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Diagnosis: The Signs and Symptoms of Body Dysmorphic Disorder (BDD)

Matthew D. Jacofsky, Psy.D., Melanie T. Santos, Psy.D., Sony Khemlani-Patel, Ph.D. & Fugen Neziroglu, Ph.D. of the Bio Behavioral Institute, edited by C. E. Zupanick, Psy.D.

Body Dysmorphic Disorder (BDD) is characterized by an excessive preoccupation with a slight or imagined bodily defect. The most common concerns are:

  • skin imperfections (acne, scars, blemishes);
  • hair (head or body hair, too little or too much); and,
  • facial features (overall shape, size, and symmetry of facial features).

woman looking in mirrorMost people with BDD engage in repetitive compulsive behaviors or mental acts in order to check, camouflage, hide, or fix the perceived defect. Examples include excessive mirror checking, repetitive efforts to camouflage their perceived flaws, and avoidance of usual activities. Sometimes these symptoms are so extreme a person may become homebound.

Most individuals with BDD use some sort of body checking. This might include examining themselves in a mirror, or measuring body parts. They often find ways to avoid full exposure of their perceived defect such as wearing additional layers of clothing or loosely-fitted clothing, and applying cosmetics. Other behaviors can include mirror avoidance, reassurance seeking, and comparing oneself to others.

Now you may be thinking that some of these behaviors are things that everyone does, at least to some extent. So, what is the difference between BDD and taking a healthy interest in your personal appearance? The key to this distinction is the degree of interest and preoccupation; i.e., the magnitude of concern. In other words, people with BDD have an excessive preoccupation with a slight or imagined defect. The degree of concern is disproportionate to the defect itself. The amount of time invested in grooming and appearance-related activities is much greater than what is customary for most folks. For instance, a woman might ordinarily take anywhere from ten minutes to an hour to get herself dressed and ready for the day. However, a woman with BDD may take four to six hours to accomplish the same thing. Furthermore, she may cancel her plans for the day if she feels her efforts were unsuccessful.

To help make these distinctions between disordered and healthy behavior more understandable, let's consider the example of Gina:

Gina is a sophomore in college. Like many young people her age, she developed a mild case of facial acne. To Gina, her acne is so "hideous," she does not go out with friends unless she spends hours meticulously putting on makeup. Sometimes, even after hours of getting ready, she is dissatisfied with her efforts. She then makes excuses not to go out at all. Gina spends several hours each day looking at her skin to see if it is changing. At times she gets so absorbed in her appearance she doesn't even attend classes. At other times, she fails to complete her homework assignments because she is so preoccupied with the condition of her skin. Whenever other people are around her, Gina makes sure that the lighting is low. She will try to position herself so others cannot see her "horrible" skin. She went to see a dermatologist who explained her acne was minimal. The doctor provided her with a topical treatment that is commonly used to treat mild acne. Gina felt the doctor misjudged the severity of her acne problem. She believes the doctor should have prescribed Accutane®. This drug is reserved for the most severe cases of acne. Gina was very frustrated this dermatologist did not prescribe Accutane®. She vowed never to return. Instead, she made appointments with several more dermatologists hoping they will realize her skin requires Accutane® for treatment.

As demonstrated by this example, Gina's behavior goes far beyond what ordinary people would do in a similar circumstance. Of course, it is perfectly normal to invest some time and money to achieve a pleasing and healthy physical appearance. However, healthy people do not become preoccupied with their appearance to the extent it interferes with their daily activities. An extreme preoccupation with appearance makes it very difficult to function well. Indeed, Gina's functioning was certainly impaired on multiple levels. Her preoccupation interfered with her educational and social functioning.

There is a particular form of BDD known as muscle dysmorphia. This refers to a preoccupation with musculature. It occurs most often in men. No matter how large their musculature, they are dissatisfied. Due to this chronic dissatisfaction, they engage in compulsive behaviors such as excessive exercise and extreme forms of body building and dieting. Some may use dangerous steroidal drugs to increase muscle mass. As with BDD, this preoccupation is excessive and most individuals have a normal musculature build.