Body Dysmorphic Disorder

Body dysmorphic disorder (BDD) is preoccupation with perceived defects in appearance that are slight or unobservable, with repetitive behaviours or mental acts.

• Prevalence 1.7 to 2.4%; onset in adolescence; equal in both sexes.
• Muscle dysmorphia variant in men.
• Comorbid depression, social anxiety, OCD, eating disorders, substance misuse.
• High suicide risk (suicidal ideation in 80%, attempts 25%); poor insight.

• Concerns about skin, hair, nose, body shape; mirror checking, camouflaging, comparing, skin picking, excessive grooming, reassurance seeking, avoidance.
• Seeking dermatological or cosmetic procedures (usually dissatisfied afterwards).
• Social withdrawal, house boundness, school or work absence.

• DSM-5 criteria; BDD Questionnaire, Yale-Brown Obsessive Compulsive Scale modified for BDD.
• Assess insight (delusional variant), suicide risk.
• Exclude eating disorders, social anxiety, OCD, major depression with psychosis, gender dysphoria, true physical anomalies.
• Review cosmetic surgery history.

• CBT with exposure and response prevention (12 to 24 sessions) is first line.
• SSRIs at high doses: fluoxetine 40 to 80 mg daily, escitalopram 20 to 30 mg, sertraline 150 to 200 mg, fluvoxamine 200 to 300 mg, clomipramine 150 to 250 mg; trial 12 weeks at maximum tolerated dose.
• Augmentation: aripiprazole 2 to 10 mg, buspirone, clomipramine plus SSRI.
• Avoid cosmetic and dermatological procedures (worsen or no benefit).
• Manage suicide risk, comorbid depression.
• Delusional variant: SSRI with possible antipsychotic.