Article

Body dysmorphic disorder (BDD)

Body dysmorphic disorder (BDD) is a psychiatric condition marked by a persistent, excessive preoccupation with one or more perceived defects or flaws in physical appearance that are either not observable or appear slight to others. It is commonly grouped with obsessive–compulsive and related disorders and frequently causes significant distress and functional impairment.

Key facts

  • Typical age of onset: adolescence or early adulthood.
  • Lifetime prevalence in community samples: roughly 0.7–2.4%; higher in cosmetic‑surgery, dermatology and cosmetic psychiatry settings.
  • Affects all genders; recognised subtypes include muscle dysmorphia (preoccupation with muscularity).

Core features

  • Persistent preoccupation with perceived appearance flaws.
  • Repetitive behaviours or mental acts in response (mirror checking or avoidance, excessive grooming, skin picking, comparing with others, reassurance seeking).
  • Marked distress or impairment in social, occupational or other important areas of functioning.

Causes and maintaining factors

BDD is best understood as biopsychosocial. Common contributors include:

  • Biological: familial risk, neurocognitive differences in visual processing, overlap with obsessive–compulsive traits.
  • Psychological: perfectionism, rumination, low self‑esteem, body‑focused attention, history of teasing or trauma.
  • Social/cultural: internalisation of narrow beauty ideals, pervasive edited images on social media, peer reinforcement.

Clinical picture and comorbidity

Patients often present with severe preoccupation about a specific body area (face, skin, hair, nose, breasts, genitals, etc.). Comorbidities are common and include:

  • Major depressive disorder
  • Social anxiety disorder
  • Obsessive–compulsive disorder
  • Eating disorders

Suicidal ideation and attempts are elevated in BDD; clinicians should assess risk directly and urgently when present.

BDD and elective/cosmetic procedures

Many people with BDD seek cosmetic or dermatological procedures (fillers, rhinoplasty, breast augmentation, liposuction, laser treatments). Evidence shows:

  • Cosmetic procedures rarely resolve BDD and can result in persistent dissatisfaction or repeated interventions.
  • Surgery can sometimes worsen symptoms when underlying psychopathology is not addressed.

Practical recommendation for practitioners: screen for BDD before elective cosmetic procedures and consider psychiatric referral when BDD is suspected.

Red flags in cosmetic settings

  • Long daily preoccupation with appearance (hours per day).
  • Multiple previous unsatisfactory procedures or requests for repeat revisions.
  • Unrealistic demand for a 'perfect' result.
  • Excessive reassurance‑seeking or fixation on particular measurements/angles.
  • Functional impairment (avoiding work/social life) or current suicidal ideation.

When red flags are present, document the concerns, delay elective interventions, and arrange mental health assessment (CBT for BDD, with pharmacotherapy such as an SSRI when indicated).

Practical clinical checklist

  • Ask open questions: "How much time each day do you spend thinking about this feature?" "Does it stop you doing things you want to do?"
  • Look for behaviours: repeated mirror checking, photographing, concealing, skin picking, repeated comparisons.
  • Use a brief screening tool when available (for example, BDDQ or clinician interview items).
  • If screening suggests BDD: consider psychiatric referral, explain risks of cosmetic treatment, and offer conservative alternatives (psychological therapy, watchful waiting).

Guidance for writers

When portraying BDD in fiction or character work, be trauma‑informed and avoid stigmatising language. Useful focal points:

  • Show the lived experience: intrusive images, repetitive rituals, shame, secrecy and the impact on relationships and work.
  • Avoid reducing the character to their appearance; include help‑seeking, treatment options and recovery narratives where realistic.
  • Small, concrete details (mirror rituals, measuring, comparing photos) create credibility.

Example snippet (2–4 lines):

She spent the morning tracing the scar's outline in the bathroom light, convinced everyone at work would notice it and judge; a single glance could undo the week. She cancelled the consultation and, for the first time, booked a therapy appointment.

Why this works: It focuses on behaviour, emotion and a simple action (booking help) rather than making the character only their appearance.

Terminology note

Some people use "body dysmorphia" informally to mean general dissatisfaction with appearance; "body dysmorphic disorder (BDD)" refers to the clinical diagnosis that meets specified criteria for severity and impairment.

Related pages

  • body_dysmorphia.md
  • post-surgery.md

Sources and further reading

This summary synthesises clinical reviews and publicly available references. For clinical decisions follow up‑to‑date guidelines and specialist advice. (Public sources such as peer‑reviewed summaries and reference texts informed this entry.)

Symptoms

  • Preoccupation with appearance: persistent, intrusive thoughts about perceived flaws in one's body. In people considering plastic surgery, signs include excessive concern over specific areas (eg face, nose) even when others do not notice them; this can lead to avoidance of social situations and impairment in daily routines.

  • Repetitive behaviours: mirror checking, repeated photographing, comparing oneself to images, imagining surgical outcomes. These rituals often intensify during decision-making about procedures and can reinforce the perceived need for intervention.

  • Seeking reassurance: repeatedly asking friends, family or professionals whether a feature looks 'wrong' or could be 'fixed' by surgery, despite reassurances.

  • Significant distress or impairment: anxiety, depression, social withdrawal or interference with work/study; such distress suggests that surgery may not resolve the underlying problem without psychological treatment.

Relevance to Plastic Surgery

  • High rates of BDD among cosmetic surgery patients: individuals with BDD often have specific concerns tied to their chosen procedure; for example, those seeking rhinoplasty may obsess over nasal asymmetry or a bump. This pattern occurs across procedures including breast augmentation and facelifts (see plastic surgery statistics).

  • Surgery rarely resolves underlying psychological issues: many patients remain dissatisfied post-procedure if the operation targets BDD obsessions. See post-surgery.md for general outcomes discussion.

  • Screening for BDD is recommended before elective procedures: ask how concerns affect quality of life and whether surgery is expected to remove intrusive thoughts. When symptoms are likely to be driven by psychopathology, favour referral to mental health rather than immediate surgery.

  • Everyday functioning: preoccupation can affect grooming, shopping and social interactions, with small perceived flaws repeatedly noticed and magnified.

  • Decision-making and rituals: repetitive behaviours (mirror checking, repeated photo comparisons) can intensify the decision to pursue surgery and are useful clinical signals.

  • Reassurance and expectations: repeated requests for validation or precise measurements are common and predict poorer satisfaction when psychological distress drives the choice.

  • Differentiation strategies: ask open questions about duration, impact and prior responses to reassurance; use standardised screening items where available and consider a psychiatric or psychological opinion when in doubt.