies in patients seeking rhinoplasty surgery (total n = 1001) found that the point prevalence of BDD was approximately 20 percent [2]. However, heterogeneity across studies was large. Thus, BDD appears more common in rhinoplasty settings than in general cosmetic surgery settings, which is consistent with findings that the nose is one of the most common body areas of concern in patients with BDD.
●Orthognathic surgery – A meta-analysis of two studies in patients seeking orthognathic surgery (total n = 259) found that the point prevalence of BDD was approximately 11 percent [2].
●Orthodontic/cosmetic dentistry – Based upon multiple reviews, the point prevalence of BDD in orthodontic and cosmetic dentistry patients is approximately 5 to 10 percent [2,19].
Dermatology — A meta-analysis of five studies in general dermatology outpatient clinics (total n = 914 patients) estimated that the point prevalence of BDD was 11 percent [2]. However, heterogeneity across studies was large, and one review found that the prevalence of BDD ranged from 7 to 42 percent of the dermatology patients [19].
PATHOGENESIS — Although the pathogenesis of body dysmorphic disorder (BDD) remains largely unknown, the etiology is likely multifactorial, involving biologic (including evolutionary), psychologic, and social factors [20-22]. Studies of the pathogenesis have used cross-sectional designs, making it unclear whether abnormalities (eg, neuroimaging findings) represent etiologic causes, sequelae, neither, or both.
Heritability/genetics — Based upon multiple twin studies, the heritability of BDD is moderate [23]:
●A study of monozygotic and dizygotic female twin pairs (total n >5400) found that the relative contribution of genetic factors (heritability) to BDD was 43 percent, and the remaining contribution was attributable to environmental factors [23]. In addition, the risk of developing BDD involved genetic factors that were shared with obsessive-compulsive disorder, as well as other genetic factors that were unique to BDD.
●Another study of monozygotic and dizygotic female twin pairs (total n >3500) examined “dysmorphic concern” (excessive preoccupations with a perceived or slight flaw in physical appearance), which differs from but substantially overlaps with the diagnosis of BDD. The results indicated that dysmorphic concern was a heritable trait, such that 44 percent of the variance in dysmorphic concern was due to genetic factors and 56 percent to nonshared (unique) environmental factors [24]. Also, the association between dysmorphic concern and obsessive-compulsive symptoms appeared to be primarily due to shared genetic factors [25].
●In a registry study of twin individuals (n >15,000), the heritability of clinically significant BDD symptoms in adolescents and young adults was as follows [26]:
•Age 15 years – 49 percent
•Age 18 years – 39 percent
•Age 20 to 28 years – 37 percent
The remaining variance was due to nonshared environmental factors.
One preliminary candidate gene study detected an association between BDD and the GABA-A-gamma-2 (5q31.1-q33.2) receptor gene [27].
Visual processing — Visuospatial and psychophysical studies of BDD, using tasks such as the Rey-Osterrieth Complex Figure Test, the inverted faces task, and the embedded figures task, have observed enhanced detail-oriented (“local”) visual processing and impaired global (holistic) visual processing [21,28].
Functional magnetic resonance imaging (MRI) studies also suggest that BDD is associated with abnormal visual processing, manifesting as overattention to detail accompanied by deficiencies in global/holistic perception [29-31]. These abnormalities may make it difficult to see “the big picture” and to contextualize details, so that miniscule details appear abnormally prominent and out of proportion and thereby flawed and unattractive [32]. As an example, multiple studies used functional MRI to compare BDD patients with healthy controls while viewing faces and objects, and found that patients had hyperactivation (abnormally increased visual processing) in left ventral visual stream (temporal lobe), and hypoactivation (abnormally reduced neural activity) in dorsal visual stream (visual cortex); this suggested greater processing of detail and underutilization of brain systems dedicated to global/holistic (“big picture”) visual processing [29-31]. In addition, BDD symptom severity was correlated with increased frontostriatal activity and activity in extrastriate visual cortex.
Other functional MRI studies compared activation and connectivity in BDD and anorexia nervosa, which both involve distorted perception of appearance [12]. One study examined visual information processing of images of faces and houses in patients with BDD or anorexia nervosa and found similar abnormal hypoactivity in visual processing regions for holistic and configural information. However, the BDD group displayed hyperactivity in the fusiform cortex, which correlated with lower attractiveness ratings of others’ faces, and suggested that enhanced detail visual processing in BDD may lead to a greater likelihood of detecting flaws [21,33]. A subsequent study in BDD and anorexia nervosa found partially overlapping as well as different patterns of connectivity when viewing bodies (rather than faces); in both groups of patients, abnormal activity and/or connectivity were directly related to symptom severity and appearance ratings of others’ bodies [34].
Anatomic abnormalities — MRI has been used to compare brain structure in BDD patients with that in healthy controls, but the results have varied [21,35]. As an example, two structural MRI studies indicated that total white matter volume was larger in patients with BDD compared with control subjects [36,37], but other studies failed to replicate this finding [38]. In a relatively large morphometric study (BDD, n = 65; healthy controls, n = 68), the BDD group had larger gray matter volume in early extrastriate visual cortex in the occipital lobe [32], which overlaps with regions in which reduced functional activation has been detected when viewing faces and objects [29,31]. (See 'Visual processing' above.)
Increased gray matter volume might reflect insufficient synaptic pruning during neurodevelopment, which could interfere with normal development of holistic/global visual processing strategies and thus manifest as a reduced ability to integrate visual details into a more global context [32]. Alternatively, obsessive preoccupation with appearance and excessive repetitive behaviors such as checking one’s appearance in mirrors might modify early extrastriate architecture and result in larger brain volumes.
Studies of white matter integrity in patients and controls have yielded inconsistent results [39,40]. One study of neural networks found that white matter network organization was abnormal in BDD [41], whereas another study did not [40]. However, the latter study found correlations between fiber disorganization and poorer BDD-related insight in white matter tracts that facilitate communication between visual and emotion/memory systems as well as interhemispheric communication [40].
Neurocognitive dysfunction — Multiple studies suggest that executive function, which involves cognitive processes such as planning, making decisions, and response inhibition, is impaired in BDD [42-44]. As an example, a study that compared patients (n = 14) with controls who had no psychiatric history (n = 14) found that the ability to plan and to manipulate and organize information was inferior in BDD patients [45].
Deficits in executive function may represent frontal lobe dysfunction and help explain why patients with BDD focus on specific details of their body rather than the entirety of their appearance [45]. Findings from neuroimaging studies are consistent with this hypothesis.
Emotional processing deficits — Patients with BDD may also have deficits in recognizing emotions conveyed by the facial expressions of other people [44]. One study of patients with BDD (n = 18) and healthy controls (n = 18) found that patients were more likely to misinterpret neutral facial expressions in photographs as contemptuous and angry [46]. A second study suggested that patients have a bias toward interpreting neutral scenarios as threatening [47]. The results of these studies are consistent with the belief among patients that they are ridiculed and mocked because they look “ugly.”
Childhood maltreatment and trauma — Studies indicate that compared with published norms, patients with BDD report lower than average levels of perceived parental care during childhood, greater teasing by peers, and more maltreatment during childhood (neglect and abuse) [48,49]. As an example, one study found that a history of emotional, physical, and/or sexual abuse was reported by more patients with BDD (n = 50) than patients with obsessive-compulsive disorder (n = 50; 38 versus 14 percent) [50]. Several other studies found that self-reports of childhood maltreatment and early life traumatic events were greater in patients with BDD than healthy controls [51,52]. However, the accuracy of reports of childhood maltreatment in the studies was not confirmed.
Sociocultural factors — Sociocultural factors such as body ideals and beauty standards appear to increase the risk of developing BDD [22]. In addition, greater use of social media may be associated with poorer body image more generally [53], whereas greater use of image-based social media (eg, Instagram and Snapchat), and greater appearance focus when using social media (eg, filtering self-photos before posting them), may be associated specifically with BDD [15,16,54]. However, the studies of social media and BDD are cross-sectional, and it is thus not known whether certain types of social media increase the likelihood of developing BDD.
INFORMATION FOR PATIENTS — Many patients can benefit from reading about their illness at websites such as those maintained by the International OCD Foundation and the author of this topic at her website.
SUMMARY
●Diagnosis – Body dysmorphic disorder (BDD) is diagnosed according to DSM-5-TR criteria (table 1). (See "Body dysmorphic disorder: Assessment, diagnosis, and differential diagnosis", section on 'Diagnosis'.)
●Point prevalence – The estimated point prevalence of BDD in different populations is as follows:
•Adult general population – 2 to 3 percent.
•Psychiatric patients with other mental disorders (eg, depression) – 6 to 7 percent. The rate is even higher in certain subgroups, such as patients with anxiety disorders, obsessive-compulsive disorder, atypical major depressive disorder, and eating disorders.
•Cosmetic surgery (including rhinoplasty) patients – 11 to 20 percent.
•Dermatology patients – 11 to 13 percent.
(See 'Epidemiology' above.)
●Pathogenesis –The pathogenesis of BDD is not known. Neuroimaging and other studies suggest that BDD is associated with abnormal visual processing, with a bias for encoding and analyzing details of faces, as well as nonfacial objects, rather than using holistic visual processing strategies (ie, seeing “the big picture”). Other studies suggest that genetic factors; perceived teasing, neglect, and abuse; and sociocultural factors may also play a role. (See 'Pathogenesis' above.)
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