Body dysmorphic disorder: symptoms, causes and treatment in therapy

Alba is 19 and spends more than an hour in the bathroom every morning checking her nose. She says her pores are "huge" and that there is a shadow on one side you can see from across the room. She is late for class most days, has stopped posting photos and turns her camera off on group video calls. Several times a day she asks her sister whether it shows, and the answer ("you can't see anything") settles her for a few minutes. She has seen three dermatologists and is now saving up for a cosmetic procedure. Her sister can't see any flaw; Alba sees it every time she passes a mirror. What she is going through has a name, body dysmorphic disorder, and it can be treated.

This guide is written for psychologists and therapists who come across the disorder in their practice, often hidden behind another reason for consulting, and also for patients and families looking for reliable information. It covers what body dysmorphia is, how to recognise it, why you should always ask about suicide risk, how it is assessed and which treatments have the strongest support.

What is body dysmorphic disorder?

Body dysmorphic disorder (BDD) is a preoccupation with one or more flaws in one's own appearance that other people either can't see or think are minor. The person spends hours thinking about the flaw, checks it, hides it or tries to fix it, and feels intense distress about something that looks insignificant from the outside. It is also called body dysmorphia and, in older texts, dysmorphophobia.

In DSM-5 it moved to the chapter on obsessive-compulsive and related disorders, alongside OCD, trichotillomania and excoriation (skin-picking) disorder, and the WHO's ICD-11 places it in the same group. According to DSM-5-TR, four conditions have to be met:

1. Preoccupation with one or more perceived defects in physical appearance that are not observable or appear slight to others.
2. At some point, repetitive behaviours (mirror checking, excessive grooming, skin picking, asking for reassurance that it doesn't show) or mental acts (comparing oneself with others) in response to that preoccupation.
3. Clinically significant distress or impairment in social life, studies, work or other areas.
4. It is not better explained by concerns about weight or body fat in someone who meets the criteria for an eating disorder.

The diagnosis is completed with two specifiers: whether there is muscle dysmorphia, and how much insight the person has into their beliefs (good or fair, poor, or absent with delusional beliefs).

Symptoms of body dysmorphic disorder

The preoccupation usually centres on the face or head: the skin (acne, pores, scars, marks, wrinkles), thinning or excess hair, the nose, eyes, lips or the shape of the face. It can involve any part of the body and move from one area to another over the years. Patients describe it in very harsh terms: "deformed", "monstrous", "disgusting".

Around that preoccupation come behaviours that take up a lot of time and give you the clues in a session:

• Mirror checking many times a day, in shop windows or with the phone camera. Other people do the opposite and cover or avoid mirrors, and some switch between the two.
• Comparing themselves with other people, in the street or on social media.
• Camouflaging the flaw: make-up, caps, a fringe, a beard, baggy clothes, angling the body so a profile doesn't show.
• Excessive grooming, changing clothes over and over, picking at the skin to make it "smooth" or plucking hairs.
• Seeking reassurance from others ("can you see it?") or trying to convince them that the flaw is real.
• Looking for dermatological, dental or cosmetic treatments to fix it.

All of this can take several hours a day. Many patients also believe that people are looking at the feature or laughing at it, so they end up avoiding going out, going to class, having their photo taken or dating. In severe cases some people only leave the house at night, or not at all.

Muscle dysmorphia

This is a form of body dysmorphic disorder that mostly affects men: the conviction that their body isn't muscular or lean enough, even when objectively it is. It comes with hours at the gym, rigid diets and sometimes the use of anabolic steroids and supplements, a practice with serious health risks. Informally it is sometimes called bigorexia.

When the patient is convinced the flaw is real

Most people with body dysmorphic disorder have poor or no insight into the fact that their perception is distorted: they genuinely believe the body part they dislike looks ugly or abnormal. Even when that conviction becomes delusional, the diagnosis is still body dysmorphic disorder, not a psychotic disorder. This has a practical consequence for therapy: arguing about whether the flaw exists gets you nowhere, and motivation has to be worked on from the start.

Causes of body dysmorphic disorder

There is no single cause. What we know points to several factors adding up:

• Biological and family factors. It is more likely if a relative has body dysmorphic disorder, OCD or depression.
• Early experiences. Being teased about their looks, bullied at school or abused as a child comes up often in these patients' histories.
• Traits and the way the image is processed. Perfectionism, sensitivity to rejection and attention locked onto the details of one's own face keep the problem going: the closer you look, the more you find.

Social media, filters and video calls don't cause the disorder, but they offer many more chances to compare and check. Terms that circulate online, such as "Zoom dysmorphia" or "smile dysmorphia", are not diagnoses in DSM-5-TR or ICD-11, and they often blur the disorder with ordinary dissatisfaction with one's body.

How common is it? When does it start?

More common than it seems. According to the MSD Manual Professional Edition, nationwide population-based studies put the current prevalence at 2 to 3%, and smaller community studies at 2 to 5%. It may be somewhat more common in women and usually begins during adolescence.

In settings where people seek to change their appearance, the figures jump: around 11% in dermatology, 13 to 19% in plastic surgery and about 20% among people asking for a rhinoplasty. Even so, the disorder can go undiagnosed for years, because many patients feel too ashamed to talk about it and come in for depression, social anxiety or problems at school or work.

Body dysmorphic disorder in teenagers

It is most common in teenagers and young adults, and at that age it is easily mistaken for ordinary adolescent insecurity. The difference lies in the time, the distress and what gets dropped: a teenager with hang-ups may have a bad moment over a photo; one with body dysmorphic disorder skips class because they can't bear being seen in profile. The UK's NICE guideline recommends that the first treatment for children and young people should be cognitive behavioural therapy with exposure and response prevention, adapted to their age and involving the family. If you work with this age group, our article on therapy with teenagers and how to set it up may help.

Suicide risk: always ask

This is the one thing no assessment can leave out. Body dysmorphic disorder carries higher suicide rates than many other mental disorders: over their lifetime, about 80% of people with BDD have suicidal thoughts and around a third attempt suicide.

NICE asks clinicians to assess the risk of self-harm and suicide in everyone diagnosed, especially if they also have depression, and in children and young people to carry out a full risk assessment before starting treatment. In practice:

• Ask directly about thoughts of death and suicide. Asking does not put the idea in their head.
• Ask again at sensitive moments: after a cosmetic procedure that didn't turn out as hoped, a break-up, a comment about their looks or an increase in avoidance.
• If there is risk, draw up a safety plan with the patient and record it in the clinical notes. Our suicide risk protocol for psychology practices sets out the steps and when to refer.

In Spain, the 024 line responds to suicidal crises 24 hours a day, and in an emergency you should call 112. Elsewhere, use your local crisis line or emergency number.

Not every appearance concern is body dysmorphic disorder

Almost everyone has a part of their body they like less. What separates that dissatisfaction from the disorder is the time it eats up, the distress and the impairment it causes. Other explanations should also be ruled out:

• Eating disorders. If the only concern is weight or body fat and eating behaviour is disturbed, anorexia or bulimia nervosa is the more likely diagnosis. The two can co-occur. We cover this in our article on the psychological treatment of eating disorders.
• OCD. It shares the logic of obsession and ritual, but in OCD the obsessions aren't about appearance. Both can be present; our guide to OCD treatment covers the exposure work.
• Social anxiety. Here the fear is of embarrassing oneself or being judged in general; in BDD, avoidance is driven by the perceived flaw.
• Gender dysphoria. If the only concern is the sexual characteristics and there is a marked incongruence between experienced and assigned gender, a different diagnosis needs to be considered.
• Trichotillomania and skin picking. If someone pulls out hair or picks their skin to fix a flaw only they can see, the picture is better explained by body dysmorphic disorder. We discuss this in our article on trichotillomania.

How body dysmorphic disorder is assessed in practice

The diagnosis is clinical and based on the interview. Since patients rarely bring it up themselves, the first step is to ask.

The five NICE questions

The NICE guideline on OCD and body dysmorphic disorder suggests five questions for people at higher risk: those with depression, social phobia, alcohol or substance misuse, OCD or an eating disorder, and people with mild disfigurements or blemishes who are seeking a cosmetic or dermatological procedure:

1. Do you worry a lot about the way you look and wish you could think about it less?
2. What specific concerns do you have about your appearance?
3. On a typical day, how many hours a day is your appearance on your mind? (More than 1 hour a day is considered excessive.)
4. What effect does it have on your life?
5. Does it make it hard to do your work or be with friends?

Scales to measure severity

To quantify severity and track progress, the most widely used tool is the BDD-YBOCS, the version of the Yale-Brown scale adapted to body dysmorphic disorder: twelve items scored from 0 to 48 that cover the time taken up by the preoccupation, distress, avoidance, control over the behaviours and insight. For screening there are self-report questionnaires such as the BDDQ or the seven-item Dysmorphic Concern Questionnaire (DCQ). Giving the same scale at the start and every few weeks lets you show the patient changes they don't notice in the mirror.

Self-monitoring

Before intervening, it helps to know how much space the problem takes up day to day. A simple record over one or two weeks gives you that picture: minutes in front of the mirror, times they ask for reassurance, situations they avoid, time spent getting ready before going out, and how intense the distress is from 0 to 10. Alba was surprised to add up almost three hours a day between the bathroom, her phone and shop windows.

Treatment for body dysmorphic disorder

The two treatments with the strongest support are cognitive behavioural therapy designed for the disorder and serotonergic medication, alone or combined. The Cochrane review of pharmacotherapy and psychotherapy for body dysmorphic disorder found few, small trials (five, of which four could be analysed, with 169 participants in total), but the results pointed the same way: cognitive behavioural therapy and medication reduced symptom severity.

NICE organises treatment for adults according to how much the disorder affects the person's life: with mild impairment, CBT including exposure and response prevention, individually or in a group; with moderate impairment, a choice between an SSRI antidepressant or more intensive individual CBT; and with severe impairment, both together.

BDD-specific cognitive behavioural therapy

Not just any CBT will do: the one that works is designed around the symptoms of body dysmorphic disorder and usually includes:

• Psychoeducation and motivation. With poor insight, the first goal isn't to convince the patient the flaw doesn't exist, but that the time and suffering they put into it are a problem that can be treated.
• Cognitive restructuring of beliefs about their appearance and about what others think ("if they see my profile, they'll laugh").
• Exposure and response prevention, the core of the treatment.
• Perceptual retraining in front of the mirror.
• Habit reversal techniques if there is skin picking or hair pulling.
• Relapse prevention in the final sessions.

Exposure and response prevention in practice

It means gradually facing the situations being avoided without carrying out the rituals that ease the anxiety. With Alba, a hierarchy was built from her self-monitoring: brushing her teeth without going close to the mirror, turning her camera on during a video call with friends, going out to buy bread without make-up on her nose, sitting in profile by the window in class, posting a photo without a filter. Alongside that, response prevention: limiting time in front of the mirror, no longer asking her sister and not touching up her make-up in the toilets.

Much of the work happens between sessions, so tasks have to be specific and easy to record. If you want to shape them, our article on therapy homework assignments has ideas for designing and reviewing them.

Perceptual retraining in front of the mirror

People with body dysmorphic disorder look at themselves very close up and only at the area they worry about, and they judge what they see harshly. Retraining teaches them to look at a normal distance, from top to bottom, describing what they see in neutral words ("my nose is straight and the pores are visible at this distance") instead of judgements ("horrible"). It is practised first in session and then at home, for an agreed length of time.

What about medication?

Selective serotonin reuptake inhibitors (SSRIs) and clomipramine are often effective, frequently at higher doses than those used for depression. In the only placebo-controlled trial in the Cochrane review, 56% of patients treated with fluoxetine responded compared with 18% on placebo, and in the medication trials response did not depend on how much insight people had. NICE recommends fluoxetine as the first option for adults, and it can take up to 12 weeks for the effect to show. Prescribing and monitoring are for psychiatry or the GP, and younger patients need to be watched closely for suicidal thoughts at the start of treatment.

What about cosmetic surgery?

It isn't recommended. Cosmetic treatments almost never relieve body dysmorphic disorder and often make it worse: the preoccupation stays, moves to another area or fixes on the result. NICE asks that anyone with suspected BDD who seeks cosmetic surgery or dermatological treatment is first assessed by a mental health professional with expertise in the disorder. If your patient is saving up for an operation, as Alba is, that is something to bring up in therapy, without forbidding it and without arguing.

If someone in your family has body dysmorphia

Families are often worn out from answering the same question. Some guidelines that help:

• Don't argue about whether the flaw exists. You can say you understand they are having a hard time without getting into whether it shows.
• Gradually cut down on reassurance ("you can't see anything"). It calms them for a few minutes and keeps the problem going. It is best agreed with their therapist.
• Avoid comments about their appearance, including repeated compliments, and don't joke about the time they spend in the bathroom.
• Encourage them to seek help without making it sound like criticism: "I can see you're suffering a lot over this and I think someone can help".
• If they mention death or suicide, take it seriously and get help that same day.

When to seek professional help

It is worth seeing a psychologist if worrying about a feature takes up more than an hour a day, if things are being dropped because of it (classes, work, dates, photos, the beach), if significant amounts are being spent on treatments to fix it, or if it causes distress that doesn't go away. If thoughts of death or suicide appear, don't wait: seek help immediately.

How to document follow-up in body dysmorphic disorder

Treatment for body dysmorphic disorder takes months, and patients tend to judge their progress by what they see in the mirror, which is precisely what changes least at the beginning. That is why it is worth keeping a written record of:

• The BDD-YBOCS score at baseline and at each review, with the date.
• The weekly summary of self-monitoring: minutes in front of the mirror, reassurance requests, situations avoided.
• The exposure hierarchy and which step the patient is on.
• The suicide risk assessment, every time it is repeated, and the safety plan if there is one.
• Medication, who prescribes it and what was agreed in coordination with psychiatry or the GP.
• For minors, what was agreed with the family.

Going over this information with the patient every few months is often therapeutic in itself: the improvement they can't find in the mirror shows up in their own records.

Body dysmorphic disorder in your practice with My Psico Agenda

My Psico Agenda doesn't assess or treat anyone: that's your job. What it does is organise everything around a long treatment like this one:

• The clinical record, session by session. In each session's private notes you log the BDD-YBOCS score, the step on the hierarchy and the risk assessment, and you can see the progress without digging through paper.
• Your own fields in the record. Under "Additional data" you add the fields you need, such as "Area of concern", "Baseline BDD-YBOCS" or "Referring psychiatrist". If you work in a centre, the centre can also add its own "Centre fields", shared across all its therapists' records.
• Self-monitoring in the patient's hands. You upload the template to "Patient files". It goes up as "Hidden"; when you switch it to "Visible", the patient finds it in their space under the "Documents" tab, and in the record you see "Seen" with the date they opened it.
• The minor's record, with their guardians. Since the disorder usually starts in adolescence, the "Minor patient?" option stores "Guardian 1" and, if there is one, "Guardian 2", and the informed consent can be signed by the guardians with their own link or on your device.
• A fixed slot every week. With "Recurring therapy" you book the patient's slot, and they get a WhatsApp reminder 24 hours before with buttons to confirm or cancel.
• Bookings without a phone call. Many people with this disorder find it hard to phone. From "Patient Space" you can open your calendar to the public with your own link: anyone who opens it sees your free times and asks you for an appointment on WhatsApp with a message already written.
• Consistency, in numbers. In each patient's statistics you see "Total sessions", "Attendance" and "Cadence", useful when you start spacing out sessions towards the end of treatment.

There are plans for therapists from €4.99/month + VAT and for centres from €99.99/month + VAT, and you can try it free for 1 month, no card needed and no lock-in. Our software for psychologists page has everything that's included.