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David Baxter

Mar 26, 2004
Body dysmorphic disorder
By Mayo Clinic Staff
Nov. 5, 2008

Body dysmorphic disorder is a type of chronic mental illness in which you can't stop thinking about a flaw with your appearance ? a flaw either that is minor or that you imagine. But to you, your appearance seems so shameful and distressing that you don't want to be seen by anyone. Body dysmorphic disorder has sometimes been called "imagined ugliness."

When you have body dysmorphic disorder, you intensely obsess over your appearance and body image, often for many hours a day. You may seek out numerous cosmetic procedures to try to "fix" your perceived flaws but never are satisfied. Body dysmorphic disorder is also known as dysmorphophobia, or the fear of having a deformity.

Signs and symptoms of body dysmorphic disorder include:

  • Preoccupation with your physical appearance
  • Strong belief that you have an abnormality or defect in your appearance that makes you ugly
  • Frequently examining yourself in the mirror or, conversely, avoiding mirrors altogether
  • Believing that others take special notice of your appearance in a negative way
  • Frequent cosmetic procedures with little satisfaction
  • Excessive grooming, such as hair plucking
  • Feeling extremely self-conscious
  • Refusing to appear in pictures
  • Skin picking
  • Comparing your appearance with that of others
  • Avoiding social situations
  • Wearing excessive makeup or clothing to camouflage perceived flaws
Body features you may obsess about include:

  • Nose
  • Hair
  • Skin
  • Moles or freckles
  • Acne and blemishes
  • Baldness
  • Breast size
  • Muscle size
  • Genitalia
The body feature you focus on may change over time. You may be so convinced about your perceived flaws that you become delusional, imagining something about your body that's not true, no matter how much someone tries to convince you otherwise.

When to see a doctor
Shame and embarrassment about your appearance may keep you from seeking treatment for body dysmorphic disorder. But if you have any signs or symptoms of body dysmorphic disorder, see your doctor, mental health provider or other health professional. Body dysmorphic disorder usually doesn't get better on its own, and if untreated, it may get worse over time and lead to suicidal thoughts and behavior.

It's not known specifically what causes body dysmorphic disorder. Researchers believe that, like many other mental illnesses, body dysmorphic disorder may result from a combination of causes:

  • Biochemical. Some evidence suggests that naturally occurring brain chemicals called neurotransmitters, which are linked to mood, may play a role in causing body dysmorphic disorder. In particular, the neurotransmitter serotonin may have a causal role.
  • Genes. Some studies show that body dysmorphic disorder is more common in people whose biological family members also have the condition. This may indicate a genetic pathway behind body dysmorphic disorder.
  • Environment. Your environment, life experiences and culture may contribute to body dysmorphic disorder, especially if they involve negative experiences about your body or self-image.
Risk factors
Although the precise cause of body dysmorphic disorder isn't known, researchers have identified certain factors that seem to increase the risk of developing or triggering the condition, including:

  • Having biological relatives with body dysmorphic disorder
  • Childhood teasing
  • Physical or sexual abuse
  • Low self-esteem
  • Societal pressure or expectations of beauty
Overall, about 1 percent of the population is estimated to have body dysmorphic disorder. But as many as 10 percent of people seeking dermatology or cosmetic treatments may have body dysmorphic disorder. Body dysmorphic disorder usually starts in adolescence. It affects men and women in equal numbers.

Complications that body dysmorphic disorder may cause or be associated with include:

  • Suicidal thoughts or behavior
  • Depression and other mood disorders
  • Anxiety disorders
  • Obsessive-compulsive disorder
  • Eating disorders
  • Social phobia
  • Substance abuse
  • Low self-esteem
  • Social isolation
  • Difficulty attending work or school
  • Lack of close relationships
  • Unnecessary medical procedures, especially cosmetic surgery
  • Becoming housebound
Preparing for your appointment
In some cases, your health care provider, cosmetic dentist or surgeon, or other professional may ask you about your feelings about your appearance. Or you may decide to schedule an appointment with your family doctor or general practitioner to talk about your concerns. In either case, because body dysmorphic disorder often requires specialized care, you may be referred to a mental health provider, such as a psychiatrist or psychologist, for evaluation and treatment. In other cases, you may seek out a mental health provider on your own first.

What you can do
Being an active participant in your care can help your efforts to manage your condition. One way to do this is by preparing for your appointment. Think about your needs and goals for treatment. Also, write down a list of questions to ask. These questions may include:

  • Why can't I get over body dysmorphic disorder on my own?
  • How do you treat body dysmorphic disorder?
  • Will psychotherapy help?
  • Are there medications that might help?
  • How long will treatment take?
  • What can I do to help myself?
  • Are there any brochures or other printed material that I can take home with me?
  • What Web sites do you recommend visiting?
In addition to your prepared questions, don't hesitate to ask questions at any time during your appointment if you don't understand something.

What to expect from your doctor
During your appointment, your doctor or mental health provider is likely to ask you a number of questions about your mood, thoughts and behavior, and how you perceive your appearance. You may be asked such questions as:

  • When did you first notice symptoms?
  • How is your daily life affected by your symptoms?
  • How much time do you spend each day thinking about your appearance
  • What other treatment, if any, have you had?
  • What cosmetic procedures, if any, have you had?
  • What have you tried on your own to feel better or control your symptoms?
  • What things make you feel worse?
  • Have friends or family commented on your mood or behavior?
  • Have any relatives had a mental illness?
  • What do you hope to gain from treatment?
  • What medications or over-the-counter herbs and supplements do you take?
Tests and diagnosis
If your doctor or mental health provider believes you may have body dysmorphic disorder or another mental illness, he or she typically runs a series of medical and psychological tests and exams. These can help pinpoint a diagnosis, rule out other problems that could be causing your symptoms, and also check for any related complications.

These exams and tests generally include:

  • Physical exam. This may include measuring height and weight, checking vital signs, such as heart rate, blood pressure and temperature, listening to your heart and lungs, and examining your abdomen.
  • Laboratory tests. These may include a complete blood count (CBC), screening for alcohol and drugs, and a check of your thyroid function.
  • Psychological evaluation. A doctor or mental health provider will talk to you about your thoughts, feelings and behavior patterns. He or she will ask about your symptoms, including when they started, how severe they are, how they affect your daily life and whether you've had similar episodes in the past. You'll also discuss any thoughts you may have of suicide, self-harm or harming others.
Pinpointing which condition you have
It can be difficult to diagnose body dysmorphic disorder. This may be because you're so embarrassed about your appearance that you avoid medical help, because you don't reveal your true feelings to doctors, or because you don't even realize that your body image is distorted. Also, body dysmorphic disorder can sometimes seem similar to other conditions, such as an eating disorder or obsessive-compulsive disorder. It can take some time and effort to get an accurate diagnosis. Be sure to stick with it, though, so that you can get appropriate treatment.

Diagnostic criteria for body dysmorphic disorder
To be diagnosed with body dysmorphic disorder, you must meet the symptom criteria spelled out in the Diagnostic and Statistical Manual of Mental Disorders (DSM). This manual is published by the American Psychiatric Association and is used by mental health providers to diagnose mental conditions and by insurance companies to reimburse for treatment.

Symptom criteria required for a diagnosis of body dysmorphic disorder include:

  • Being extremely preoccupied with an imagined defect or a minor flaw in your appearance
  • Being so preoccupied with appearance that it causes you significant distress or impairment in your social, work, school or other areas of functioning
Treatments and drugs
Treatment of body dysmorphic disorder can be difficult, especially if you aren't a willing and active participant in your care. But effective treatment is often successful.

Treatment options: Psychotherapy and medications
The two main treatments for body dysmorphic disorder are:

  • Psychotherapy
  • Medications
Often, treatment involves a combination of psychotherapy and medications.

Psychotherapy for body dysmorphic disorder
Psychotherapy can help you learn about your condition and your feelings, thoughts, mood and behavior. Using the insights and knowledge you gain in psychotherapy, you can learn to stop automatic negative thoughts and to see yourself in a more realistic and positive way. You can also learn healthy ways to handle urges or rituals, such as mirror checking or skin picking.

Specific types of psychotherapy that may be helpful for body dysmorphic disorder include:

  • Cognitive behavioral therapy
  • Behavior therapy
You and your therapist can talk about which type of therapy is right for you, your goals for therapy, and other issues, such as the number of sessions and the length of treatment. Therapy can be as an individual or in a group setting.

Medications for body dysmorphic disorder
There are no medications specifically approved by the Food and Drug Administration to treat body dysmorphic disorder. However, psychiatric medications used to treat other conditions, such as depression, can also be prescribed for body dysmorphic disorder off-label ? that is, even if they haven't been specifically FDA approved for that use.

Because body dysmorphic disorder is thought be caused in part by problems related to the brain chemical serotonin, the medications prescribed most commonly are those that affect serotonin, including:

  • Selective serotonin reuptake inhibitors (SSRIs)
  • Tricyclic antidepressants
These medications can help control your obsessions and repetitive behaviors. In general, treatment of body dysmorphic disorder requires higher doses of these medications than does depression. You can gradually increase your dose to make sure you can tolerate the medication and possible side effects.

It may take as long as 12 weeks for noticeable improvement in your symptoms. You may need to try two or more medications before finding one that works well for you and has the fewest side effects. And you may need to try other types of antidepressants or medications if the main choices aren't effective enough.

In some cases, you may benefit from taking medications in addition to your primary antidepressant medication. For instance, your doctor may recommend that you take an antipsychotic medication in addition to an SSRI if you have delusions related to body dysmorphic disorder.

The risk of relapse is typically high once you stop taking a medication for body dysmorphic disorder. You may need to continue to take a medication indefinitely, especially if you've had suicidal thoughts or behavior in the past.

In some cases, your body dysmorphic disorder symptoms may be so severe that you require psychiatric hospitalization. Psychiatric hospitalization is generally recommended only when you aren't able to care for yourself properly or when you're in immediate danger of harming yourself or someone else. Psychiatric hospitalization options include 24-hour inpatient care, partial or day hospitalization, or residential treatment, which offers a supportive place to live.

Cosmetic procedures
While it may seem that a procedure to "fix" your perceived flaw is a good option, cosmetic surgery, dentistry or other approaches usually don't relieve the distress of body dysmorphic disorder. You may not get the results you hoped for, or you may simply begin obsessing about another aspect of your appearance and seek out more cosmetic procedures. Cosmetic procedures don't address your underlying condition ? they are only temporary fixes, at best.

Lifestyle and home remedies
In most cases, body dysmorphic disorder won't get better if you try to treat it on your own. But you can do some things for yourself that will build on your professional treatment plan, such as:

  • Stick to your treatment plan. Don't skip therapy sessions, even if you don't feel like going.
  • Take your medications as directed. Even if you're feeling well, resist any temptation to skip your medications. If you stop, symptoms may come back. You could also experience withdrawal-like symptoms from stopping a medication too suddenly.
  • Learn about your condition. Education about body dysmorphic disorder can empower you and motivate you to stick to your treatment plan.
  • Pay attention to warning signs. Work with your doctor or therapist to learn what might trigger your symptoms. Make a plan so that you know what to do if symptoms return. Contact your doctor or therapist if you notice any changes in symptoms or how you feel.
  • Get active. Physical activity and exercise can help manage many symptoms, such as depression, stress and anxiety. Activity can also counteract the effects of some psychiatric medications that may cause weight gain. Consider walking, jogging, swimming, gardening or taking up another form of exercise you enjoy.
  • Avoid drugs and alcohol. Alcohol and illicit drugs can worsen mental illness symptoms or interact with medications.
  • Get routine medical care. Don't neglect checkups or skip visits to your family doctor, especially if you aren't feeling well. You may have a new health problem that needs to be addressed, or you may be experiencing side effects of medication.
Coping and support
Coping with body dysmorphic disorder can be challenging because it's so distressful and affects many areas of your life. It also makes it hard to engage in the behavior and activities that may help you feel better. Talk to your doctor or therapist about improving your coping skills, and consider these tips to cope with body dysmorphic disorder:

  • Write in a journal to express pain, anger, fear or other emotions.
  • Don't become isolated. Try to participate in normal activities and get together with family or friends regularly.
  • Take care of yourself by eating a healthy diet and getting sufficient sleep.
  • Read reputable self-help books and consider talking about them to your doctor or therapist.
  • Join a support group so that you can connect to others facing similar challenges.
  • Stay focused on your goals. Recovery from body dysmorphic disorder is an ongoing process. Stay motivated by keeping your recovery goals in mind. Remind yourself that you're responsible for managing your illness and working toward your goals.
  • Learn relaxation and stress management. Try such stress reduction techniques as meditation, yoga or tai chi.
  • Don't make important decisions, such as having cosmetic surgery, when you're in the depths of despair or distress, since you may not be thinking clearly.
There's no sure way to prevent body dysmorphic disorder. Because body dysmorphic disorder often starts in adolescence, identifying children at risk of the condition may be of some benefit by enabling early intervention or treatment. In addition, taking steps to control stress, to increase your resilience and to boost low self-esteem may help. And long-term maintenance treatment also may help prevent a relapse of body dysmorphic disorder symptoms.
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