By Katharine A. Phillips, M.D.
Professor of Psychiatry, Weill Cornell Medical College
Attending Psychiatrist, New York-Presbyterian/Weill Cornell Medical Center
New York, NY, USA
Editor: Dr. Phillips (Bio) is one of the leading experts on the topic of body dysmorphic disorder (BDD), not only in the US but in the entire world. She is the author or co-author of the leading books on body dysmorphic disorder for clinicians and for patients and their families. Please see: BEST books about Body Dysmorphic Disorder.
Dr. Phillips is also a member of the Editorial Board of Simple and Practical Medical Education.
Since body dysmorphic disorder (BDD) may be less familiar to clinicians than many other mental disorders, we’ll start with how DSM-5 (American Psychiatric Association, 2013) defines it (paraphrased), which is fairly straightforward.
In DSM-5, body dysmorphic disorder is one of the conditions included in the chapter on Obsessive-Compulsive and Related Disorders.
The key clinical features of body dysmorphic disorder (BDD) are:
1. Preoccupation with nonexistent or slight flaws in one’s physical appearance. Patients think that they look ugly, unattractive, deformed, abnormal, or even monstrous, though they actually look fine.
On average, concerns focus on five to seven different body areas over the course of the illness. Preoccupations most often focus on skin (such as perceived acne or scarring), hair (such as perceived balding or excessive facial hair), or nose (such as size or shape). But they can be focused on any body area (Phillips et al., 2005a).
A particular type of concern that DSM-5 identifies with a specifier is “muscle dysmorphia” in which the patients are preoccupied with the belief that their body build is either too small or not muscular enough, even though others would not think so (American Psychiatric Association, 2013; Phillips et al., 2010). If this is one of the concerns present, DSM-5 asks us to diagnose “Body dysmorphic disorder, with muscle dysmorphia”.
2. Repetitive behaviors (that is, compulsions, rituals) or mental acts in response to the preoccupations about perceived defects.
Examples of such behaviors or mental acts include (Phillips et al., 2005a; American Psychiatric Association, 2013):
– Repeatedly comparing one’s appearance with that of other people
– Repeatedly trying to improve the perceived defects in appearance by various means, including by seeking cosmetic surgery
– Compulsive grooming
– Trying to hide the perceived defect (for example, through makeup, items of clothing, accessories); this is sometimes repetitive (for example, when reapplying makeup 20 times a day).
– Excessively checking one’s appearance in mirrors or other reflecting surfaces
– Repeatedly seeking reassurance from others about one’s appearance
– Skin picking to try to improve perceived skin imperfections.
As in the case of most other mental disorders, we only make a DSM-5 diagnosis of BDD if the preoccupation(s) cause either clinically significant distress or impairment in functioning.
Insight in body dysmorphic disorder
Insight in BDD ranges from good to absent (that is, a delusional conviction that the person looks ugly or deformed).
Tip: Patients with the absent-insight/delusional form of BDD (about one-third of patients; Phillips et al., 2012), should be diagnosed with BDD rather than a psychotic disorder.
What body dysmorphic disorder isn’t
We don’t diagnose BDD if the preoccupation with appearance is about body fat or weight in a person with an eating disorder.
Next, please see the following articles on this website:
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Washington, DC, American Psychiatric Association, 2013.
Phillips KA, Menard W, Fay C, Weisberg R. Demographic characteristics, phenomenology, comorbidity, and family history in 200 individuals with body dysmorphic disorder. Psychosomatics. 2005 Jul-Aug;46(4):317-25. doi: 10.1176/appi.psy.46.4.317. PMID: 16000674; PMCID: PMC1351257.
Phillips KA, Pinto A, Hart AS, Coles ME, Eisen JL, Menard W, Rasmussen SA. A comparison of insight in body dysmorphic disorder and obsessive-compulsive disorder. J Psychiatr Res. 2012 Oct;46(10):1293-9. doi: 10.1016/j.jpsychires.2012.05.016. Epub 2012 Jul 21. PMID: 22819678; PMCID: PMC3432724.
Phillips KA, Wilhelm S, Koran LM, Didie ER, Fallon BA, Feusner J, Stein DJ. Body dysmorphic disorder: some key issues for DSM-V. Depress Anxiety. 2010 Jun;27(6):573-91. doi: 10.1002/da.20709. PMID: 20533368; PMCID: PMC3985412.
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