REVI EW

Psychopathologic Aspects of Body Dysmorphic Disorder:

A Literature Review
C. Pavan P. Simonato M. Marini F. Mazzoleni L. Pavan
V. Vindigni
Published online: 26 January 2008
Springer Science+Business Media, LLC 2008
Abstract Body dysmorphic disorder (BDD) is a so-
matoform disorder characterized by the patients excessive
concern with an imagined or minor defect in physical
appearance. Patients with BDD often have been observed
in aesthetic surgery settings seeking surgical enhancement
at a reported prevalence of 6% to 15%. Published studies in
the general population tend to aggregate a prevalence of
0.7% to 2.3%. This review aimed to search the literature
for data on the prevalence, psychopathologic aspects, and
comorbidity of BDD, and to provide an update on current
BDD research. Relevant literature was identied by
searching the Medline, PubMed, PsycINFO, and EMBASE
databases. The following search words were used alone or
in combination when appropriate: body dysmorphic dis-
order, somatoform disorder, obsessive compulsive
spectrum disorder, personality disorders, presurgical
counseling, aesthetic surgery, cosmetic surgery, and
plastic surgery. Further articles were sourced from the
reference lists of the articles ascertained through the
search. Recent ndings include the relationship between
BDD and the obsessive-compulsive spectrum, treatment of
BDD based on pharmacologic and psychological approa-
ches, and the hypothesis that the often distinguished
delusional and nondelusional variants of BDD very likely
are the expression of a single disorder with varying degrees
of severity. Retrospective outcome studies suggest that
patients affected by BDD typically do not benet from
surgical treatment. In contrast, serotonin reuptake inhibi-
tors and cognitive-behavior therapy appear to be good
practice in addressing the disorder. Further research is
needed to identify effective interventions for patients who
do not respond to these treatment methods.
Keywords Aesthetic surgery
Body dysmorphic disorder Comorbidity Etiology
Obsessive compulsive spectrum disorder
Somatoform disorder
Individuals increasingly feel an inner need for their
appearance to reect a certain aesthetic model as contem-
porary social customs attribute increasing importance to a
persons looks in his or her daily interactions, in both the
private and the professional spheres. The demand to
improve ones features or to retain their youthfulness in
later life is constantly on the rise, as society has come to
believe that improvement on nature is acceptable.
It is, however, important to understand that the dividing
line between this common wish to improve ones looks
and neurosis can sometimes become very ne. Extreme
dissatisfaction with ones appearance may conceal psy-
chopathologic traits that are not always easy to recognize,
and which if neglected may involve serious iatrogenic and
medicolegal consequences. A plastic surgeon was recently
accused of malpractice for not taking into due consider-
ation the psychiatric problems of his patient, who was
judged incapable of giving her informed consent for the
scheduled operation because she had a diagnosis of body
dysmorphic disorder (BDD) [1].
Plastic surgery constitutes a privileged vantage point for
the analysis of BDD because it is strategically situated with
C. Pavan (&) P. Simonato M. Marini L. Pavan
Psychiatric Clinic, University of Padova, Via Giustiniani 2,
35122 Padova, Italy
e-mail: chiara.pavan@unipd.it
F. Mazzoleni V. Vindigni
Unit of Plastic and Reconstructive Surgery, University of
Padova, Via Giustiniani 2, 35122 Padova, Italy
1 3
Aesth Plast Surg (2008) 32:473484
DOI 10.1007/s00266-008-9113-2
regard to the study of the body image among BDD patients.
In fact, BDD is a pathology that psychiatrists often are not
informed to observe because the patients, who do not
understand the true nature of their problem, turn to der-
matologists and above all to plastic surgeons. It must be
stressed that such a patient may benet from psychiatric
treatment alone. An operation, even if perfectly performed,
is incapable of resolving the psychological discomfort
stemming from the supposed physical defect and leads
more often than not to a lawsuit [210].
This review includes the history of BDD, the current
diagnostic criteria, etiologic theories, clinical and demo-
graphic features, comorbidity, and treatment. This article
aims to stress to plastic surgeons and other physicians who
offer aesthetic procedures the importance of promptly
recognizing and properly treating patients with BDD.
The relevant literature was identied by searching the
Medline, PubMed, PsycINFO, and EMBASE databases.
The following search words were used alone or in combi-
nation when appropriate: body dysmorphic disorder,
somatoform disorder, obsessive compulsive spectrum
disorder, personality disorders, presurgical counsel-
ing, aesthetic surgery, cosmetic surgery, and plastic
surgery. Further articles were sourced from the reference
lists of the articles ascertained through the search.
History
The rst clinical description of BDD dates back to Enrico
Morselli [11], who in 1891 introduced the term dysmor-
phophobia to describe a subjective feeling of ugliness or
of a physical defect, which makes the patient believe he
or she is observed by others despite a normal appearance.
Pierre Janets [12] subsequent descriptions of the disorder
indicated the presence of an obsession with shame of the
body (obsession de la hontu du corps), whereas Kraepelin
[13] maintained that the disorder stemmed from obsessive
neurosis. Jaspers [14], on the other hand, stressed that the
patients preoccupation could assume different forms and
become an obsession, a prevalent idea, or a secondary
delusion.
Etymologically speaking, the term dysmorphophobia
derives from the Greek dysmorphia, which indicates
ugliness, particularly in relation to the face. The disorder
is not, however, characterized simply by the fear of having
a physical defect, as the sufx phobia might suggest.
Rather, the patient manifests what can be described as a
polarization of attention, charged with an emotional par-
ticipation that focuses on a specic part of the body. The
subject develops repulsion for that part of the body, which
interferes to a varying degree with relations with others and
with social functioning.
Dysmorphophobia rst became a distinct diagnostic
category in 1980 in the Diagnostic and Statistical Manual
of Mental Disorders, 3rd edition (DSM-III) [15], but only
in DSM-III-R [16] was the term dysmorphophobia
abandoned in favor of body dysmorphic disorder to
avoid an emphasis on the phobic aspects of avoidance and
to classify it among the group of somatoform disorders.
Relationship of BDD to the Obsessive-Compulsive
Spectrum
The classication of BDD is a debated issue. According to
DSM-IV-TR [17], BDD is subsumed under the somatoform
disorders, but this classication has been criticized. Some
researchers assert that BDD has commonalities with the
obsessive-compulsive spectrum [18]. Morselli [11], Janet
[12], and Kraepelin [13] identied psychopathologic
analogies between the two disorders related to the presence
of intrusive thoughts and repetitive behavior.
The study by Phillips [19] that investigated 200 cases of
BDD showed at least one repetitive behavior for each
patient aimed at reducing levels of anxiety about physical
appearance. The most frequently encountered behaviors
were camouaging, comparing the imagined abnormal part
with that of others, mirror checking, glancing in reective
surfaces, excessive grooming, frequent changes in dress,
skin picking [20], dieting, and excessive physical exercise.
There is indeed some clinical and pathologic overlap
between obsessive-compulsive disorder (OCD) and BDD
such as obsessive thoughts and the performance of ritual
behavior (safety behavior). Other characteristics fre-
quently encountered in both are the desire for symmetry (in
the positioning of objects or in ones own body), the search
for perfection, and the patients need to control the envi-
ronment surrounding his or her appearance. Both disorders
are characterized by frequent requests for reassurance [21].
There is further overlap between the two disorders in
age of onset, sex distribution, chronic course, family his-
tory of psychiatric disorders, and type of treatment. Reports
in the literature suggest that some personality traits such as
asthenia/hyposthenia, a robust tendency toward self-criti-
cism, insecurity, and perfectionism may be considered
premorbid factors predisposing to the development of BDD
and OCD. Among patients with a primary diagnosis of
OCD, ndings have shown BDD to be a comorbidity in 8%
to 37%, whereas among those with a primary diagnosis of
BDD, the rate of OCD comorbidity is reportedly 20% to
30% [18, 2128]. Many other studies have described
similarities in both symptomatology and therapeutic
approach [18, 2128].
A study by Eisen et al. [29] compared a sample of 64
OCD patients with 85 BDD patients and discovered that
474 Aesth Plast Surg (2008) 32:473484
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the latter had less insight and a worse clinical course,
conrming the ndings of Phillips et al. [18] and Simeon
et al. [30]. Conversely, the survey by Neziroglu et al. [22]
suggested a higher tendency toward delusionality than
found among patients with OCD.
As observed by Phillips and Diaz [28], it seems that
BDD patients are less frequently married, have greater
suicidal ideation, are at greater risk for the development of
major depression or social phobia, and are more frequently
addicted to substance abuse than subjects with OCD. From
a neurophysiologic standpoint, Neziroglu et al. [22] and
Phillips et al. [31] reported serotonergic system involve-
ment with both disorders, conrming the rationale behind
the use of serotonin reuptake inhibitors.
As observed [18, 29, 32], despite these analogies, it is
appropriate to make a distinction between BDD and other
obsessive-compulsive spectrum disorders, both clinically
and in the research eld. This is illustrated by a recent
Italian study conducted at Pisa University [33] that
compared three different groups of patients, comprising
those affected by BDD (n = 34), by BDD and OCD (n =
24), and by OCD (n = 79). The groups presenting with
BDD or BDD and OCD were slightly younger, less fre-
quently married, and more often unemployed, in addition
to presenting with bulimia, substance abuse disorders, and
social phobia. The authors conrmed that it was appro-
priate to include BDD in the OCD spectrum, but,
according to their ndings, it could not simply be con-
sidered a variant. Rather, the copresence of BDD and
OCD indicated a more severe syndrome with a greater
psychopathologic load.
Denition
By denition, BDD consists of an excessive, dispropor-
tionate preoccupation with an imagined or slight defect in
physical appearance by a person of normal appearance. In
particular, DSM-IV-TR [17] identies the following as
essential diagnostic criteria:
1. Preoccupation with an imagined defect in physical
appearance. If a slight physical anomaly is present, the
persons concern is markedly excessive.
2. The preoccupation causes clinically signicant distress
or impairment in social, occupational, or other impor-
tant areas of functioning.
3. The preoccupation is not better accounted for by
another mental disorder (e.g., dissatisfaction with body
shape and size in anorexia nervosa).
The pathologic nucleus is preoccupation about a physical
defect that generally concerns the face but may also
involve other parts of the body. Attention may be focused
on one portion or may transfer over time according to a
pattern known as substitution [34].
Etiology
The etiology of BDD is most likely multifactorial (bio-
logic, psychological, and sociocultural). An impairment of
the frontal-striatal and temporo-parietal-occipital circuits,
which process facial images and emotional information,
has been shown by neuropsychological and brain imaging
studies [35], suggesting some evidence for genetic links
and familiar aggregation [36] with OCD, although the lit-
erature on these relationships is limited.
A role for the serotonin system and receptors is sug-
gested by the evidence of a therapeutic response to
serotonergic antidepressants. Symptoms of BDD have been
exacerbated after tryptophan depletion, and onset has
occurred after abuse of a serotonin antagonist [35].
Few studies describe certain cognitive decits with
BDD such as loss of executive function, memory, facial
emotion perception, and attributional bias. Some authors
[36] have shown that BDD patients had no difculty
identifying facial features. They were less accurate than
normal controls but more accurate than a group of patients
with OCD in identifying facial expressions of emotion.
Veale [37] suggests a cognitive-behavioral model of
BDD based on an excessive self-focused attention to neg-
ative body-related information. Veale et al. [38] have in
fact shown that BDD patients have an unrealistic ideal for
appearance, failing to achieve their own aesthetic standard.
In summary the cognitive data suggest that abnormal per-
ception and emotional processing decits have an
important role in BDD, but further empiric testing is
required.
Epidemiology
Currently available studies indicate a BDD prevalence of
approximately 1% in the general population of the United
States [39, 40]. A community survey in Florence, Italy by
Faravelli et al. [41] demonstrated a BDD prevalence of
0.7%. Published studies in the general population aggre-
gate a prevalence of 0.7% to 2.3% [36]. Certain groups of
individuals have higher rates of BDD, such as those in
plastic surgery and dermatologic settings, among whom the
prevalence is 6% to 15% [4244]. A recent study based on
administration of a questionnaire to 1,000 patients [45]
conrmed an incidence of 3% to 8% in the same groups.
According to a recent report, 20% of patients affected by
BDD probably have at least one rst-degree relative
affected by the same disorder [19], suggesting some form
Aesth Plast Surg (2008) 32:473484 475
1 3
of heredity. However, this hypothesis warrants further
investigation.
Epidemiologically speaking, the incidence of BDD
seems to present a bimodal distribution. The disorder tends
to manifest primarily in adolescence and early adulthood,
with a second incidence peak after menopause [46]. Most
clinical series of patients describe an onset in the teenage
years, but many patients with BDD describe sensitivity
about their appearance throughout their lives.
A survey conducted by Phillips et al. [19] with 200
subjects affected by BDD identied the mean age of onset
to be 16.4 years. When subclinical forms were included in
the analysis, the mean age of onset was lowered to
12.9 years. In some cases [47], the disorder also may be
manifested in childhood. Overall, therefore, the mean age
of BDD onset is estimated to be approximately 33.7 years
[28, 42].
Many studies have shown BDD to be common among
the student population, both male and female. In a ques-
tionnaire study by Cansever et al. [48] that investigated a
sample of 420 female college students, 43.8% of the
respondents reported dissatisfaction with their appearance,
and 4.8% met the DSM-IV diagnostic criteria for BDD. A
similar survey by Bohne et al. [23], based on a sample of
133 students at a German college (73.3% women), identi-
ed a 5.3% prevalence of BDD, associated with low self-
esteem, depressive symptoms, and behavior characteristic
of the obsessive-compulsive sphere. A study of 102 college
students showed a prevalence of 13% [49]. In another
college population study, Sarwer et al. [50] reported a
BDD prevalence of 2.5%.
Dening gender differences has been more difcult.
Some authors [26] have observed a higher incidence of
BDD among males, but others [27, 28] have reported the
incidence to be unvaried. Studies conducted by Rosen et al.
[51] and Biby [49] point to a greater presence of the dis-
order among women. Specically, Cororve and Gleaves
[52], by aggregating patients who voluntarily consulted a
psychiatrist with those experiencing milder forms of BDD,
found the prevalence rate decidedly higher in the female
population.
There are, however, clinically signicant gender dif-
ferences in the body parts on which the patient focuses
attention. Phillips and Diaz [28] and Perugi et al. [53, 54],
for example, found that men were more concerned about
their genitals, muscle mass, and hair, whereas women were
more preoccupied with their breasts, thighs, and legs.
These differences are likely to have sociocultural conno-
tations and to be reinforced by models proposed by the
mass media.
A recent study by Phillips et al. [55] examined the
similarities and differences in an extensive sample (n =
200) of subjects affected by BDD and found that in addi-
tion to being older, the men were less frequently married
than the women and also more prone to substance abuse.
Conversely, the women tended to present repetitive
behavior and to camouage their supposed defects. Con-
sequently, although BDD is sometimes considered to be a
female disorder, the gender ratio ranges from 1:1 to 3:2
(female:male), in contrast to eating disorders, which are
essentially disorders of females (Tables 1 and 2).
Clinical Symptoms of BDD
Patients with BDD generally show an exaggerated preoc-
cupation with imagined physical defects that have a highly
disproportionate emotional and affective charge [56, 57].
Table 1 Prevalence of body
dysmorphic disorder (BDD)
among community, college
student, cosmetic surgery, and
dermatology populations
Sample Authors Year Country Rate (%)
Community Faravelli et al. [41] 1997 Italy 0.7
Cotterill & Cunliffe [39] 1997 United States 1
Patterson et al. [40] 2001 United States 1
Castle DJ [36] 2006 Australia 0.72.3
College students Biby [49] 1998 United States 13
Bohne et al. [23] 2002 Germany 5.3
Cansever et al. [48] 2003 Turkey 4.8
Sarwer et al. [50] 2005 United States 2.5
Cosmetic surgery and
dermatology populations
Vindigni et al. [87] 2002 Italy 53.6
Phillips et al. [42] 2000 United States 11.9
Vulink et al. [45] 2006 Netherlands 38
Veale et al. [38] 2003 United Kingdom 20.7
Crerand et al. [99] 2006 United States 653
Castle et al. [84] 2004 Australia 2.9
Pavan et al. [82] 2006 Italy 27
476 Aesth Plast Surg (2008) 32:473484
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The fear experienced by these subjects is closer to shame
than to a narcissistic desire to improve or perfect
their body. In other words, they have a pervading sense of
inadequacy about their body and would like to feel
acceptable or simply normal. Anxiety arises particu-
larly when they are exposed to others, producing strong
social inhibition.
A wide array of body parts may be involved, as shown
by the extensive case set reported by Phillips et al. [55]. In
reviewing 200 cases of BDD, these authors observed a
mean involvement of ve to seven body parts and com-
pulsive behavior in all subjects, including excessive mirror
checking, grooming, or skin picking.
Many patients express concern about their skin (e.g.,
color, marks, veins, pores, wrinkles) or face, describing it
as hideous or awed because the ears are too low, the
hairline is too high, or there is acne or blackheads. Others
express a pervasive fear of resembling an animal or other
members of the family with some physical defect (e.g.,
baldness, prominent nose).
Another common complaint is lack of femininity (typ-
ically small breasts) or masculinity (small penis, puny
body). Great concern also is expressed about lack of
symmetry, particularly of the face (number of moles,
height of eyes or eyebrows, or shape of nose) and hair [28].
Cases of body parts that change appearance, shape, or
prole also have been described [28], as well as parts that
appear more delicate, as in the case of a patient who pre-
ferred to have a tooth extracted without anesthesia to
ensure that the dentist did not damage his fragile nose.
Often, BDD is associated with accessory symptoms, such
as reference ideas or delusions (73%) and tactile sensations
(37%) [58].
Subjects with BDD manifest self-referential thinking.
They assume that others can see the imagined physical
defect and consider every phrase, glance, or laugh to be the
expression of a judgment, a condemnation, or a sentence.
Hence the condition is not a phobia but a disorder of body
image because the subject is preoccupied solely with his or
her own presumed defects [59] but tolerates those of others.
This broad spectrum of manifestations may impair
patients daily life, even to a severe degree. As Phillips and
Diaz [28] observed in various case reports, when the dis-
order becomes very pervasive, it can potentially disrupt the
subjects entire social life. Conversely, if it remains cir-
cumscript, taking on milder, less debilitating forms, it
may be associated with high, almost compensatory social
functioning. In their study of 200 patients affected by
BDD, Phillips et al. [19] reported that in the previous
month, 36% of the sample (n = 63) had been absent from
work, and 32% (n = 56) had skipped school because of the
disorder. They also reported that 11% had permanently left
school.
Hence, BDD impairs the social life of affected subjects.
Hollander et al. [47] observed that 50% of a student sample
was concerned about their appearance and that social
functioning was affected in 25% of cases. In a study of 62
subjects affected by BDD [60] the quality of life experi-
enced by BDD patients was assessed on the basis of various
scales and compared with the general U. S. population. The
ndings showed that the mental health status and quality of
life experienced by BDD patients was far inferior to that of
the general population.
Very often, self-esteem can be so low as to result in
social isolation. One important nding emerging from
some studies is that most patients with BDD are not mar-
ried [28, 60, 61].
This brief discourse is a source for much reection and
calls for future studies. It is not clear, for example, how
patients choose the body part on which to concentrate their
attention. Subjects undoubtedly present an anomalous
perception of their own body image, but the mechanisms
underlying the choice of one aspect to the exclusion of
others is not known. It also is not certain how subjects
judge details as being anomalous that most people consider
irrelevant.
Table 2 Comorbidity in body
dysmorphic disorder (BDD)
Comorbidity in BDD Prevalence among patients with BDD (%)
Obsessive compulsive disorder (OCD) 630 [99]
Depressive disorders 80 (lifetime) [58, 60, 71]
Social phobia 12 [72]/39.3 (lifetime) [73]
Substance abuse disorders 48.9 [78]
Suicidal ideation 78 [74]
Eating disorders 32.5 [79]
s Anorexia nervosa 9.0
s Bulimia nervosa 6.5
s Not otherwise specied ED (eating disorders) 17.5
Personality disorders (cluster C) 1543 [22, 32]
Aesth Plast Surg (2008) 32:473484 477
1 3
Delusional and Nondelusional Forms of BDD
Patients complaints also can present delusional aspects.
Although these generally are less severe than in other forms
of delusion, they exceed mere attention to ones own
physical appearance. Several studies have described some
severe variants characterized by poor insight, in which the
patient loses the capacity for realistic criticism of his or her
own symptoms, as observed in four case reports by Lucchelli
et al. [62]. Currently, approximately 35% to 40% of BDD
cases are believed to present the delusional pattern [19,
63, 64]. The DSM-IV-TR [17] does in fact envisage an
additional diagnosis of delusional disorder, somatic type,
in which the patient presents absolutely unrealistic, primarily
pathologic thinking that does not permit criticism [22, 65].
However, the delusional and nondelusional variants of
BDD are very likely to be the expression of a single disorder
with various degrees of severity. Numerous studies based on
this hypothesis [27, 60, 66] have observed uctuations in
delusional ideation in patients with BDD related to envi-
ronmental stressors. Specically, Phillips et al. [60] noted an
overlap between the two forms in terms of demographic
factors, clinical presentation, natural history, comorbidity,
family history, and response to pharmacologic treatment.
Course of BDD
Usually, BDD is lifelong, but the outlook for those who
receive treatment is much more favorable. Phillips et al. [67]
reported the chronic course of BDDin a study of 183 patients
with a 12-month follow-up period. After 1 year, the proba-
bility of complete spontaneous remission was 9%and that of
partial remission was 21%, without signicant gender or
ethnic differences. The authors stressed that BDD had an
extremelylowprobabilityof remissioncomparedwithmood,
personality, and anxiety disorders surveyed with similar
methods. Moreover, a prospective study showed that the
severity of symptoms at onset, the long duration of the dis-
order, and the comorbidity with personality disorders are
indices of the low probability for partial or spontaneous
remission [68]. This study also evidenced that gender, eth-
nicity, age of onset, socioeconomic status, adolescence or
adulthood, comorbidity with social phobia, OCD, and eating
disorders were not, however, predictors of remission proba-
bility, nor was being a recipient of nonpsychiatric treatments.
BDD Comorbidity
Comorbidity with Depressive Disorders
Findings show that BDD has a high rate of comorbidity
with depressive disorders (estimated to be 80% of cases),
as corroborated by our study. Various reports in the liter-
ature have conrmed that subjects with BDD present with
depressive symptoms marked by emotional lability, social
withdrawal, loss of pleasure or interests, or comorbidity
with axis 1 and 2 disorders [27, 6972].
A recent study [70] using the Symptom Questionnaire
to compare 75 patients with a control group recorded
high scores for the anxiety, depression, somatization, and
anger and hostility scales. The literature reports major
depression to be the disorder most frequently associated
with BDD, with a lifetime prevalence exceeding 80%
[58] [60, 71].
In many ways, BDD differs from depressive disorders,
although it may be that feelings of low self-esteem about
ones own body develop during an episode of major
depression. Nonetheless, these feelings never focus on
specic aspects of physical appearance, nor are they cor-
related with compulsive behavior. Moreover, depression
affects more women than men, with a later age of onset and
a less chronic course than experienced with BDD. Thera-
peutically, BDD also responds far less to serotonin
reuptake inhibitor-type antidepressants. Currently, BDD
appears to be correlated and often comorbid with depres-
sive disorders, but to date the relationship between the two
has not been fully understood.
Patients with BDD also seem to be particularly
exposed to suicidal ideation and suicide risk. A recent
study by Phillips et al. [74] examined 200 subjects with
BDD and found a 78% lifetime frequency of suicidal
ideation and an attempted suicide rate of 27.5%. In
addition, the study showed that BDD was the main reason
for suicidal ideation experienced by 70.5% of patients and
that it was correlated with a high suicidal risk, particu-
larly in patients with comorbid depressive and substance
abuse disorders.
Conversely, Phillips and Menard [75] conducted the rst
prospective study of 185 patients affected by BDD over a
period of 4 years. The annual incidence was reported to be
57.8% for suicidal ideation and 2.6% for attempted sui-
cides. Two subjects (0.3%) completed suicide. The authors
emphasized that suicidal ideation was high with BDD and
suggested that the frequency of completed suicides was
probably also signicant.
Comorbidity with Social Phobia
Social phobia is another comorbidity of BDD, with an
estimated rate of 12% [72]. An interesting study conducted
by Coles et al. [73] examined the relationship between
BDD and social phobia in a series of 178 patients with
BDD. These patients showed comorbidity with social
phobia at a lifetime rate of 39.3%, and 34.3% presented
478 Aesth Plast Surg (2008) 32:473484
1 3
ongoing comorbidity, sharing similar general characteris-
tics (age, gender, degree of BDD severity, functional
disability) and correlation with poorer social functioning.
The authors also emphasized that comorbid patients pre-
sented greater suicidal ideation than patients affected by
BDD but not social phobia.
Like BDD, social phobia is characterized by robust
social anxiety and avoidance behavior, but there is no clear
focus on a single feature of the body. Phillips and Diaz [28]
maintained that social phobia develops secondarily in
patients with BDD.
Comorbidity with Substance Abuse
Various studies have reported high rates of BDD comor-
bidity with substance abuse disorders [32, 57, 71, 76, 77].
Grant et al. [78] examined 176 subjects affected by BDD
and found a lifetime substance abuse disorder rate of 48.9%
(n = 86) and a lifetime substance dependency rate of
35.8%, particularly alcohol dependency (29% lifetime
rate). In 68% of these subjects, BDD was the main causal
element of substance abuse.
Comorbidity with Eating Disorders
There is a signicant correlation between BDD and eating
disorders, with moderate comorbidity. A recent research
study [79] examined 200 subjects with BDD and found a
32.5% rate of lifetime comorbidity with eating disorders
including anorexia nervosa (9%), bulimia nervosa (6.5%),
and other unspecied disorder (17.5%). The ndings also
showed that patients with eating disorders have received
more mental health care than other subjects with BDD.
Anorexia nervosa, BDD, and bulimia nervosa share the
commonalities of compulsive behavior (mirror checking
and measuring parts of the body) and an underlying pre-
occupation with bodily appearance, accompanied by a
distortion of ones own body image. However, important
differences also exist. Subjects affected by BDD appear
normal to other people, whereas anorexics have a cachetic
appearance. The more emaciated they seem, the better they
think they look. In addition, eating-disordered patients
concentrate chiey on their weight rather than on a single
part of the body, unlike those with BDD. Epidemiologi-
cally, eating disorders differ from BDD in that they more
frequently affect women [59]. However, Phillips and co-
authors suggested [79] the presence of a gray area between
eating disorders and BDD, maintaining that the overlap of
symptoms hindered differential diagnosis and prevented
clinicians from completely ruling out eating disorders as a
form of BDD.
Comorbidity with Personality Disorders
Comorbidity in axis 2 is more frequent among patients with
BDD, particularly cluster C personality disorders [43, 54,
80] including avoidance (43%), dependence (15%), and
obsession-compulsion (14%). Several studies conducted in
aesthetic surgery departments also have evidenced cluster
A disorders [69], showing a high frequency of paranoid
disorder (14%). Similarly, the survey by Maffei and Fossati
[81] positively correlated BDD with avoidance and
dependent personality disorders in a sample of 30 subjects
seeking corrective aesthetic surgery.
A study investigating a group of patients from the
Plastic Surgery Department of Padova University surveyed
not only the presence of BDD but also temperamental and
personologic charactersitics using the Three-dimensional
Personality Questionnaire (TPQ) and Neo Five-Factor
Inventory (Neo-FFI) [82]. Subjects affected by BDD had
elevated scores on the Harm Avoidance (HA) scale of the
TPQ, suggesting greater behavioral inhibition, with high
levels of anticipatory anxiety (HA1), fatigability and
asthenia (HA4). Conversely, on the Neo-FFI, the patients
with BDD presented lower scores on the Open to experi-
ence (O), Agreeableness (A), Conscientiousness (C), and
Extraversion (E) subscales, conrming greater introversion
and hostility.
Bellino et al. [69] examined a sample of 57 subjects
presenting for plastic surgery. This study included testing
with standardized instruments for the presence of BDD and
personality disorders. The results showed an association
between symptom severity and the number of cluster per-
sonality traits (schizotypal and paranoid characteristics).
The authors concluded that these personality traits, marked
by a tendency toward suspiciousness, fear of the judgment
of others, social anxiety, and an essentially fragile per-
sonality, probably predisposed subjects to abnormal
cognitive experiences, with amplication of bodily
imperfections to the point of psychic decompensation.
Surveys of personality and temperamental traits in patients
with BDD have preliminary but important clinical impli-
cations because patients who meet a high number of
diagnostic criteria for personality disorders in perioperative
assessment may constitute a risk group (Table 2).
BDD and the Request for Aesthetic Surgery
Body dysmorphic disorder is considered a relatively fre-
quent disorder among patients seeking aesthetic surgery,
and these specialist departments often are the rst to make
contact with these subjects. Reports published in the lit-
erature indicate a high prevalence of BDD particularly in
departments of dermatology and plastic surgery, with an
Aesth Plast Surg (2008) 32:473484 479
1 3
estimated frequency of 6% to 15% [4244]. The study
conducted by Vulink et al. [45] described an 8.5% preva-
lence of patients affected by BDD in a plastic surgery
population (n = 1,000). This conrms, as do other studies
[83], that the rst treatment to be sought by patients with
BDD is nonpsychiatric and that intervention often is
multiple.
Another study [26] found that 40% of assessed patients
(n = 50) had received at least one aesthetic operation, but a
research study [44] showed no differences among receivers
and nonreceivers of nonpsychiatric treatment in terms of
clinical or demographic characteristics. Still another study
examined 268 patients awaiting dermatologic treatment
and reported that 11.9% of patients were affected by BDD
according to DSM-IV criteria [42].
A questionnaire administered by Castle et al. [84] to 137
patients awaiting aesthetic improvement identied 4
patients affected by BDD and many others with a sub-
clinical level of dysmorphic preoccupation attributable
to states of anxiety, manifestations of social anxiety, and a
decline in social functioning. Phillips et al. [83] surveyed
289 subjects affected by BDD (250 adults and 39 adoles-
cents) and found that 76.4% had received nonpsychiatric
medical care including dermatologic (45.2%) and surgical
(23.2%) treatment. These treatments were rarely able to
improve the symptoms of the patient with BDD.
In addition to these retrospective studies [19, 32, 83], the
literature also contains an important prospective study
demonstrating that medical or surgical treatment of patients
with BDD is not associated with a high probability of
remission from the disorder. Rather, the clinical results of
these treatments are perceived as unsatisfactory to the point
of exposing the attending physician to risk [43, 61, 85].
One article published in a specialist surgical journal [5]
emphasized the urgent need for plastic surgeons to identify
patients with BDD promptly despite the multiform nature of
the disorder. These subjects are prone to a syndrome of
overoperation. There is a risk that they will not be satised
with the aesthetic procedure and may constitute a (poten-
tially physical) threat to the attending surgeon. Indeed, many
authors have suggested and stressed the importance of con-
ducting preoperative psychiatric assessment to avoid
subsequent psychopathologic decompensation [8688]. De
Jongh and Adair [89], reporting on a patient with BDD who
became enraged after dental treatment, emphasized the need
to assess patient vulnerability and psychological problems,
primarily to avoid exposure to potential treatment stressors.
In the practice of liposuction, Glaser and Kaminer [90]
highlighted the need to recognize patients with BDD and
diagnose their condition because they were highly subject
to dissatisfaction with the treatment received and difcult
to manage postoperatively. A study conducted by Veale
et al. [91] used a screening questionnaire to assess the
presence of BDD among patients requesting rhinoplasty
and obtained a frequency of 20.7%. The authors subse-
quently compared patients with and without BDD
undergoing the procedure, showing that the former were
younger, more depressed, more anxious, and more preoc-
cupied about their nose. Moreover, they were signicantly
less functional at work, in their social life, and in personal
relations besides being more avoidant. Finally, these sub-
jects were more convinced that their life would
dramatically change after the rhinoplasty. The authors
suggested identifying patients with BDD, particularly those
with the more serious variants, for whom the prognosis for
aesthetic rhinoplasty is signicantly worse.
BDD Treatment
Individuals with BDD often refuse psychiatric referral
because of poor insight into their underlying illness, but
certain pharmacologic and psychological treatments have
shown some success. Psychiatric treatment of BDD
envisages the use of selective serotoninergic antidepres-
sants (uoxetine and uvoxamine) and tricyclics (e.g.,
clomipramine). In particular, the retrospective study of 50
patients by Hollander et al. [26] demonstrated that
improvement in symptoms was greater for subjects treated
with clomipramine, uoxetine, or uvoxamine. Another
study conrmed the greater efcacy of the aforementioned
compounds in association with buspirone compared with
other compounds (Tryciclic antidepressants (TCA), ben-
zodiazepines, neuroleptics, or anticonvulsants) that showed
minimal efcacy [92].
A double-blind study by Phillips et al. [93] conrmed the
efcacy of uoxetine compared with placebo, whereas a
survey by Hollander et al [72], conducted in double-blind
fashion with 29 patients, correlated the use of clomipramine
with an improvement in global symptoms and a return to
social functioning. Conversely, Phillips et al [31] obtained
a 63% response with uvoxamine in a study of 30 patients.
A recent study showed good therapeutic efcacy with
citalopram, but suspension of medication led to a relapse in
83.8% of cases after a mean period of 38 weeks [94].
As these studies [72, 94] indicate, the presence of
delusional characteristics is apparently not a factor pre-
dicting a negative response to serotoninergics. Patients
respond to treatment with a reduction in preoccupations, a
decrease in stress, a reduction in behavioral rituals, and
signicant improvement in social and occupational func-
tioning. The defect is generally noted (it rarely is no longer
perceived), but usually causes less distress.
The most effective psychological intervention is cogni-
tive-behavior therapy used to change specic beliefs and
assumptions thought to underlie both BDD and
480 Aesth Plast Surg (2008) 32:473484
1 3
maladaptative behavior patterns [95]. Cognitive therapy
aims to challenge dysfunctional thinking, replacing it with
adaptive cognitive styles, whereas behavior therapy
involves prolonged and graded exposure to distressing
situations with prevention of compulsive overt and covert
responses (e.g., rituals) [36]. The cognitive-behavioral
approach involves self-monitoring of thoughts and behav-
ior related to appearance, cognitive strategies, and
behavioral exercises [96]. Other components of cognitive-
behavior therapy in the treatment of BDD are social skills
training, psychoeducation, and role-playing [36].
A recent metaanalysis [36] of trial and case series
involving pharmacologic and psychological treatments for
BDD suggests that cognitive-behavior therapy was signif-
icantly more effective than treatment with medications.
Medication associated with cognitive-behavioral psycho-
therapy has proved to be an effective intervention [27, 51,
9699], although it currently is not possible to tease out the
effects of combined treatments. The published literature
has a paucity of combined psychological and pharmaco-
logic treatments evaluated rigorously [36].
BDD: Probably an Underestimated Disorder
In conclusion, BDD probably is an underestimated disor-
der. First, it may escape notice because few psychiatrists or
specialists who make rst contact with BDD patients know
or recognize the condition [100]. By contrast, it is
acknowledged that subjects affected by BDD consult der-
matologists and plastic surgeons to change their
appearance [65, 101], but the outcome of the procedure
very often is unsatisfactory, with the patient requesting
further (potentially unlimited) aesthetic interventions for
the same or other parts of the body, to which there is a
transfer in the focus of attention. However, few studies
have been conducted to assess the outcome of any treat-
ments received [43, 102, 103], although they were unlikely
to cure the disorder.
Second, patients with BDD often are reluctant to
manifest their preoccupation openly to either their family
or the psychiatrist, whom they tend to avoid consulting
in any case [28]. This is linked to the fear of feeling that
others will judge them to be absurdly vain and
narcissistic, triggering a mechanism of social with-
drawal, which very often is identied, diagnosed, and
treated as major depression. Many studies conducted
with these patients have noted an episode of major
depression in their history. Paradoxically, the need to
keep their preoccupation secret is sometimes fueled by
the fear that their anxieties will be conrmed if they
reveal them to others. Currently, it is believed that
patients with BDD seek out psychiatric treatment after
an average estimated delay of 11 years following onset
of the disorder [103105].
How to Test for BDD in Clinical Practice
Although psychological evaluation of patients is not stan-
dard in clinical practice, it is very important for the plastic
surgeon to diagnose BDD during preoperative consultation,
not only for medicolegal reasons but also with a view to
referring affected patients for proper treatment. The con-
sultation should start with questions for the patients about
their motivation for surgery, their personal expectations,
and whether they are dissatised with how they look or
worry considerably about their appearance [35, 106].
A group of authors has recently developed an algorithm
to help lter out BDD patients preoperatively. The algo-
rithm focuses attention on the severity of the deformity and
the patients general behavior. The authors have identied
three groups of patients with different characteristics. The
rst group includes patients with unreasonable behavior but
no deformity. Under these circumstances, the diagnosis of
BDD has to be considered, and the patients should be
referred to a psychiatrist. The second group consists of
patients with a correctable deformity and reasonable
expectations, to whom a surgical intervention could
potentially be offered. The third is a risk group formed by
patients with a minimal but correctable deformity and
inadequate behavior. The surgeon must be extremely crit-
ical when proposing a procedure in these cases. Risk group
patients should at least be revaluated during a second
preoperative consultation [106].
The tests that can be used to diagnose BDD are the Body
Dysmorphic Disorder Questionnaire and the Body Dys-
morphic Disorder Examination Self-Report. Diagnosis and
follow-up evaluation of BDD can be simplied by a visual
analog scale (VAS), but the VAS results should be cross-
checked with the patient interview [107, 108]. Phillips
developed the BDD-Yale-Brown Obsessive Compulsive
Scale (YBOCS) [21] to determine the severity of BDD, but
as suggested by Hodgkinson [107], this tool is more likely
to be used as a clinical research tool by psychiatrists. In any
event, the diagnosis of BDD must be conrmed by a psy-
chiatrist in accordance with DSM-IV criteria and after a
psychiatric interview.
How to Inform BDD Patients
Phillips and Dufresne [109] suggested adopting a psycho-
education approach for patients with BDD. It is vitally
important to inform patients that they seem to have a dis-
turbance of body image known as BDD. Instead of a
Aesth Plast Surg (2008) 32:473484 481
1 3
signicant surgical problem, they have a problem with
body image that makes them excessively concerned with
and absorbed by their physical appearance. This is dem-
onstrated by the large amount of time they spend obsessing
about how they look and the repercussions this has on their
quality of life. It also is important to inform them that BDD
is a known disorder affecting many people that can be
treated by someone with expertise in the condition (i.e., a
psychiatrist). It may be helpful to recommend that these
patients read material on BDD to become more acquainted
with their condition.
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