Body Dysmorphic Disorder (BDD)

Body dysmorphic disorder (BDD) is a mental health condition in which a person is preoccupied with one or more perceived defects or flaws in their appearance that are not observable, or appear only slight, to other people. The preoccupation is intense and time-consuming and leads to repetitive behaviors, such as mirror checking, grooming or seeking reassurance, or mental acts like comparing oneself with others. BDD affects roughly 2% of people, yet it often goes unrecognized for years and is a common reason people seek cosmetic procedures that do not help.

The DSM-5 (2013) moved BDD from the somatoform disorders to the chapter on obsessive-compulsive and related disorders, alongside OCD, hoarding disorder, trichotillomania and excoriation (skin-picking) disorder. The move reflects the obsession-like thoughts and compulsion-like behaviors at its core. The DSM-5-TR (2022) keeps this classification.

DSM-5 Diagnostic Criteria

The DSM-5-TR describes BDD (ICD-10-CM F45.22) using four criteria:

1. Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others.
2. At some point, the person has performed repetitive behaviors (for example, mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (for example, comparing their 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 preoccupation is not better explained by concerns with body fat or weight in someone whose symptoms meet criteria for an eating disorder.

Clinicians add two kinds of specifier:

• With muscle dysmorphia: preoccupation with the idea that one's body is too small or insufficiently muscular.
• Insight: good or fair, poor, or absent insight/delusional beliefs. Many people with BDD have poor insight, and some are completely convinced their view of their appearance is accurate. When conviction is total, the DSM-5-TR still diagnoses BDD rather than a psychotic disorder.

In ICD-11, BDD is also grouped with obsessive-compulsive or related disorders (code 6B21).

Symptoms and Behaviors

Common Areas of Concern

Any body part can become the focus, but the skin (acne, scars, complexion), hair (thinning or texture) and nose are among the most common. Others include the stomach, teeth, eyes, lips, breasts, genitals, body shape and overall symmetry. Most people are concerned with several areas, and the focus can shift over time.

Compulsive Behaviors

Repetitive behaviors are meant to check, fix, hide or get reassurance about the perceived flaw. They usually bring only brief relief and can take hours each day:

• Checking: in mirrors, phone cameras or shop windows; some people avoid mirrors altogether.
• Grooming: excessive hair styling, makeup or shaving.
• Camouflaging: using hats, clothing, makeup, posture or hands to hide the area.
• Comparing: with other people, photos or past images of oneself.
• Reassurance seeking: repeatedly asking others whether the flaw is noticeable.
• Skin picking to "improve" perceived blemishes.
• Researching or pursuing cosmetic treatments.

Thoughts and Beliefs

People with BDD often believe the flaw makes them ugly, abnormal or even "deformed," and that others notice and judge it. Ideas of reference, believing that others are staring at or talking about the flaw, are common. Many experience intense shame, and the thoughts can feel intrusive and hard to stop, similar to the intrusive thoughts of OCD.

Functional Impact

BDD can be highly disabling. People may avoid social events, dating, school or work, or leave home only at certain times. Some become housebound in severe cases. Depression is very common, and the DSM-5-TR notes high rates of suicidal thinking and suicide attempts. If you or someone you know is struggling with thoughts of suicide, see our crisis resources.

Causes and Risk Factors

BDD likely results from several interacting factors:

• Genetics: BDD is more common in first-degree relatives of people with BDD or OCD, and twin studies suggest moderate heritability.
• Visual processing: brain imaging studies, such as work by Jamie Feusner and colleagues, suggest people with BDD tend to process faces and bodies with a strong focus on fine details rather than the overall picture, which may make small imperfections loom large.
• Experiences: teasing or bullying about appearance, childhood maltreatment and other adversities are reported more often by people with BDD.
• Personality and cognition: perfectionism, high sensitivity to rejection, and a tendency to link self-worth closely to appearance.
• Culture: appearance-focused media and social comparison may shape the focus of concerns, though they do not by themselves cause BDD. See social media and mental health.

Cognitive behavioral models describe a cycle: an appearance-related trigger leads to a distorted, detail-focused self-image and negative thoughts, which cause distress; checking or camouflaging brings brief relief but maintains the preoccupation over time.

Muscle Dysmorphia

Muscle dysmorphia, sometimes called "bigorexia" in the media, is a form of BDD in which a person is preoccupied with the belief that their body is too small, thin or insufficiently muscular, often despite being well above average in muscularity. It is more common in men, particularly in weight-training communities.

Typical features include rigid exercise and diet routines that take priority over work and relationships, distress when a workout is missed, frequent body checking or avoidance of being seen, and, in some cases, use of anabolic steroids or other performance-enhancing substances, which carry significant health risks. Because intense training is socially admired, muscle dysmorphia often goes unrecognized.

BDD vs. Eating Disorders

BDD and eating disorders both involve distress about appearance and often co-occur. The main distinctions are:

Both conditions benefit from specialist assessment. Our guide to body image covers the broader psychology of how people see their bodies.

BDD vs. Normal Appearance Concern

Appearance worries are common, particularly in adolescence. BDD differs in several ways:

• Time: preoccupation typically takes at least an hour a day, often much more.
• Distress and impairment: concerns cause significant suffering or disrupt daily life.
• Resistance to reassurance: evidence that the flaw is minor does not ease the concern for long.
• Self-view: people often describe themselves as ugly or abnormal, regardless of how others see them.

Other conditions a clinician will consider include social anxiety disorder, OCD, depression, and, where hair pulling or skin picking is mainly about relieving tension rather than improving appearance, trichotillomania or excoriation disorder.

Cosmetic Surgery and BDD

Many people with BDD seek dermatological, dental or surgical treatments to fix the perceived flaw. Research suggests these rarely help:

• Studies estimate that around 10–15% of people seeking cosmetic surgery have BDD.
• In follow-up research by Katharine Phillips and colleagues, most people with BDD who received cosmetic treatments reported no improvement in overall BDD severity.
• Some people become more distressed after a procedure or shift their focus to a different feature.
• Professional bodies increasingly encourage practitioners to screen for BDD and to recommend psychological assessment before treatment.

Treatment

CBT with Exposure and Response Prevention (First-Line)

Cognitive behavioral therapy designed for BDD has the strongest research support and is recommended in clinical guidelines such as those from the UK's NICE. Protocols developed by Sabine Wilhelm, Katharine Phillips, Gail Steketee and David Veale include:

• Psychoeducation about how BDD works and how rituals maintain it.
• Exposure and response prevention (ERP): gradually facing avoided situations, such as going out without camouflage, while resisting checking, grooming or reassurance seeking.
• Cognitive restructuring: examining beliefs such as "if my skin isn't perfect, no one will want to be with me."
• Perceptual retraining: learning to look in mirrors in a more balanced, whole-body way rather than zooming in on single features.
• Relapse prevention.

Randomized trials, including a 2014 trial of modular CBT for BDD by Wilhelm and colleagues and a 2019 trial comparing CBT with supportive therapy, have found CBT reduces BDD severity, with gains largely maintained at follow-up. Internet-delivered CBT for BDD has also shown promise. See cognitive behavioral therapy for more on the approach.

Medication

Medication is another option a doctor or psychiatrist may discuss, particularly for moderate to severe BDD or when depression is also present. Research supports certain medicines used for OCD, and decisions about whether to use medication, and which, belong with a prescribing clinician. Many people use therapy and medication together.

Approaches to Avoid

• Cosmetic procedures as a treatment for BDD: they rarely relieve symptoms.
• Repeated reassurance: statements like "you look fine" give brief relief but can reinforce the cycle, as with OCD.
• Arguing about appearance: debates rarely change beliefs and can increase distress.

Supporting someone with BDD

Family members can help by expressing care without engaging in appearance debates, gently reducing participation in rituals (such as answering repeated questions about looks), and encouraging assessment by a clinician familiar with BDD. Our guide on how to support someone offers general advice.

Conclusion

Body dysmorphic disorder is a serious and under-recognized condition that often presents as a "real" appearance problem, sending people toward dermatologists and surgeons rather than mental health care. It is treatable, especially with specialized CBT, but only when it is correctly identified. Because depression and suicidal thoughts are common, early recognition matters. Anyone whose appearance concerns take up a great deal of time or limit daily life can talk with a primary care doctor or a licensed therapist about an assessment.