By Katharine A. Phillips, M.D
Many people with body dysmorphic disorder (BDD) – distressing or impairing preoccupation with perceived appearance flaws — don’t know that they have it. Friends, family, and even their mental health clinician may not know either.
BDD can be missed for many reasons. People with BDD may be too embarrassed to speak up about it. Or they may worry that if they do, other people will think they’re vain (even though BDD isn’t vanity). Some clinicians aren’t familiar with BDD. And many people with BDD think that they truly do look ugly (even though they actually don’t), so they mistakenly think they don’t have BDD and that they don’t need mental health treatment. They may get cosmetic treatment instead (for example, a nose job or hair transplant), which almost never improves BDD and can make it worse.
BDD can also be confused with other mental disorders. It’s often confused with obsessive-compulsive disorder (OCD), because both disorders consist of recurring obsessional thoughts that trigger repetitive compulsive behaviors. Or BDD can be confused with social anxiety disorder, because if you think you look ugly, you’ll probably feel anxious around other people and may avoid social interactions. These are just a few examples of how BDD can be misdiagnosed.
Why Is It a Problem to Not Diagnose BDD or to Misdiagnose It?
Not recognizing that someone has BDD, or confusing BDD with another disorder, is a problem. The main problem is that the person with BDD may not get any treatment, or they may get the wrong treatment. The two first-choice treatments for BDD are 1) medications called serotonin-reuptake inhibitors (also known as SRIs or SSRIs), often at high doses, and/or 2) cognitive-behavioral therapy (CBT) that is tailored to BDD’s unique symptoms.
What Is BDD?
People with BDD are preoccupied with flaws or defects that they perceive in their appearance, for example, a large nose, an asymmetrical jaw, or thinning hair. However, other people can’t see these flaws or consider them to be only slight. In other words, people with BDD have distorted body image. People with BDD think that they look ugly, unattractive, or even hideous, even though they actually look normal or attractive to others. They obsess about their appearance, in total, for at least an hour a day (usually more than this).
For BDD to be diagnosed, the preoccupation with perceived appearance flaws must cause significant emotional distress (such as depressed mood or anxiety) or impairment in day-to-day functioning (for example, avoidance of social situations, or difficulty with work, school, or other life activities). This requirement helps to differentiate BDD – which needs mental health treatment — from less problematic dissatisfaction with appearance that many people experience.
In addition, the appearance preoccupations trigger repetitive behaviors (also called compulsions or rituals). Common repetitive behaviors include checking mirrors and other reflecting surfaces, asking people for reassurance about how you look, excessive grooming (such as hair combing), skin picking to try to improve the skin’s appearance, and taking excessive selfies to check perceived flaws. Repetitive behaviors (these are just some of them) can be a clue that a person has BDD.
How to Differentiate BDD from Other Disorders
The table below lists some disorders that BDD may mistakenly be diagnosed as. It contains tips on how to differentiate each disorder from BDD. If BDD is present (based on the definition I discussed above), it needs to be diagnosed and treated.
| Diagnosis | Differentiation from BDD |
| Obsessive-compulsive disorder (OCD) | If obsessions and compulsions focus on perceived appearance flaws (including asymmetry of body parts), BDD should be diagnosed rather than OCD. |
| Generalized anxiety disorder (GAD) | If anxiety or worry is due to appearance concerns, diagnose BDD rather than GAD. |
| Social anxiety disorder | When social anxiety, social avoidance, and fear of rejection and humiliation are caused by appearance concerns, BDD should be diagnosed rather than social anxiety disorder. |
| Agoraphobia | If fear and avoidance of public places is due to appearance concerns, diagnose BDD rather than agoraphobia. |
| Excoriation (skin-picking) disorder | If skin picking intends to improve perceived skin flaws, diagnose BDD rather than excoriation (skin picking) disorder. |
| Trichotillomania (hair-pulling disorder) | If hair pulling or hair plucking intends to improve perceived appearance flaws, diagnose BDD rather than trichotillomania. |
| Major depressive disorder (depression) | Appearance preoccupations that qualify for a diagnosis of BDD should not be considered to simply be a symptom of depression. In these cases, BDD should be diagnosed. |
But keep in mind that people with BDD can have any of the disorders in the table in addition to BDD. Any mental disorder can co-occur with BDD. For example, many people have both BDD and OCD, or both BDD and social anxiety disorder.
BDD Versus Eating Disorders
Differentiating BDD from an eating disorder can sometimes be a little tricky. Here are some general guidelines:
- In a person who has the eating disorder anorexia nervosa or bulimia nervosa, concern about being overweight or fat is a symptom of the eating disorder. It is not BDD.
- If someone has some but not quite all of the symptoms that are required for a diagnosis of anorexia nervosa or bulimia nervosa, preoccupation with being overweight or fat is diagnosed as “other specified feeding and eating disorder” (OSFED).
- In people without anorexia nervosa, bulimia nervosa, or OSFED, distressing or impairing preoccupation with weight is considered a symptom of BDD.
- In people with an eating disorder who have distressing and/or impairing preoccupations about nonexistent or slight appearance flaws that don’t involve weight or body fat (for example, their “ugly” nose), both BDD and the eating disorder are diagnosed.
Concluding Thoughts
It’s important to diagnose BDD when it’s present, and not confuse it with other disorders, so it can be correctly treated (and treatment usually helps!).
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Katharine A. Phillips, M.D., is Professor of Psychiatry, DeWitt Wallace Senior Scholar, and Psychiatry Residency Research Director in the Department of Psychiatry at Weill Cornell Medical College in New York City. She is also Attending Psychiatrist at New York-Presbyterian/Weill Cornell Medical Center.
Dr. Phillips is author of The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder (also the Revised and Expanded Edition) and Understanding Body Dysmorphic Disorder: An Essential Guide. She is the editor of Body Dysmorphic Disorder: Advances in Research and Clinical Practice. She has authored or edited 8 additional books on BDD, body image, OCD, and other topics, and she has published hundreds of articles on BDD in scientific journals and books.
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