ICD-116B21	BODY DYSMORPHIC DISORDER (BDD) Body dysmorphic disorder
ICD-10F45.2	Hypochondriacal disorder
DSM-5-TRF45.22	Body Dysmorphic Disorder

1. Definition and nosology

Body Dysmorphic Disorder (BDD; ICD-11: 6B21; DSM-5-TR: F45.22) — obsessive preoccupation with an imagined or very slight defect in appearance; this preoccupation leads to repetitive behaviors (mirror checking, skin picking, seeking cosmetic procedures) or mental acts (comparing).

2. History

• Morselli E. (1891) — ‘dysmorphophobia’.
• DSM-III-R (1987) — ‘Body Dysmorphic Disorder’ within somatoform disorders.
• DSM-5 (2013) and ICD-11 — moved to the obsessive-compulsive spectrum category.

3. Epidemiology

• Prevalence in general population: 1.7–2.4% (Buhlmann U. et al. Psychiatry Res 2010).
• 9–15% in cosmetic dermatology and plastic surgery clinics.
• Gender: approximately equal.
• Onset: mean 15–16 years.
• Comorbidity: MDD ~75%, OCD ~30%, social anxiety ~37%, substance use.
• Suicide risk high: attempt ~24–28%, completion rate 45 times higher than population (based on reviews by Phillips K.A.).

4. Aetiology and pathogenesis

• Genetic overlap with OCD.
• Neurobiological — orbitofrontal-striatal circuit hyperactivity (similar to OCD); impaired visual processing (Feusner J.D. et al. reviews — patient overfocuses on details, fails to integrate the global image).
• Social-cultural — idealized appearance in mass media.
• Childhood peer victimization (humiliation, “bullying”).

5. Clinical features

• Obsessive focus on a specific part of appearance (face, skin, hair, nose, body shape).
• No actual defect or invisible/unimportant to others.
• Repeated behaviors: mirror checking, skin picking, comparison, seeking cosmetic procedures, clothing/makeup/camouflage.
• Cognitive actions: comparing oneself to others.
• Insight often poor; sometimes at delusional level.
• “Muscle dysmorphia” subtype — obsession with “insufficient muscle development” in males; leads to anabolic steroid use.
• High social isolation, academic and occupational disruption.

6. Diagnosis

6.1 Unified diagnostic criteria

A. Preoccupation with a perceived defect or flaw in appearance; not observable or appears slight to others.

B. The patient has at any point performed a repetitive behavior (mirror checking, skin picking, excessive dressing) or mental act (comparison).

C. The preoccupation causes clinically significant distress or functional impairment.

D. There must be no body image preoccupation meeting eating disorder criteria (anorexia/bulimia).

Qualifiers: with muscle dysmorphia; insight (good / moderate — poor / absent / delusional).

6.2 Source-specific clarifications

• DSM-5-TR / ICD-11 — in the OCD spectrum category; muscle dysmorphia qualifier.
• NICE CG31 — BDD and OCD joint recommendations.

6.3 Diagnostic algorithm

1. Clinical interview (patient often does not speak openly due to shame).
2. BDDQ (Body Dysmorphic Disorder Questionnaire) — screening.
3. BDD-YBOCS — severity scale.
4. Comorbidity (depression, OCD, social anxiety, suicide risk).
5. History of anabolic steroid use or cosmetic procedure.

6.4 Differential diagnosis

7. Examination and assessment

• BDDQ — screening (Phillips K.A.).
• BDD-YBOCS — modified OCD scale, 12 items.
• C-SSRS — high suicide risk.

8. Treatment

1. First-line psychotherapy: CBT (adapted for BDD, Wilhelm S., Phillips K.A.) — cognitive restructuring + exposure + mirror retraining + behavioral experiments. 12–22 sessions.
2. First-line pharmacotherapy: SSRIs at high dose — similar to OCD; fluoxetine (40–80 mg), escitalopram, sertraline.
3. Clomipramine — alternative.
4. Augmentation — atypical antipsychotic (especially insight at delusional level).
5. Duration of treatment is long; ≥ 1–2 years after remission.
6. Suicide risk monitoring.
7. Prevention of cosmetic procedures — patient collaboration with dermatologist/plastic surgeon; evidence: surgical procedure does not improve BDD symptoms, often creates new focus (Crerand C.E. et al. Plast Reconstr Surg 2010).

Source-specific specifications

• NICE CG31 — CBT + high-dose SSRI first-line.
• Phillips K.A. studies — SSRIs effective in BDD; high dose, long-term.

Treatment methods

1. CBT for BDD — Wilhelm S., Phillips K.A — Manualized 22-session protocol — psychoeducation, cognitive restructuring, mirror retraining, behavioral experiments, ritual prevention (ERP), relapse prophylaxis.
2. Body Dysmorphic Disorder Questionnaire (BDDQ) — Phillips (Phillips K.A.) — Screening.
3. BDD-YBOCS — Adaptation of Y-BOCS for BDD.
4. SSRI High Dose — Similar to OCD; response within 8–12 weeks.

9. Prognosis

• Chronic course.
• Significant improvement with adequate treatment; remission is possible but requires long-term maintenance.
• Suicide risk monitored.

10. Myths and misconceptions

Myth 1: “BDD patients have a ‘real defect’, cosmetic surgery helps”

Evidence: Crerand C.E. Plast Reconstr Surg 2010 — cosmetic procedures do not improve BDD; most patients are dissatisfied with the result or develop a new focus. Surgeons are recommended to screen for BDD.

Myth 2: “A BDD patient should be ‘reassured’ by complimenting their appearance”

Evidence: praise or reassurance gives short-term relief but strengthens the obsession; reducing family accommodation is a treatment component.

Myth 3: “BDD is common ‘self-doubt’”

Evidence: BDD is accompanied by functional impairment and high suicide risk (attempts 24–28%, 45 times higher than the general population); it is assessed as a clinical condition.

Myth 4: “SSRIs are effective for BDD at depression doses”

Evidence: Similar to OCD — high dose required; response in 8–12 weeks.

Myth 5: “Muscle dysmorphia is not a female disorder, does not occur in men either, it's just fitness motivation”

Evidence: Muscle dysmorphia is prevalent among men; it is accompanied by the use of anabolic steroids, compulsive exercise, social isolation, and depression; it is a qualifier in DSM-5-TR.

Myth 6: “Seeking sequential procedures from a plastic surgeon is normal”

Evidence: Sequential procedures are a sign of BDD; surgeon should screen for BDD and refer to psychiatry.

11. Sources

1. WHO. ICD-11. 6B21 Body dysmorphic disorder. 2024.
2. APA. DSM-5-TR. 2022.
3. NICE CG31. 2005, 2019 surveillance.
4. Phillips K.A. The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder. Oxford Univ Press; 2005.
5. Wilhelm S., Phillips K.A., Steketee G. Cognitive-Behavioral Therapy for Body Dysmorphic Disorder: A Treatment Manual. Guilford Press; 2013.
6. Buhlmann U. et al. Updates on the prevalence of body dysmorphic disorder: a population-based survey. Psychiatry Res 2010;178(1):171–175.
7. Crerand C.E., Menard W., Phillips K.A. Surgical and minimally invasive cosmetic procedures among persons with body dysmorphic disorder. Plast Reconstr Surg 2010;126(2):504–510.
8. Feusner J.D., Townsend J., Bystritsky A., Bookheimer S. Visual information processing of faces in body dysmorphic disorder. Arch Gen Psychiatry 2007;64(12):1417–1425.