1. Perkins, Amanda DNP, RN


Imagine waking up every morning dreading looking in the mirror while at the same time being compelled to so flaws can be identified, judged, and camouflaged. For patients with BDD, this is a daily reality and struggle.


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Everything around us focuses on beauty, from commercials to magazines, social media to movies. Already beautiful models are airbrushed to make them look "perfect" in a way that's unattainable. People can easily apply filters to their selfies, removing even the slightest imperfections. In this way, our society reinforces the need to be beautiful.

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Body dysmorphic disorder (BDD) is a body image disorder that pushes people toward perfection, affecting approximately 1 out of 50 people, or 5 to 7.5 million people in the US, according to the Anxiety and Depression Association of America (ADAA). Individuals who have BDD spend a great deal of time focusing on perceived flaws and ways in which to hide these flaws. The time spent on these negative thoughts can consume most of the day, interfering with quality of life and the ability to carry out daily tasks.


This article discusses BDD, including symptoms, diagnosis, treatment, complications, and the nurse's role.


The basics

BDD is newly classified as an obsessive-compulsive and related disorder. According to the ADAA, it tends to affect both men and women equally. At this time, no cause has been identified, but it's believed that genetics, serotonin malfunction, personality traits, and life experiences such as abuse or trauma may play a role. It's also thought that stressors during adolescence may influence the development of BDD.


In many cases, BDD develops during the adolescent years, typically between ages 12 and 13. This can be a challenging time when the peer group takes center stage. Adolescents often place emphasis on peer acceptance. It's quite common for adolescents to focus on their appearance and worry about how their peer group perceives them. For patients with BDD, this goes beyond the typical adolescent worries over appearance, reaching unhealthy levels.


Individuals with BDD are hyperfocused on perceived flaws, which often go unnoticed by others. The most common areas that patients with BDD focus on are the hair, skin, nose, chest, eyes, lips, and/or stomach, although they can focus on any area(s) of the body. These patients may worry about symmetry, size, and shape.


Patients with BDD become so focused on their perceived flaws that they feel threatened by them. These patients can't control their negative thoughts, despite a desire to do so, leading to significant distress and impairment in functioning. In fact, many patients with BDD feel as if they're defined by their perceived flaw(s). Beliefs about appearance and perceived flaws can become so significant that they reach a delusional level. Over time, these individuals can become socially isolated, afraid to leave their home for fear of being seen, judged, and/or ridiculed by others.


In some instances, individuals may become hyperfocused on someone else, such as a family member. When this happens, it's referred to as BDD by proxy (see BDD by proxy).


Snapchat dysmorphia

It's becoming more common for patients to ask plastic surgeons to surgically alter them so that they resemble Snapchat filters. Snapchat is a social media app in which pictures and messages are only available for others to view for a short time. Patients bring heavily edited selfies that have had a filter applied and ask surgeons to give them the look from the selfie. This phenomenon has been referred to as "Snapchat dysmorphia."


It's interesting to note that selfies are a driving force behind requests for surgery, with patients wanting surgery to look better in selfies. In individuals between ages 16 and 25, the need for a perfect selfie is so persistent that they spend an average of 16 minutes and 7 attempts to take an acceptable selfie.


Social media filters, paired with an overabundance of selfies, alter a person's perception of beauty and may trigger BDD. At this time, anyone with a smartphone, tablet, or computer can use filters or editing tools to remove imperfections in their appearance, almost instantly. Many people love this ability to change their appearance instantaneously because we live in a society that places emphasis on instant gratification. Due to this need, many patients requesting plastic surgery expect things to happen quickly, which is typically an unrealistic expectation.


It's also important to be aware that, in many cases, cosmetic procedures can't reproduce the look created by filters and editing tools. In many instances, these filters portray an image that's surgically unattainable.


Signs and symptoms

Patients' signs and symptoms depend on the degree of BDD. In milder cases, patients may describe themselves as unattractive, whereas those with severe BDD may describe themselves as monstrous. Individuals who have BDD can experience severe distress and, for some, signs and symptoms may be significant. It's unknown how or why symptoms progress over time, but the main symptom associated with BDD is obsessive thoughts about appearance. These individuals will spend hours each day focusing on the flaws they've identified. In general, patients with BDD will have low self-esteem, a tendency to avoid social situations, and problems with work and/or school.


The following compulsive or repetitive behaviors are also commonly seen in patients with BDD:


* camouflaging


* comparing themselves to others


* seeking surgery


* checking their appearance in the mirror


* skin picking


* excessive grooming


* excessive exercise


* frequently changing clothes


* excessive tanning


* excessive shopping.



Camouflaging involves the use of makeup to cover flaws, repetitively fixing clothing or using clothing to hide body parts, and/or covering body parts with the hand. Excessive shopping may be concomitant with camouflaging and can lead to financial difficulties.


Patients with BDD frequently compare themselves to others. Additionally, individuals with BDD may frequently ask others if they look okay or they may persistently insist that they're ugly or unattractive, which can lead to strained relationships. Some patients are drawn to mirrors and they'll excessively check on their perceived flaw(s). Excessive grooming may be seen as vain by those who are associated with the patient.


Individuals who excessively exercise or lift weights may have a type of BDD known as muscle dysmorphia (see Muscle dysmorphia).


Patients with BDD report feelings of shame, self-disgust, hopelessness, depression, anger, and anxiety. These individuals worry excessively about their appearance, reporting shame associated with the way they look. They also tend to fear rejection or humiliation. They may feel hopeless and distressed, which can escalate into suicidal ideation.


For many of these patients, plastic surgery feels like the solution to the way that they perceive themselves. Although they feel that surgery is their best option, plastic surgery often leads to increased distress. In many cases, patients with BDD who undergo surgery aren't satisfied with the results, causing them to feel like they need additional surgery, or they'll begin to focus on other areas of their body that they would like fixed. Another concern is that some patients will become addicted to surgery. It's important to prevent unnecessary surgery for these individuals because cosmetic treatment has been associated with negative outcomes.



The typical patient with BDD will suffer in silence for 10 years before seeking assistance and receiving the diagnosis of BDD. Asking these patients if they worry about minimal or nonexistent flaws won't be a beneficial diagnostic tool. This poor insight can lead to a resistance in acceptance of the diagnosis and/or treatment. In addition to individuals with BDD failing to seek treatment, awareness of this disorder is lacking among healthcare professionals and the public, leading to delays in diagnosis. In many instances, this disorder is missed or misdiagnosed.


Patients with BDD may be misdiagnosed as having:


* obsessive-compulsive disorder (OCD)


* social anxiety disorder


* major depressive disorder


* trichotillomania disorder (hair-pulling disorder)


* excoriation disorder (skin-picking disorder)


* agoraphobia


* generalized anxiety disorder


* schizophrenia and schizoaffective disorder


* olfactory reference syndrome (preoccupation with smelling bad)


* eating disorder.



Many patients with BDD are hesitant to discuss their thoughts and/or feelings because they're ashamed or embarrassed, making diagnosis a challenge. When clinicians are diagnosing a patient with BDD, they use the following criteria from the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, 5th edition:


* appearance preoccupations


* repetitive behaviors


* clinical significance


* differentiation from an eating disorder.



Diagnosis depends on a variety of factors, one of which is the amount of time spent focusing on perceived flaws. Patients diagnosed with BDD must spend at least 1 hour per day focusing on their perceived flaws. Although diagnosis hinges on a minimum of 1 hour per day focusing on flaws, many patients with BDD will spend 3 to 8 hours per day focusing on these flaws. The clinician diagnosing the patient with BDD will determine if he or she has repetitive behaviors, such as frequently applying makeup throughout the day. It's also important for clinicians working with these patients to determine if the "flaw" is easily visible. The clinician should determine if the symptoms affect the patient in a clinically significant way; for example, do the symptoms affect the patient's ability to work or go to school?



When treating patients with BDD, it's preferable to start treatment early before negative thoughts take hold.


Cognitive behavioral therapy (CBT) may be used as a treatment option for patients with BDD. The goal of CBT for these patients is the identification and recognition of unhealthy thoughts and then changing those thoughts. The patient learns to replace negative ways of thinking with positive ones. When patients use CBT, they're learning new ways to think about themselves. CBT has been shown to assist in the reduction of symptoms for patients with BDD. Studies have shown that CBT improves depressive symptoms, insight, quality of life, and global functioning. Research has shown that CBT is beneficial to patients with BDD in the short term, but more research needs to be conducted to determine its long-term effects.


In some cases, antianxiety and antidepressant medications may be prescribed. Thoroughly explain the medication to the patient, including the reason for use, potential adverse reactions, and how to take the medication. Monitor the patient for adverse reactions. Educate patients about the importance of taking all medications as prescribed. Treatment also involves assisting patients to be flexible with their thinking. We want to help them learn to tolerate their anxiety until it lessens.


It's important to be compassionate, patient, and flexible. The development of a strong, therapeutic relationship with the patient should take priority. If a strong relationship isn't developed, the patient may not respond appropriately. Help the patient identify his or her personal reasons for wanting to change. When doing this, it may be important to help the patient determine how BDD has impacted his or her life. The perceived flaws threaten these patients' sense of self-worth as human beings and cause them to feel uncomfortable in their body. BDD can lead to negative impacts on emotional, educational, and social functioning. Determining and developing the patient's level of insight will help guide care.


In more severe cases, the patient with BDD may require psychiatric hospitalization. Nursing care of the patient in the psychiatric hospital is dependent on organizational policies and procedures. Regardless of whether the patient is hospitalized, treatment by a mental health professional is important for the patient with BDD. When patients are being cared for by mental health professionals, encourage them to attend all treatment sessions because missed sessions can lead to a return or worsening of symptoms.



Maintaining employment and/or going to school can be a challenge for the individual with BDD. When these patients attempt to go to school or work, they may have trouble concentrating, spending much of their time focusing on perceived flaws or worrying about what others think about these flaws. They may spend hours researching surgeries and the best ways to cover up their flaws. In some cases, these patients may become housebound. Social anxiety can take hold, causing these individuals to avoid social situations due to worry over other people seeing their flaw(s). They start to believe that others are looking at them and talking about them. This can lead to difficulty forming or maintaining relationships, which may be strained due to the frequent need to seek reassurance from others and the mismatch between how others see the person with BDD and how the person views him- or herself.


Often, the patient with BDD will also experience anxiety disorders, depression, eating disorders, and/or OCD. In some instances, the patient with BDD may be misdiagnosed with one of these conditions due to an overlap of symptoms. Additionally, patients with BDD have an increased risk of both attempted and completed suicide. Approximately 80% of patients with BDD report suicidal thoughts and as many as one-fourth of these patients will attempt suicide. It's essential to assess these patients for suicidal ideation and treat them accordingly.


Shining a light

BDD is a hidden disorder, with many patients not seeking assistance, often unaware that they have a treatable condition. Nurses can help bring attention to BDD by educating patients about it, providing support and encouragement to patients with BDD, and conducting research to gain a better understanding of the disorder. Through research, nurses can greatly impact the future of patients with BDD.


BDD by proxy

BDD by proxy is a type of BDD in which the patient is hyperfocused on another person, such as a family member, friend, or even a stranger. These individuals worry excessively about another person's appearance. The excessive worry can negatively impact their daily lives and lead to a decreased quality of life. Treatment for these patients is the same as treatment for BDD.


Muscle dysmorphia

Muscle dysmorphia is a type of BDD in which the patient is preoccupied with his or her body build. This type of BDD is seen more often in men than women. These individuals worry about being weak and, as a result, may spend an excessive amount of time exercising. This condition is associated with increased rates of suicidality and substance abuse, and reports of a poor quality of life. Treatment for muscle dysmorphia is the same as for BDD and includes CBT as the treatment of choice.


consider this

HP is a 23-year-old female patient who's being seen at her primary care provider's office for a pre-op physical exam. Your patient assessment reveals that she's undergoing plastic surgery to fix her "misshapen nose." She reports that she's wanted to have her nose fixed for years but couldn't afford the procedure. Upon examining her nose, you find no abnormalities. You ask HP to clarify what the plastic surgeon will be doing to her nose and she states, "He'll be making my nose smaller and will fix the bump on the top of my nose."

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You ask HP about previous surgeries and she reports that this will be her first surgery, but not her last, because she needs to have the "excess skin" under her chin removed. While reviewing her history, you find that she's undergone many nonsurgical cosmetic procedures. You believe that she may have an inaccurate perception of her appearance and could benefit from further evaluation from the healthcare provider. You document your findings and relay your concerns to the healthcare provider for follow-up.


cheat sheet

Compulsive or repetitive behaviors seen in patients with BDD


* Camouflaging


* Comparing themselves to others


* Seeking surgery


* Checking their appearance in the mirror


* Skin picking


* Excessive grooming


* Excessive exercise


* Frequently changing clothes


* Excessive tanning


* Excessive shopping


cheat sheet

DSM-5 criteria


* Appearance preoccupations


* Repetitive behaviors


* Clinical significance


* Differentiation from an eating disorder


on the web

Anxiety and Depression Association of America

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Body Dysmorphic Disorder Foundation


International OCD Foundation


Mayo Clinic


INSTRUCTIONS Body dysmorphic disorder: The drive for perfection



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