Signs & Symptoms of BDD
By Katharine A. Phillips, MD
Body dysmorphic disorder (BDD) consists of preoccupation with perceived flaws in one's physical appearance that to other people actually look non-existent or only slight. To be diagnosed as BDD, the appearance preoccupations must cause clinically significant distress or impairment in functioning. In addition, at some point during the course of the disorder, the person has performed excessive repetitive behaviors, such as comparing with others, mirror checking, skin picking, or excessive grooming.
In individuals with weight concerns who are actually normal weight or only slightly overweight, the clinician must determine whether these concerns are better explained by an eating disorder or BDD. BDD and eating disorders are frequently comorbid.
People with BDD intensely dislike one or more aspects of their physical appearance, believing that these body areas look ugly, abnormal, deformed, or disfigured. People with milder BDD may describe the disliked areas as looking “unattractive,” whereas those with more severe BDD may say they look “hideous” or like a monster.
The most commonly disliked body parts are:
- Skin (usually facial skin — for example, perceived scarring, blemishes, or color)
- Hair (for example, perceived balding or too much facial or body hair)
- Nose (for example, size or shape).
Symmetry concerns (for example, uneven eyebrows or hair length) are also common BDD concerns. However, people with BDD can be preoccupied with the appearance of any body area. Some people focus on just one part of their body, whereas others are preoccupied with virtually their entire body.
Nearly all people with BDD spend at least an hour a day in total thinking about the disliked body part/area. People who spend less time than one hour a day probably don’t have BDD. The average is 3 hours to 8 hours a day. Some people find that BDD preoccupations consume their entire day. The appearance preoccupations are usually difficult to resist or control, and they cause significant distress.
Repetitive, Compulsive Behaviors
BDD preoccupations fuel repetitive compulsive behaviors that are intended to fix, hide, inspect, or obtain reassurance about the disliked body parts. On average, these behaviors consume from 3 – 8 hours a day. They are usually difficult to control or stop. These behaviors may be clues that a person has BDD. People who engage in them should be assessed for the possible presence of BDD.
Common repetitive BDD behaviors include the following:
- Camouflaging: Trying to hide or cover up the disliked body areas with things such as a hat, heavy makeup, clothing, hair, sunglasses, one’s hands, or body position. Camouflaging often involves repetitive behaviors, such as repeatedly adjusting one’s clothing to hide disliked body parts or repeatedly applying makeup.
- Comparing: Comparing the disliked features to those of other people.
- Mirror checking: Repeatedly checking the perceived defects in mirrors and other reflecting surfaces, such as windows or a cell phone.
- Excessive grooming: Repeatedly applying makeup, styling or combing hair, plucking hair, or shaving. NOTE: People who pull or pluck out their hair only as a symptom of BDD (in response to appearance concerns) should not receive a diagnosis of trichotillomania (hair-pulling disorder).
- Reassurance seeking/questioning of others: Frequently asking others how they look or if they look okay. Alternatively, some people with BDD repeatedly insist that they look ugly or abnormal.
- Skin picking: Compulsively picking one’s skin to try to make it look better – note that the intent of this skin picking is not to harm oneself. This behavior can cause skin lesions and scarring. It is occasionally life-threatening (for example, when picking into a major artery and losing large amounts of blood). NOTE: People who pick their skin only as a symptom of BDD (in response to appearance concerns) should not receive a diagnosis of excoriation (skin-picking) disorder.
- Clothes changing: Frequently changing clothes to try to better hide disliked body areas or find a more flattering outfit.
- Tanning: Excessively tanning to darken skin that is considered too pale or for other reasons (for example, to try to minimize perceived acne).
- Excessive exercising or weight lifting: Excessive weight lifting is especially common in men with the muscle dysmorphia form of BDD.
- Excessive shopping: Excessively shopping for makeup, skin products, other products, or clothes to try to improve the appearance of the disliked body areas.
- Seeking cosmetic surgery, dermatologic treatment, or other cosmetic procedures: A majority of people with BDD receive cosmetic treatment, but these treatments are almost never helpful for BDD concerns and can make them worse.
- Excessive selfies
Insight Regarding BDD Beliefs
Most people with BDD are mostly or completely convinced that they look ugly or abnormal, even though other people don’t see them this way. In reality, the perceived defects are actually non-existent or slight (click here for more information about visual processing aberrations in BDD). In other words, insight regarding the perceived appearance defects is usually absent (i.e., delusional beliefs) or poor.
This mismatch between how people with BDD see themselves and how other people see them can cause friction in relationships, because people with BDD usually don’t believe other people’s reassurance that they really do look “normal.” In addition, about two-thirds of people with BDD have ideas or delusions of reference (i.e., referential thinking); that is, they believe that other people take special notice of the “defective” body areas, talk about them in a negative way, or make fun of them because of how they look. These beliefs result from a misinterpretation of others’ behavior.
Core Beliefs and Emotions in BDD
Many individuals with BDD report intense feelings of shame and low self-esteem. A deep sense of self-loathing may result in the belief that they are fundamentally inadequate, unacceptable to others, or unlovable, or that they will always be alone because of how they look. Emotions that are common in people with BDD include depression, anxiety, self-consciousness, guilt, frustration, anger, disgust, embarrassment, and grief.
Increasingly, many poorly defined terms are being used to describe BDD, such as body dysmorphia, skin dysmorphia, acne dysmorphia, zoom dysmorphia, penile dysmorphia, and other types of dysmorphia. The problem with all of these neologisms is that they are colloquial terms that are not in DSM-5 or ICD-11 and that have no agreed-upon definition. It's likely that they often refer to BDD, but they may refer to normal appearance concerns – and it's often difficult to figure this out.
It's important, as with all mental disorders, to differentiate disorder from non- disorder so we don't over-pathologize normal concerns and behaviors. In addition, the presence of a disorder indicates the need for treatment. The disorder BDD, as defined in DSM-5, is an often severe mental disorder that can lead to suicide and requires treatment, whereas treatment is not needed for the normative discontent that most of us have with some aspect of how we look.
Katharine A. Phillips, MD, is Professor of Psychiatry at Weill Cornell Medical College, Cornell University, and Attending Psychiatrist at New York-Presbyterian Hospital, both in New York City. She is internationally known for her pioneering research and clinical expertise in body dysmorphic disorder. She is author of The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder (Revised and Expanded Edition) (2005), Understanding Body Dysmorphic Disorder: An Essential Guide (2009), and Body Dysmorphic Disorder: Advances in Research and Clinical Practice (2017) (all published by Oxford University Press). She is also co-author of Cognitive-Behavioral Therapy for Body Dysmorphic Disorder: A Treatment Manual, published by Guilford Press in 2013 (with Drs. Sabine Wilhelm and Gail Steketee) and The Adonis Complex: The Secret Crisis of Male Body Obsession, published by The Free Press in 2000 (with Drs. Harrison Pope and Roberto Olivardia).