body dysmorphic disorder

**Definition (DSM-5-TR):** BDD is classified under obsessive-compulsive and related disorders. Criteria: - Preoccupation with one or more perceived defects or flaws in appearance that are not observable or appear slight to others. - At some point, repetitive behaviors (mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (comparing one's appearance with others) in response to the concern. - Clinically significant distress or functional impairment. - Not better explained by concerns about body fat or weight in a patient who meets criteria for an eating disorder. - Specifiers: **with muscle dysmorphia** (preoccupation that one's body build is too small or insufficiently muscular, even if the person is muscular) and **insight level** (good or fair, poor, or absent insight/delusional beliefs).

**Epidemiology and risk factors:** - Prevalence is about 2% of the population. - Onset is usually in adolescence (mean age about 16). - Men and women are affected about equally. Women more often focus on skin, weight, hips, and breasts. Men more often focus on genitals, body build, and hair thinning. - Common sites of concern are skin (acne, scars), hair, and nose. - Risk factors include childhood abuse or neglect, a family history of BDD or OCD, and comorbid depression, social anxiety, or OCD.

**Pathophysiology:** - Serotonergic dysfunction is suggested by the response to SSRIs. - Imaging suggests abnormal visual processing, with excessive attention to detail and a bias toward local rather than global processing. Frontostriatal circuit abnormalities overlap with OCD. - Genetic and environmental contributions are both implicated.

**Clinical significance and associations:** - Patients often present to dermatologists, plastic surgeons, and dentists rather than psychiatrists. Cosmetic procedures rarely help and often worsen the preoccupation. Patients may become angry or litigious toward the surgeon. - **Suicide risk is high.** Suicidal ideation is common, and attempts and completed suicide rates exceed those in many other psychiatric disorders. Always screen for it. - Comorbidities include major depressive disorder (most common), social anxiety disorder, OCD, and substance use. - Patients may be housebound or socially avoidant. - Muscle dysmorphia is associated with anabolic steroid abuse and excessive exercise.

**Differential (high-yield distinctions):** - **Anorexia nervosa:** the concern is body weight or shape, with restricted intake. Use this diagnosis when the concern is body fat or weight. - **Illness anxiety disorder:** the fear is of having a disease, not a defect in appearance. - **OCD:** obsessions are not limited to appearance. Insight may be similar, but BDD is specifically appearance-focused. - **Social anxiety disorder:** fear of negative evaluation without a perceived physical defect. - **Gender dysphoria:** distress about incongruence between gender identity and sex characteristics. - **Delusional disorder, somatic type:** diagnose BDD with absent insight/delusional beliefs instead of a separate delusional disorder when appearance preoccupation is the focus. - **Normal appearance concerns:** these lack the time-consuming preoccupation and impairment.

**Treatment:** - **First line:** SSRIs (fluoxetine, escitalopram, fluvoxamine), often at higher doses and for longer trials than for depression. Clomipramine is an alternative. - **Psychotherapy:** CBT with exposure and response prevention (ERP), including mirror retraining and cognitive restructuring. - **Combination** therapy is used for severe cases. - Avoid cosmetic or surgical procedures, which are generally ineffective. - Antipsychotics are not first line, even in patients with delusional-level conviction. SSRIs are still the treatment for those patients.

**Board pearls:** - Classic vignette: an adolescent or young adult with a normal appearance who is convinced their nose or skin is deformed, spends hours checking mirrors, and keeps seeking surgery. The answer is BDD, and the treatment is an SSRI plus CBT. - Eating disorder concerns about weight go to anorexia or bulimia, not BDD. - Screen for suicidality.