Body Dysmorphic Disorder: When Is Concern About Appearance a Mental Illness?

Body dysmorphic disorder (BDD) is a mental health condition in which a person becomes preoccupied with a perceived flaw in their appearance that is minor or not noticeable to others, and the preoccupation drives distress, time-consuming rituals, or trouble functioning. Ordinary dislike of a feature is common and often passes. Thoughts of suicide need prompt attention: call or text 988 at any hour, or call 911 for immediate danger. This article covers the signs, how clinicians evaluate it, how it differs from look-alike conditions, and treatment.

What body dysmorphic disorder is, and how it differs from normal appearance worry

Most people have a feature they wish looked different. That is a normal part of living in a body and seeing it in photos and mirrors. Body dysmorphic disorder is different in degree and in effect. The worry about a perceived defect takes over a large part of the day, feels hard to control, and causes real distress or gets in the way of school, work, relationships, or leaving the house.

The perceived flaw is usually slight or cannot be seen by other people. Someone with BDD may be convinced that a nose looks crooked, skin looks scarred, hair looks thin, or one side of the face looks uneven. Reassurance from friends and family often does not change the belief, or it helps only briefly.

MedlinePlus (NIH) groups conditions like this under mental disorders, which are real health conditions that affect thinking, mood, and behavior. BDD is not vanity. People with it often describe the preoccupation as painful and unwanted.

A quick way to tell worry from a disorder

• Time: Thinking about the perceived flaw takes up a large part of many days, and it is hard to put aside.
• Behavior: You feel driven to check, fix, hide, or compare.
• Distress: The worry causes real suffering, not just passing annoyance.
• Impact: You skip events, avoid photos, miss school or work, or pull away from people.

One of these alone does not establish BDD. Clinicians look at the whole pattern.

Signs and repetitive behaviors to look for

BDD usually shows up as a set of repeated behaviors that are meant to reduce anxiety about the flaw but often keep the cycle going. A primary care guide to BDD published in PubMed Central describes many of these behaviors and notes that people often keep them private because of shame.

• Mirror checking or avoiding mirrors altogether. Some people check reflective surfaces many times a day. Others cover mirrors or avoid them.
• Camouflaging. Examples include heavy makeup, hats, hoodies, hair styled to cover a feature, or posing at certain angles.
• Comparing. This can mean studying other people's faces or bodies, or scrolling photos for hours.
• Seeking reassurance. People may ask others repeatedly whether a feature looks noticeable.
• Grooming and skin picking. Picking at skin to smooth it can cause wounds, scarring, and infection, which can then deepen the worry.
• Seeking cosmetic procedures. This can include repeated visits to dermatologists or surgeons.
• Avoidance. People may skip social events, dating, work meetings, or photos.

Common areas of focus

Skin, hair, and the nose are among the common areas of focus, though any body part can be involved, and a person may focus on more than one. Concerns about symmetry, for example the belief that two sides of the face or body do not match, can be a feature of BDD. A research article on symmetry concerns as a symptom of BDD in PubMed Central discusses this pattern.

Muscle dysmorphia

Some people, most often males, become preoccupied with the idea that their body is too small or not muscular enough, even when they are muscular by others' standards. This form is sometimes called muscle dysmorphia. It can involve rigid workout and eating routines, avoiding situations where the body would be seen, and using supplements or other substances. If you notice a pattern like this, tell a clinician about the exercise, eating, and supplement habits so they can assess the risks.

How insight can vary

People with BDD differ in how much they recognize that their view of their appearance may be distorted. Some can say, "I know this is probably out of proportion, but I cannot stop thinking about it." Others are fully convinced the flaw is real and obvious. Clinicians describe this as good, fair, poor, or absent insight. Poor insight does not mean a person is not intelligent or is lying. It is a feature of how the condition can work, and it can make people less willing to seek mental health care.

When the belief is held very firmly, the person may seek only dermatology or cosmetic care. That is one reason BDD can go unrecognized for a long time.

Who develops it, and what may contribute

BDD often begins in the teen or young adult years, though it can appear at other ages. MedlinePlus (NIH) has a page on teen mental health that notes how mental health conditions can begin during adolescence and affect daily life.

The cause is not fully understood. Several factors probably contribute. These can include a family history of anxiety, obsessive-compulsive, or related conditions, differences in how the brain processes visual information, painful experiences such as teasing or bullying about looks, and personality traits such as perfectionism. Cultural messages about appearance may also play a part. One study of young adults in PubMed Central looked at how attitudes toward appearance, self-esteem, and BDD symptoms were related. Studies like this show associations, not proof that any single factor causes the disorder.

Conditions that can look like BDD or occur alongside it

BDD is often mixed up with other conditions, and it can occur together with them. A clinician sorts these out by looking at what the person is actually preoccupied with and why.

• Eating disorders. In an eating disorder, the central concern is usually weight, shape, and eating. In BDD, the concern is a specific feature, and the person may not be focused on weight at all. The two can overlap. Our article on spotting anorexia or bulimia early covers the eating disorder side.
• Obsessive-compulsive disorder. BDD shares features with OCD, such as intrusive thoughts and repeated behaviors, and clinicians often consider the two together. See our OCD article for the general picture.
• Social anxiety. A person with social anxiety fears judgment in general. A person with BDD fears judgment about a particular perceived flaw. They can coexist.
• Depression. Low mood is common alongside BDD, and either condition can make the other harder to live with.
• Skin conditions. A real skin condition such as acne or scarring can coexist with BDD. A narrative review of BDD and dermatological conditions in PubMed Central discusses how the two can overlap and why a dermatologist may be the first clinician to meet someone with BDD.

How BDD is evaluated

There is no blood test or scan for BDD. Clinicians combine history, examination, and sometimes standardized questionnaires such as the BDD Questionnaire. People often do not volunteer these concerns, so a clinician may need to ask directly. US clinicians use the DSM-5-TR criteria, which describe preoccupation with a perceived appearance flaw, repetitive behaviors or mental acts in response to it, and clinically significant distress or impairment. A PubMed Central article on key issues for DSM-V discusses how BDD has been defined and where it sits among related conditions.

A primary care clinician may ask short screening questions, such as:

• Are you very worried about the way you look, and do you wish you could worry less?
• What specifically bothers you about your appearance?
• How much time do you spend thinking about it each day?
• Has it caused problems with school, work, friends, or family?

Be as specific as you can, even if it feels embarrassing. A clinician will also usually ask about mood, anxiety, eating habits, substance use, and thoughts of self-harm, because these often occur together with BDD. Tell the clinician about skin picking, past procedures, and any supplement or substance use so they can consider the physical effects.

Treatment options that clinicians use

Outcomes vary, but BDD is generally treatable, and many people improve with appropriate care. Treatment is usually chosen by the person and their clinician together.

Psychotherapy

Cognitive behavioral therapy (CBT) adapted for BDD is a commonly used psychological treatment, and many people improve with it. It typically involves identifying unhelpful beliefs about appearance, gradually facing feared situations without hiding, and cutting back on checking, camouflaging, and reassurance seeking. This approach is related to exposure and response prevention, which is also used in OCD. A therapist who has experience with BDD or obsessive-compulsive related conditions may be especially helpful.

Medication

A prescriber may consider a selective serotonin reuptake inhibitor (SSRI), a type of antidepressant, sometimes alongside therapy. Responses vary, and it can take time to judge whether a medicine is helping; ask the prescriber what dose and trial length are appropriate for you. Antidepressant labels carry a boxed warning about increased suicidal thoughts and behavior in children, adolescents, and young adults up to age 24, mostly early in treatment or after a dose change. BDD often starts in this age group, so teens, young adults, and their families should know about this warning. Report new or worsening agitation, anxiety, trouble sleeping, or suicidal thoughts to the prescriber promptly, and talk with the prescriber before stopping the medicine. Do not change the timing or dose of a prescription on your own. Ask the prescriber or pharmacist about side effects, how closely you will be monitored, and what to do if you notice new or worsening distress.

Cosmetic surgery and procedures: a careful look

It is understandable to want to fix what feels so distressing. But cosmetic procedures do not address the preoccupation itself, and people with BDD may stay unsatisfied after a procedure, sometimes shifting their concern to a new feature or to the result. Cosmetic surgery also carries ordinary surgical risks, such as bleeding, infection, scarring, and anesthesia complications. MedlinePlus (NIH) has a page on plastic and cosmetic surgery with background on procedures and risks.

Injections and fillers carry their own risks, especially when given by an unlicensed provider. A filler can sometimes block or press on a blood vessel. Warning signs include sudden vision changes, severe or worsening pain, or skin that turns pale, white, blue-gray, or blotchy. These are rare but serious complications. They need emergency care, because delay can risk vision or cause skin and tissue damage. A serious allergic reaction, with trouble breathing, swelling of the face or throat, or fainting, also needs emergency care.

If you are considering a procedure and recognize several of the signs above, consider telling the surgeon or dermatologist about your worry and also speaking with a mental health clinician first. Some surgeons screen for BDD, and a pause to get an assessment can be a reasonable step.

Safety: suicidal thoughts and self-treatment

Suicidal thoughts are a recognized concern in BDD. The shame, isolation, and distress can be heavy. If you or someone you know has thoughts of suicide, call or text 988, the Suicide and Crisis Lifeline, at any hour. If there is a plan, intent, or immediate danger, call 911. Thoughts of suicide without a plan or intent still need same-day evaluation by a clinician, and 988 can help you decide on next steps.

Self-treatment can also cause harm. Cutting, scraping, or injecting at home, using improvised tools to change skin or features, or heavy picking can lead to infection, scarring, and serious injury. Seek medical care for wounds and infections, and tell the clinician what caused them.

How to support someone you think has BDD

• Listen without arguing about whether the flaw is real. Debates about appearance usually go nowhere.
• Try not to answer the same reassurance question over and over. Gently say you care and that you are worried about how much distress this causes.
• Focus on the suffering and the lost time, not on looks.
• Offer to help find a clinician, and offer to go along to the first visit.
• Ask directly about thoughts of suicide if you are worried, and share the 988 number.

When to Seek Medical Care