A GP’s guide to identifying and managing body dysmorphic disorder

Body dysmorphic disorder (BDD) is a chronic condition that affects approximately 1 in 50, or 2% of adults.  

This article guides GPs in how to identify BDD in patients and help them understand and manage their disorder, as well as when to refer patients to psychologists or other medical specialists.

What is body dysmorphic disorder?

BDD is characterised by a debilitating preoccupation with a perceived defect in one’s physical appearance. The physical attribute of concern may be non-existent or so minor that it’s unnoticeable to others. 

Behavioural characteristics of BDD — such as constantly checking one’s appearance, repeated attempts at correcting the perceived defect, or excessive exercising — can limit daily function.

Muscle dysmorphia is a form of BDD where there is a perceived lack of muscularity. Excessive exercise and specific dietary patterns are common behavioural consequences of muscle dysmorphia¹. Misuse or abuse of androgenic steroids appears common in males with muscle dysmorphia².

Males are more likely than females to have genital manifestations of BDD³.

BDD most commonly manifests in adolescence, with subclinical symptoms occurring for years before diagnosis⁴. There is no gender difference in the prevalence of BDD⁵ but muscle dysmorphia occurs much more often in males⁶.

BDD is distinct from gender dysphoria — the distress felt by people whose gender experience differs from the sex they were assigned at birth. Although both may occur in individuals.

What causes body dysmorphic disorder? 

Body dysmorphic disorder is likely due to genetic, psychosocial and cultural factors⁷. 

BDD is more likely to occur in people who:

• Have a first-degree relative with BDD
• Experience childhood trauma
• Are from sexual or racial minority groups.

Using social media, especially image-sharing services like Snapchat and Instagram, is associated with concern about body image⁸. But there is no high-quality evidence linking social media use and BDD diagnosis.

Body dysmorphic disorder comorbidities  

BDD can persist throughout adulthood and its influence on adolescent social and emotional development may have long-term functional consequences⁵. However, treatment can lessen the symptom severity and the negative functional impact of BDD³.

In males, BDD often accompanies depression, social and generalised anxiety, emotional and behavioural difficulties, problems with peer relationships, hyperactivity, drive for masculinity and low quality of life⁵. When these comorbidities occur during adolescence, they can have lasting deleterious effects on social functioning, romantic relationships, and educational and vocational achievements⁵.

People with BDD are more likely to have suicidal thoughts or behaviours than people without the disorder, with increasing severity and presence of comorbidities related to increasing risk⁹.

Screening and diagnosing body dysmorphic disorder

Only a minority of people with BDD are diagnosed¹⁰.

People with BDD may lack insight into their disorder, making them unlikely to seek direct help for the condition⁴. Moreover, some behaviours that accompany muscle dysmorphia, such as adhering to exercise routines and avoiding unhealthy foods, can be misinterpreted as beneficial and positively reinforced.

To increase the diagnosis and treatment of BDD, GPs should become familiar with the disorder’s behavioural characteristics and diagnostic criteria, as well as screening questions to ask patients.  

Behavioural signs

Common repetitive behaviours of people with BDD:

• Grooming
• Picking at skin
• Checking appearance in the mirror, or avoiding mirrors
• Seeking reassurance
• Touching the perceived defect
• Excessive exercise
• Seeking correction of the perceived defect e.g. cosmetic surgery
• Comparing their appearance with others
• Camouflaging e.g. covering the perceived defect with makeup, hair or clothing.

Screening questions

Useful screening questions for BDD include:

• Are you concerned about some aspect of your appearance?
• Do you spend a lot of time worrying about some aspect of your appearance?
• Do you spend a lot of time trying to hide physical defects?
• Do you think you are malformed, misshapen or disfigured in some way?
• Do you think your body functions in an offensive way e.g. bad body odour, flatulence, sweating?
• Has anyone told you that you look normal, even though you know something is wrong about your appearance?
• Have you felt like you need to see a medical specialist e.g. cosmetic surgeon or dermatologist, to correct a problem with your appearance?
• Do you feel the need to change your appearance in photos by using filters, or apps like Facetune?

Diagnostic criteria

The diagnostic criteria for BDD² are:

• Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others
• Performing repetitive physical or mental behaviours e.g. skin picking, comparing one’s physical appearance with others, in response to appearance concerns
• Significant distress or impairment in important functions e.g. social or occupational
• Preoccupation with appearance is not better explained by concerns about body fat or weight in the presence of an eating disorder.

BDD occurs with muscle dysmorphia if there is a belief of insufficient muscularity or small build (with or without preoccupations about other body regions)².

Insight into BDD² is considered absent for people who are convinced their body dysmorphia beliefs are true, or poor for people who think the beliefs might be true. Good or fair insight into BDD is attributed to people who consider their body dysmorphic beliefs to be definitely or probably false, or may or may not be true.

Treating body dysmorphic disorder

Psychological and psychopharmacological treatment of BDD can moderate symptoms and improve functionality, but only a minority of people with the disorder receive therapy¹⁰.

Barriers to treatment include shame and stigma, a perception that psychological and psychiatric treatments are ineffective, and denial of the disorder (and hence, failure to seek treatment)¹⁰.

Many people with BDD seek cosmetic treatments to fix the perceived physical defect, but these procedures generally have poor outcomes¹¹ and should be discouraged⁴.

People with BDD should be counselled about the likely futility of pursuing cosmetic outcomes, and the associated distress and cost that can arise⁴. People with BDD who seek referral for cosmetic procedures would likely be better served by discussion aimed at providing an understanding of the underlying psychological problem, and highlighting the benefit of appropriate treatment.

Cognitive behavioural therapy for BDD commonly consists of exposure with response prevention over 3-6 months. It seems effective at reducing symptom severity for some time, however, longer-term monitoring is recommended to detect symptom severity and relapse¹². Telehealth and internet-based therapy shows promise in treating BDD¹³.

Selective serotonin reuptake inhibitors (SSRIs) may take weeks to months to be effective for BDD, and are usually needed in a higher dose than for treatment of depression⁴. In cases where SSRIs are ineffective, the tricyclic antidepressant clomipramine may be used. Alternatively, off-label use of some antipsychotics may be considered⁴.

Find our online Clinical Summary Guide on Body Dysmorphic Disorder here and order a hard copy here.