body dysmorphia research questions

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Published: 07 June 2021

Prevalence of symptoms of body dysmorphic disorder (BDD) and associated features in Swiss military recruits: a self-report survey

Marie Drüge ORCID: orcid.org/0000-0001-5721-9327 1 ,
Gabriela Rafique 1 ,
Anne Jäger 1 &
Birgit Watzke 1

BMC Psychiatry volume 21 , Article number: 294 ( 2021 ) Cite this article

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Body dysmorphic disorder (BDD), defined as the obsessive idea that some aspect of one’s own body or appearance is severely flawed/deformed, is relatively common in the general population and has been shown to have strong associations with mood and anxiety disorders and substance abuse disorders. Furthermore, a previous study on symptoms of BDD among people in the military showed that muscles are an important area of preoccupation. Hence, this study aimed to 1. assess the prevalence of BDD symptoms in Swiss military recruits, 2. specify the areas of preoccupation, and 3. analyze associated features (depression and alcohol/drug abuse).

A total of 126 Swiss male military recruits (age: M = 20.12, SD = 1.09, range: 18–24) were examined using self-report measurements to assess symptoms of BDD, depression, alcohol/drug abuse.

The results showed that symptoms of BDD were relatively common (9.5% reached the cutoff value for probable BDD, 84% reported some symptoms), with the muscles as the most common area of preoccupation. A positive correlation (r = .38, p < .001) between depressive symptoms and symptoms of BDD was found, thus no correlation between alcohol/drug abuse and symptoms of BDD.

The results indicate a need to develop and implement measures for prevention (e.g. raising awareness among the military) and intervention in this specific population.

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Body dissatisfaction or a critical preoccupations with one’s own appearance (e.g. muscles) are considered normal to some extent, but when unwanted thoughts, i.e. intrusions, become too excessive or repetitive behavior becomes time-consuming and causes major distress, the diagnosis of body dysmorphic disorder (BDD) needs to be considered. As BDD onset typically occurs during adolescence, it is vital to identify vulnerable populations or settings with a higher prevalence or risk factors at a younger age in order to tailor specific screenings and/or interventions. In some countries military service including an initial physical examination is mandatory for all young men. Thus, the military might strengthen the focus on physical fitness and increase the vulnerability for being preoccupied with body features, especially with one’s owns muscles, making military personnel prone to a special subtype of BDD, the so-called muscle dysmorphia. To date, there is little research on BDD in the military context, therefore the prevalence of symptoms of BDD and associated factors in this specific population is of interest in the following study.

Body dysmorphic disorder

Preoccupation with the appearance is relatively common: In a representative sample of 2552 participants of the general population, 27% percent of the males and 41% of the females reported being preoccupied with the appearance of at least one body part [ 1 ], without meeting all criteria of body dysmorphic disorder (BDD). According to the DSM-5 [ 2 ] BDD, describes the preoccupation with one or more «defects or flaws» of one’s own body part(s) or appearance, which are not apparent to others. This perception leads to repetitive and time-consuming behaviors (such as mirror checking, excessive exercising) or mental acts (such as comparing oneself to others) of some sort. These preoccupations may cause severe educational or occupational dysfunction or social isolation but do not meet the diagnostic criteria of an eating disorder. In the DSM-5, BDD is categorized in the obsessive-compulsive-spectrum [ 2 ]. BDD is highly associated with comorbidities such as mood or anxiety disorders [ 3 ], and it is associated with a high burden of disease such as impaired psychosocial functioning or high suicide risk. In a prospective study of up to 4 years on 185 patients with BDD, Phillips and Menard [ 4 ] analyzed suicide risk among individuals with BDD: 57.8% of respondents reported suicidal ideation, and 2.6% attempted suicide within one year. Two patients died by suicide throughout the study [ 4 ].

Muscle dysmorphia

In the DSM 5 there are two specifiers for BDD: One is with or without muscle dysmorphia, the other differs with or without insight. In individuals with muscle dysmorphia the preoccupation is focused on the muscles or the body built [ 2 ]. The idea that their body build is too small or insufficiently muscular might lead towards specific dieting (e. g. proteins), or physical activities (e. g. weightlifting) to increase size and definition of the muscles. Also the preoccupations may cause avoidance (e.g. avoiding situations where the body is exposed) or safety behaviors (e.g. giving up social activities to continue with time-consuming work-out). First described in 1993, Pope et al. [ 5 ] conducted a survey to analyze the body images of 108 male body builders; they did not examine BDD or muscle dysmorphia but found something described as a “reverse anorexia” syndrome in nine (8.3%) of the subjects, where the body builders believed that they appeared small and weak even though they were actually tall and muscular. This could be interpreted as a form of muscle dysmorphia.

Point prevalence

BDD has prevalence rates ranging from 1.7–2.9% [ 1 , 6 ] and an overall weighted prevalence in the community of 1.9% [ 7 ] . As a systematic review found slightly higher prevalences for men than for women [ 7 ], some found them to be similar (2.4% vs. 2.2%), but gender differences in the areas of preoccupation have been found (e.g., muscle dysmorphia occurs almost exclusively in males) [ 8 ]. Prevalences vary in different samples, such as in student populations (3.3%) or in psychiatric outpatients (5,8%), and the prevalence reached up to 20.1% among patients undergoing rhinoplasty surgery [ 7 ]. Point prevalences for muscle dysmorphia are also higher in professional male weightlifters [ 5 , 9 ].

Comorbidity

Gunstad and Phillips [ 3 ] gave an overview of the lifetime axis I comorbidity rates in published studies of BDD; the most common comorbidities using Structured Clinical Interviews for DSM-III-R (SCID-P) were major depression (range: 8–82%), obsessive compulsive disorder (OCD; range: 6–78%), social phobia (range: 12–69%), and substance use disorders (range: 21–36%). Against the background of the range of comorbidities, they examined comorbidities in 293 patients with BDD; the most common comorbidity was major depression (75.5%), followed by social phobia (36.5%), OCD (32.1%) and substance use disorders (alcohol: 20.5%; other drugs: 17.1%). Furthermore, a correlation between the number of comorbid disorders and the functional impairment of a patient was found.

Gender differences in BDD

Phillips, Menard and Fay [ 8 ] analyzed similarities and differences between 63 men and 137 women suffering from BDD. Though their findings lack generalizability (e.g. due to recruitment of sample limited to northeastern United States), the results are still noteworthy. Men suffering from BDD were significantly older, more likely to be single, and more likely to have their own household than women. The age at onset is within adolescence, thus men had an older age at onset than women ( M = 17.9, SD = 6.9 vs. M = 15.9, SD = 7.1). Compared to women, the areas of preoccupation among men were more often their genitals (17.5%), body build (36.5%), and thinning hair/balding (36.5%). Men were also obsessed with their jaw (17.5%), nose (38.1%), skin (69.8%), belly (19.0%), and eyes (19.0%), but no differences were found for these areas between men and women [ 8 ]. Men were also more likely to have a comorbid substance use disorder than women [ 8 ]. Nevertheless, there are few studies focusing on male samples or gender-related research questions.

Symptoms of BDD in the military

The military requires physical and mental fitness, and pursuing a military career may lead to a rather dysfunctional attention to physical fitness. As mentioned above, if preoccupations about the body build being too small or insufficiently muscular lead through specific behavior patterns to distress and impairment, BDD might occur. Also, the age at BDD onset for men ( M = 17.9, SD = 6.9) is around the period when the initial test of fitness for the military service takes place. Thus, Campagna and Bowsher [ 10 ] conducted a survey to determine the prevalence of BDD and muscle dysmorphia in enlisted U.S. military personnel. A total of 13% of male and 21.7% of female participants reported body dysmorphic symptoms in this specific sample [ 8 ]. Further analysis showed muscle dysmorphia in 12.7% of the males and 4.2% of the females. As this first study only used self-report measure, and given the complexity to distinguish between body dissatisfaction, eating disorders and BDD, the results should be interpreted with caution. The measures used are only screening tools, and shouldn’t be interpreted as prevalence rates of BDD or MD. Still, it shows, that in this population the preoccupations about body dissatisfaction might be high and focused on the body built or muscular size, especially for men. Recent research on the prevalence of BDD and associated features (e.g., depression) lacks in specific samples (e.g. specific professions), which would be necessary to identify settings and populations where there is a high risk of BDD. This study aims to 1. assess the prevalence of BDD symptoms in Swiss military recruits, 2. specify the areas of preoccupation with particular regard to muscle dysmorphia in this sample, and 3. analyze associated features, such as depressive symptoms and alcohol/drug abuse. Due to feasibility, within the probable associated features the focus was set on depressive symptoms and alcohol/drug abuse.

Procedure and sample

We conducted a cross-sectional study aiming at a full sample of recruits of one cohort (company) at the recruit school in Chur, Switzerland. This company of infantry entered the school in 2017, and it was their first year of training when the assessment took place. The recruits were asked to participate voluntarily. A paper-pencil questionnaire was handed out to all recruits on the same day at the recruit school. All recruits participated. The nonclinical sample consisted of 126 male Swiss military recruits (age: M = 20.12 years, SD = 1.09; range: 18–24). Most of the recruits reported being single (74.6%), some of the recruits were in a relationship (23.0%), and two were married (1.6%). Regarding educational level, 69.8% had completed compulsory education, 15.1% had a vocational baccalaureate, 14.3% had baccalaureate, and one recruit had finished a university degree. All recruits had to pass a test on fitness before they began their military service, indicating that from a medical point of view, the recruits were mentally, intellectually and physically fit for service.

Instruments

In the current study, the prevalence of symptoms of BDD and associated features such as depression, alcohol abuse, and drug abuse were examined using self-reports in a nonclinical, representative sample of Swiss military recruits. To measure BDD, we used a standardized self-report questionnaire for BDD symptoms (Fragebogen Körperdysmorpher Symptome, FKS, [ 11 ]). The FKS contains 17 items scored on a 5-point Likert scale (0–4) and one open-ended question to specify the body part (the cutoff value of 14 is used to discriminate BDD; this cutoff has a high sensitivity of 0,87 and a high specificity of 0,93, Footnote 1 α = .88). To measure associated features, we applied standardized self-report questionnaires for depression, including the Allgemeine Depressionsskala (ADS [ 12 ];, the German version of the Center for Epidemiological Studies Depression Scale (CES-D; originally published by Radloff [ 13 ]), which includes 20 item-scores utilizing a Likert scale (cutoff = 23, α = .82, high specificity). To measure alcohol abuse, we applied the Alcohol Use Disorders Identification Unit (AUDIT [ 14 ];), which contains 10 items scored on a 5-point Likert scale (0–4) (cutoff = 15–20; α = .83). To measure drug abuse, we used a single dichotomous question [ 15 ]. In the current sample, the internal consistencies were good for FKS (α = .82) and for ADS (α = .84), and acceptable for AUDIT (α = .74).

Data analysis

The collected data were analyzed using descriptive statistics and correlations (Spearman rank correlation) to analyze links between BDD and associated features. For categorical data, crosstabulations and chi-square tests were used to analyze relations between variables (BDD x associated features) based on the cutoff values.

Prevalence of symptoms of BDD

Twelve recruits (9.5%) reached the cutoff value of 14 for the FKS, which indicates the presence of probable body dysmorphic disorder with high sensitivity and specificity. Of these twelve recruits, ten reported being single, and two were in a relationship. Eleven recruits were living with their parents, and one was living alone. Seven of the recruits were born as an only child, the other five were born as the last of two or three children. Regarding educational level, eight recruits had completed compulsory education, two had obtained a vocational baccalaureate, and two had finished a baccalaureate program. Six recruits reported, that they had undergone plastic surgery. Furthermore, 106 recruits (84%) showed some symptoms of BDD: 22 recruits (17.5%) scored 10–13 points, 36 (28.6%) scored 5–9 points, and 49 recruits (38.9%) 1–4 points.

Specifying the areas of preoccupation, specifically muscle dysmorphia

Taking the area of preoccupation into account, five of the twelve recruits with probable BDD specified their muscles as the area of preoccupation (see Fig. 1 ); four of the twelve reported their genitals; two their hair, eyes, ears, nose and/or skin; and two mentioned being concerned with their belly and/or the jaw. Five of the twelve recruits reported being preoccupied with only one body part, another five recruits stated two body parts, and two recruits reported three body parts.

Areas of preoccupation among the recruits with BDD

Analyzing associated features

Nine recruits reached the cutoff-score for the ADS, indicating a probable depression with a high specificity. In general, the prevalence of symptoms of BDD correlates positively with depressive symptoms (r = .38, p < .01). Furthermore, the results of the AUDIT indicated hazardous or harmful alcohol use among 44 recruits (35.5%). A total of 106 (83.5%) reported the potential for a hazardous use. Fifty-seven recruits (44.88%) had taken an illegal drug at least once, and 38 (29.9%) had taken drugs more than once. No significant relationships between those who reached the cut-off scores for BDD and substance abuse were found.

Our study shows that self-reported symptoms of BDD are common in military recruits. The prevalence of self reported probable BDD herein (9.5%) is substantially higher than the point prevalence of 1.7–2.9% in a general (German) population [ 1 , 6 ]. Although a comparison of prevalence rates of BDD and muscle dysmorphia would require a structures diagnostic interview to ensure the diagnosis, especially since preoccupations about the own appearance are relatively common in the community [ 1 ], the results might indicate the population of military recruits as a population with higher prevalences. Our finding is comparable to the 13% self-reported prevalence among males enlisted in the U.S. military [ 10 ]. It is important to note that we exclusively used self-reported data based on the FSK as screening tool in order to identify individuals who might suffer from BDD symptoms instead of conducting diagnostic assessments according to the ICD or the DSM. This may have led to an over- or underestimation of BDD diagnosis in our results - although the specificity and sensitivity values reported herein were high based on the German validation study of the FSK. Additionally, since BDD is a shame-related disorder, anonymized self-assessment tools may also be helpful for obtaining honest responses – perhaps even more honest than the responses obtained from personal clinical interviews. However, future studies should include structured clinical interviews and ICD- or DSM-based diagnostical assessments to further investigate the prevalence of BDD in recruits. As expected, based on earlier studies (e.g., [ 8 , 10 ]), the main area of preoccupation, in recruits showing BDD-symptoms, was their muscles. Contrary to some previous findings [ 8 ], the second most named area of preoccupation was their own genitals, as reported by 33.3% of the recruits. In the largest study to date looking at gender similarities and differences in 137 women and 63 men, Philips, Menard and Fay [ 8 ] found that only 17,5% of the male individuals named their genitals as the area of preoccupation. It would be interesting to further analyze whether age has an impact on the areas of preoccupation, as the sample of this study is substantially younger (M = 20.12 years, SD = 1.09, range: 18–24) than the 63 participants (M = 35.7 years, SD = 11.2) examined in Philips, Menard and Fays’ study [ 8 ]. Conversely, in our sample, the recruits reported less preoccupation with their hair (16.7%) than those in the study by Philips, Menards and Fays [ 8 ]. Again, age might have an impact, as getting bald might be an issue slightly later in life.

According to previous finding, a positive correlation between symptoms of BDD and depressive symptoms was expected, although the here found magnitude of the association was smaller than in previous research [ 3 ]. Nevertheless, these results are alarming, as recruits are expected to be mentally, intellectually and physically fit for service and for war. Forty-four recruits (35.5%) described hazardous or harmful alcohol use, which should be taken seriously. In regards to alcohol and/or drug abuse, no differences were found between those who were below or above the threshold for probable BDD. This is an unexpected result, as Gunstad and Philips [ 3 ] found high rates of substance abuse in individuals suffering from BDD. However, the rates of alcohol and drug abuse were generally so high throughout the sample that differences between clinical and nonclinical screened groups might have been too small. As in this sample the internal consistency of the AUDIT was only acceptable, these results need to be interpreted with caution. Future studies could also assess other common comorbidities such as other obsessive-compulsive spectrum disorders or social anxiety disorder for the overall picture.

Given our results showing the estimated prevalences of probable BDD, it is important to discuss which generalizations can be derived of our data. The clustered sample represents the full participation of a military unit and therefore can be assumed as representative for Swiss military recruits. Therefore, it bears the question to what extent our results are representative for young (Swiss) men in general? Approximately 2/3 of men are obliged to carry out military service in Switzerland, with the exception of those who have health issues (all recruits have to pass a test of physical and mental health before they begin their military service) and those who prefer social services as a substitute path. This results in approximately half of the Swiss male population, ca 20 years old, become a recruit. Thus, the sample represents a clustered sample of 50% of young Swiss men who are deemed physically and mentally fit and whose physical fitness is most likely above average (e.g., they have the ability to march). It is an open question whether symptoms of BDD would be more or less prevalent in an unselected sample of young men, i.e., especially in those with health concerns. Therefore, future studies could include a male age-controlled control group, to focus on differences in the setting and to further analyze whether general body dissatisfaction and/or BDD is more common in military recruits or not.

Referring to the setting of military services for which our results seem to be a reliable estimation, several implications have to be taken into account. Given that approximately one out of ten recruits shows symptoms of BDD and given that BDD typically occurs during adolescence, it appears vital to screen candidates for BDD symptoms before they begin military service. It seems also essential to increase awareness in recruits about BDD (e.g., with information materials) and to train military doctors, specifically with respect to screening BDD, regarding available information/psychoeducation, firstline treatments, and how to engage patients in treatment for BDD. This may be an important avenue to improve detection of BDD symptoms and secure access to treatment for young men suffering from symptoms of BDD. From a research perspective, the development of short and feasible screening tools with proven psychometric characteristics can help facilitate this task.

Symptoms of BDD are common among Swiss military recruits, with their muscles being the main area of preoccupation, and showing a positive correlation with depressive symptoms. Further research is required and the design of the study could be improved upon (e.g., implementing diagnostic interviews). The results point towards the importance of building up an increased awareness of BDD among military recruits and leaders.

Availability of data and materials

The datasets generated and/or analyzed during the current study are not publicly available due to confidentiality, but are available on reasonable request from the corresponding author. The set of questionnaires used in this study only included published questionnaires (FKS [ 11 ], ADS [ 12 ], AUDIT [ 14 ], One-Question Screening for Drug Abuse [ 15 ], see methods section for details). As there was no German version of the One-Question-Screening [ 15 ], we translated it into German.

Regarding the specificity of the FKS, Buhlmann et al. [ 9 ] reports a specificity of 0.07. This is due to a printing error and was corrected to 0.93 (personal communication with Ulrike Buhlmann, July 2020).

Abbreviations

Allgemeine Depressionsskala

Alcohol Use Disorders Identification Unit

Body Dysmorphic Disorder

Diagnostic and Statistical Manual of Mental Disorders

Fragebogen körperdysmorpher Störungen

International Statistical Classification of Diseases and Related Health Problems

Obsessive Compulsive Disorder

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Acknowledgments

We thank all participants of the cohort at the recruitment school in Chur for participation. We also thank Olenka Dworakowski, University of Zurich, for proofreading, and her highly constructive comments on the manuscript.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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All Authors conducted literature searches and provided summaries of previous research studies. GR and AJ author designed the study. MD and GR author derived the research questions and conducted the statistical analysis. MD and BW author wrote the first draft of the manuscript and all authors contributed to and have approved the final manuscript.

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Drüge, M., Rafique, G., Jäger, A. et al. Prevalence of symptoms of body dysmorphic disorder (BDD) and associated features in Swiss military recruits: a self-report survey. BMC Psychiatry 21 , 294 (2021). https://doi.org/10.1186/s12888-021-03288-x

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Incorporation of social media questions in body dysmorphic disorder scales: A proposed revision

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1 Department of Dermatology, Warren Alpert Medical School at Brown University, Providence, Rhode Island, USA.
2 Department of Dermatology, Warren Alpert Medical School at Brown University, Providence, Rhode Island, USA; GK Dermatology, PC, South Weymouth, Massachusetts, USA. Electronic address: [email protected].
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DOI: 10.1016/j.clindermatol.2022.02.015

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A Therapist’s Guide for the Treatment of Body Dysmorphic Disorder

by Andrea Hartmann, PhD, Jennifer Greenberg, PsyD, & Sabine Wilhelm, PhD

Overview of CBT for BDD and its empirical support

Most patients with body dysmorphic disorder (BDD) do not seek psychiatric/psychological care, but look for costly surgical, dermatologic, and dental treatments to try to fix perceived appearance flaws (e.g., Phillips, et al., 2000), that often worsen BDD symptoms (e.g., Sarwer & Crerand, 2008). Two empirically-based treatments are available for the treatment of BDD: serotonin reuptake inhibitors (SRIs) ( click here to learn more about medication treatment for BDD ) and cognitive-behavioral therapy (CBT). Several studies have found CBT to successfully reduce BDD severity and related symptoms such as depression (McKay, 1999; McKay et al., 1997; Rosen et al., 1995; Veale et al., 1996; Wilhelm et al., 1999; Wilhelm et al., 2011; Wihelm et al., 2014).

CBT models of BDD (e.g., Veale, 2004; Wilhelm et al., 2013) incorporate biological, psychological, and sociocultural factors in the development and maintenance of BDD. The model proposes that individuals with BDD selectively attend to minor aspects of appearance as opposed to seeing the big picture. This theory is informed by clinical observations and neuropsychological (Deckersbach et al., 2000) and neuroimaging findings (Feusner et al., 2007; Feusner et al., 2010). Individuals with BDD also overestimate the meaning and importance of perceived physical imperfections. For example, when walking into a restaurant, a patient with BDD who has concerns about his nose might think, “Everyone in the restaurant is staring at my big, bulbous nose.” Patients are also more likely misinterpret minor flaws (e.g., perceived asymmetry) as major personal flaws (e.g., “If my nose is crooked, I am unlovable”) (Buhlmann et al., 2009; Veale, 2004). Self-defeating interpretations foster negative feelings (e.g., anxiety, shame, sadness) that patients try to neutralize with rituals (e.g., excessive mirror checking, surgery seeking) and avoidance (e.g., social situations). Because rituals and avoidance may temporarily reduce painful feelings they are negatively reinforced and thus maintain maladaptive beliefs and coping strategies.

CBT for BDD typically begins with assessment and psychoeducation, during which the therapist explains and individualizes the CBT model of BDD. In addition, CBT usually includes techniques such as cognitive restructuring, exposure and ritual prevention, and relapse prevention. Some CBT for BDD includes perceptual (mirror) retraining. A modular CBT manual (CBT-BDD; Wilhelm et al., 2013) has been developed to target core symptoms of BDD and to flexibly address symptoms that affect some, but not all, patients. Additional modules might address depression, skin picking/hair plucking, weight and shape concerns, and cosmetic surgery seeking (e.g. Wilhelm et al., 2013). CBT-BDD has been shown to be effective in open (Wilhelm et al., 2011) and randomized control trials (Wilhelm et al., 2014).

Assessment, motivational assessment, and psychoeducation

CBT begins with an assessment of BDD and associated symptoms. Clinicians should inquire about BDD-related areas of concern, thoughts, behaviors, and impairment. It is important to ask specifically about BDD symptoms as it often goes undetected in clinical settings (e.g., Grant et al., 2002) due to embarrassment and shame. Clinicians should be aware of clues in clinical presentation such as appearance (e.g., scarring due to skin picking) and behaviors (e.g, wearing camouflage), ideas or delusions of reference (e.g., feelings that people talk about them, stare at them), panic attacks (e.g., when looking into the mirror), depression, social anxiety, substance abuse and suicidal ideation as well as being housebound. Additionally, differential diagnosis should be clarified in a structured clinical interview including eating disorders, obsessive compulsive disorder, depression, and social phobia. Given the high rates of depression and suicidality in BDD, it is critical to evaluate depression and suicidality at the onset and regularly throughout treatment.

For patients reluctant to try CBT or who hold highly delusional appearance beliefs, the therapist should incorporate techniques from motivational interviewing (MI; Miller & Rollnick, 2003) that have been adapted for the use in BDD (Wilhelm et al., 2013). In a first step, the therapist should empathize with the patient’s body image-related distress instead of directly questioning the validity of the beliefs (“I see that you really suffer because you are so worried because of the way you look. Let’s try to reduce this distress.”). Also, non-judgmental Socratic questioning can be employed (“What might be the advantages of trying CBT for BDD?“). The therapist can also discuss the discrepancy between BDD symptoms and the patient’s goals (“What should your life look like 10 years from now?“). In particular, for patients with poor insight it might be more helpful to address the usefulness of beliefs instead of the validity (e.g., “Are your beliefs preventing you from participating in activities you enjoy?“). MI strategies often need to be used throughout treatment.

Next, the therapist should provide psychoeducation about BDD, such as its prevalence, common symptoms, and differences between body image and appearance. Then, the therapist and patient develop an individualized model of BDD based on the patient’s specific symptoms. Such models include theories of how body image problems develop (including biological, sociocultural and psychological factors) (Wilhelm et al., 2013). It is important to explore factors in the patient’s current life that are serving to maintain body image concerns, including triggers for negative thoughts about appearance, interpretations of these thoughts, emotional reactions, and (maladaptive) coping strategies. This will help to inform the treatment and which specific modules are needed.

Cognitive strategies

Cognitive strategies include identifying maladaptive thoughts, evaluating them, and generating alternative thoughts. Therapists introduce patients to common cognitive errors in BDD, such as “all-or-nothing thinking” (e.g., “This scar makes me completely disgusting”) or “mindreading” (e.g., “I know my girlfriend wishes I had better skin”). Patients are then encouraged to monitor their appearance-based thoughts in and outside of the session and identify cognitive errors (e.g., “Why am I so nervous about riding the subway?” “I know others are staring at my nose and thinking how ugly it looks”. Cognitive distortion: “personalization”). After the patient has gained some skill in identifying maladaptive thoughts and cognitive errors, the therapist can start to evaluate thoughts with the patient (e.g., Rosen et al., 1995; Veale et al., 1996; Wilhelm et al., 2013). While it is often helpful to evaluate the validity of a maladaptive thought (e.g., “What is the evidence others are noticing or judging my nose?”), it can also be beneficial to examine its usefulness (e.g. “Is it really helpful for me to think that I can only be happy if my nose were straight?”; Wilhelm et al., 2013), particularly for patients with poor insight. Once the patient has become adept at identifying and restructuring automatic appearance-related beliefs, deeper level (core) beliefs should be addressed. Common core beliefs in BDD include I’m unlovable” or “I’m inadequate” (Veale et al., 1996). These deeply held beliefs filter a patient’s experiences, and if not addressed, can thwart progress and long-term maintenance of gains. Core beliefs often emerge during the course of therapy. They can also be identified using the downward arrow technique, which involves the therapist asking repeatedly about the worst consequences of a patient’s beliefs (e.g., for the thought “People will think that my nose is huge and crooked,” the therapist would ask the patient, “What would it mean if people noticed your nose was big/crooked?”) until the core belief is reached (e.g., “If people noticed that my nose was big/crooked, they wouldn’t like me and this would mean that I am unlovable.”; Wilhelm et al., 2013). Negative core beliefs can be addressed through cognitive restructuring, behavioral experiments, and strategies such as the self-esteem pie, which helps patients learn to broaden the basis of their self-worth to include non-appearance factors (e.g., skills, achievements, moral values).

Exposure and ritual prevention (E/RP)

Prior to beginning E/RP, the therapist and patient should review the patient’s BDD model to help identify the patient’s rituals (e.g., excessive mirror checking) and avoidance behaviors (e.g., avoiding riding the subway) and discuss the role of rituals and avoidance in maintaining his symptoms. The therapist and patient jointly develop a hierarchy of anxiety provoking and avoided situations. Patients often avoid daily activities, or activities that could reveal one’s perceived flaw, including shopping (e.g., changing in a dressing room), going to the beach, intimate sexual encounters, going to work or class, or accepting social invitations. The hierarchy should include situations that would broaden a patient’s overall social experiences. For example, a patient might be encouraged to go out with friends twice per week instead of avoiding friends on days when he thought his nose looked really “huge.” The first exposure should be mildly to moderately challenging with a high likelihood for success. Exposure can be very challenging for patients, therefore, it is important for the therapist to provide a strong rationale for exposure, validate the patient’s anxiety while guiding him towards change, be challenging and encouraging, be patient and a cheerleader, and quickly incorporate ritual prevention. To reduce rituals, patients are encouraged to monitor the frequency and contexts in which rituals arise. The therapist then teaches patients strategies to eliminate rituals by first learning how to resist rituals (e.g., waiting before checking the mirror) or reduce rituals (e.g., wearing less makeup when out in public). The patient should be encouraged to use ritual prevention strategies during exposure exercises. It is often helpful to set up exposure exercises as a “behavioral experiment” during which they evaluate the validity of negative predictions (e.g., if I don’t wear my hat, someone will laugh at my thinning hair”). The goal of E/RP is to help patients practice tolerating distress and acquire new information to evaluate their negative beliefs (Wilhelm et al., 2013).

Perceptual retraining

Individuals with BDD often have a complex relationship with mirrors and reflective surfaces. A patient may vacillate between getting stuck for hours in the mirror scrutinizing, grooming, or skin picking, and active avoidance of seeing his reflection. Usually patients focus only on the body parts of concern and get very close to the mirror, which magnifies perceived imperfections and maintains maladaptive BDD beliefs and behaviors. Furthermore, patients tend to engage in judgmental and emotionally charged self-talk (“Your nose looks so disgusting”). Perceptual retraining helps to address distorted body image perception and helps patients learn to engage in healthier mirror-related behaviors (i.e., not getting too close to the mirror, not avoiding the mirror entirely). The therapist helps to guide the patient in describing his whole body (head to toe) while standing at a conversational distance from the mirror (e.g., two to three feet). Instead of judgmental language (e.g., “My nose is huge and crooked.”), during perceptual (mirror) retraining, patients learn to describe themselves more objectively (“There is a small bump on the bridge of my nose”). The therapist encourages the patient to refrain from rituals, such as zoning in on disliked areas or touching certain body parts. Perceptual retraining strategies can also be used to broaden patients attention in other situations in which the patient selectively attends to aspects of their and others’ appearance (e.g., while at work or out with friends). Patients are encouraged to practice attending to other things in the environment (e.g., the content of the conversation, what his meal tastes like) as opposed to his own or others’ appearance (Wilhelm et al., 2013).

Brief overview over additional modules

Specific treatment strategies may be necessary to address symptoms affecting some but not all patients including: skin picking/hair pulling, muscularity and shape/weight, cosmetic treatment, and mood management (Wilhelm et al., 2013). Habit reversal training can be used to address BDD-related skin picking or hair pulling. Patients with significant shape/weight concern, including those suffering from muscle dysmorphia often benefit from psychoeducation and cognitive-behavioral strategies tailored to shape/weight concerns. Therapists can use cognitive and motivational strategies to address maladaptive beliefs about the perceived benefits of surgery while at the same time helping the patient to nonjudgmentally explore the pros and cons of pursuing cosmetic surgery (Wilhelm et al., 2013). Depression is common in patients with BDD and may become treatment interfering (Gunstad & Phillips, 2003). Patients with significant depression can benefit from activity scheduling, as well as cognitive restructuring techniques for more severely depressed patients (Wilhelm et al., 2013).

Relapse Prevention

Treatment ends with relapse prevention focused on consolidation of skills and helping patients plan for the future. Therapists help patients expect and respond effectively to upcoming challenges (e.g., starting college, job interview, dating). Therapists may recommend self-therapy sessions in which patients set time aside weekly to review skills and set upcoming BDD goals. Booster sessions can be offered after treatment ends as a way to periodically assess progress and review CBT skills as needed (Wilhelm et al., 2013).

Buhlmann, U., Teachman, B. A., Naumann, E., Fehlinger, T., & Rief, W. (2009). The meaning of beauty: implicit and explicit self-esteem and attractiveness beliefs in body dysmorphic disorder. Journal of Anxiety Disorders, 23 , 694-702.

Deckersbach, T., Savage, C. R., Phillips, K. A., Wilhelm, S., Buhlmann, U., & Rauch, S. L. (2000). Characteristics of memory dysfunction in body dysmorphic disorder. Journal of the International Neuropsychology Society, 6 , 673-681.

Feusner, J. D., Bystritsky, A., Hellemann, G., & Bookheimer, S. (2010). Impaired identity recognition of faces with emotional expressions in body dysmorphic disorder. Psychiatry Research, 179 , 318-323.

Feusner, J. D., Townsend, J., Bystritsky, A., & Bookheimer, S. (2007). Visual information processing of faces in body dysmorphic disorder. Archives of General Psychiatry, 64 , 1417-1425.

Grant, J. E., Kim, S. W., & Crow, S. J. (2001). Prevalence and clinical features of body dysmorphic disorder in adolescent and adult psychiatric inpatients. Journal of Clinical Psychiatry, 62 , 517-522.

Gunstad, J., & Phillips, K.A. (2003). Axis I comorbidity in body dysmorphic disorder. Comprehensive Psychiatry, 44 , 270-276.

McKay, D. (1999). Two-year follow-up of behavioral treatment and maintenance for body dysmorphic disorder. Behavior Modification, 23 , 620-629.

McKay, D., Todaro, J., Neziroglu, F., Campisi, T., Moritz, E.K., Yaryura-Tobias, J.A. (1997). Body dysmorphic disorder: A preliminary evaluation of treatment and maintenance using exposure with response prevention. Behaviour Research and Therapy, 35 , 67-70.

Miller, W.R. & Rollnick, S. (2002). Motivational interviewing: Preparing people for change (2nd edition) . New York: Guilford Press.

Phillips, K. A., Dufresne, R. G., Jr., Wilkel, C. S., & Vittorio, C. C. (2000). Rate of body dysmorphic disorder in dermatology patients. Journal of the American Academy of Dermatolology, 42 , 436-441.

Phillips, K. A., & Hollander, E. (2008). Treating body dysmorphic disorder with medication: evidence, misconceptions, and a suggested approach. Body Image, 51 , 13-27.

Rosen, J.C., Reiter, J., & Orosan, P. (1995). Cognitive-behavioral body image therapy for body dysmorphic disorder. Journal of Consulting and Clinical Psychology, 63 , 263-269.

Sarwer, D. B., & Crerand, C. E. (2008). Body dysmorphic disorder and appearance enhancing medical treatments. Body Image, 5 , 50-58.

Veale, D. (2004). Advances in a cognitive behavioural model of body dysmorphic disorder. Body Image, 1, 113-125.

Veale, D., Gournay, K., Dryden, W., Boocock, A., Shah, F., Willson, R. & Walburn, J. (1996).Body dysmorphic disorder: A cognitive behavioural model and pilot randomized control trial. Behaviour Research and Therapy, 34 , 717-729.

Wilhelm, S., Otto, M. W., Lohr, B., & Deckersbach, T. (1999). Cognitive behavior group therapy for body dysmorphic disorder: a case series. Behavior Research and Therapy, 37 , 71-75.

Wilhelm, S., Phillips, K. A., Didie, E., Buhlmann, U., Greenberg, J. L., Fama, J. M., Keshaviah, A., & Steketee, G. (2014). Modular Cognitive-Behavioral Therapy for Body Dysmorphic Disorder: A Randomized Controlled Trial. Behavior Therapy, 45 , 314–327.

Wilhelm, S., Phillips, K. A., Fama, J. M., Greenberg, J. L., & Steketee, G. (2011). Modular cognitive-behavioral therapy for body dysmorphic disorder. Behavior Therapy, 42 , 624-633.

Wilhelm S., Phillips K.A., & Steketee G. (2013). A cognitive behavioral treatment manual for body dysmorphic disorder . New York: Guilford Press.

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This is a recognised screening questionnaire for BDD. It is based on the ‘Cosmetic Procedure Screening Questionnaire’, or ‘Body Image Questionnaire’ in non-cosmetic settings and is designed to screen for Body Dysmorphic Disorder. It can also be used as an outcome measure in treating BDD. More information can be found here .

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About this test

This questionnaire has two main uses.

It can be used as a screening questionnaire to tell whether you might have BDD.
The questionnaire can also measure the severity of your symptoms, so you can use it before and after any treatment and provide feedback on whether your symptoms have improved or not. It comprises just 9 items. The range is 0-72, where 72 is the most severe.

Before you take the test, it’s important that you note that:

Only a trained health professional can diagnose BDD, although the questionnaire can help guide you and your health professional.
The questionnaire assumes that you do NOT have a disfigurement or a defect that is easily noticeable. The judgment on how noticeable your feature(s) can be made by a health professional.

The questionnaire was developed by David Veale, Nell Ellison, Tom Werner, Rupa Dodhia, Marc Serfaty and Alex Clarke (2012) Development of a cosmetic procedure screening questionnaire (COPS) for Body Dysmorphic Disorder . Journal of Plastic Reconstructive and Aesthetic Surgery, 65 (4), 530-532.

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What Is Body Dysmorphia?

Frequently asked questions.

Body dysmorphic disorder (BDD), also called body dysmorphia , is a mental health condition that involves an overwhelming preoccupation with one’s body and appearance. Someone with BDD may focus excessively on minor physical flaws or worry about perceived flaws that others don’t notice.

NickyLloyd / Getty Images

In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), BDD is listed within the category of obsessive-compulsive and related disorders. This means it involves both obsessions (intrusive, persistent thoughts) and compulsions (actions that someone performs repeatedly in an attempt to reduce anxiety).

Learn more about body dysmorphia, including symptoms, causes, and available treatment options.

Prevalence of Body Dysmorphic Disorder

Estimates suggest that up to 4% of the U.S. population meets the diagnostic criteria for body dysmorphic disorder. It is most common among people age 15–30.

People with body dysmorphia worry excessively about minor or nonexistent flaws in their body and/or face. To "fix" those flaws, they may go to extreme lengths, such as drastically altering their looks with plastic surgery .

Research suggests that people with BDD often spend three to eight hours a day worrying about their perceived physical imperfections. Any body part may become a target for these worries. However, people with body dysmorphia are most likely to worry about their skin, nose, or hair.

Common symptoms of body dysmorphia include:

Extreme preoccupation with physical flaws that are either very minor or imagined
Spending an excessive amount of time covering perceived flaws with makeup, different outfits, or new hairstyles
Buying products or getting plastic surgery to alter one's appearance
Checking the mirror excessively or avoiding mirrors
Trying to hide certain body parts with clothing or accessories
Repetitive behaviors, such as picking at their skin
Needing constant reassurance from others about physical appearance
Worrying excessively about appearing "ugly" or unattractive
Constantly comparing one's looks to others

Someone with body dysmorphia may feel so consumed with thoughts about their looks that they neglect other areas of their life. They may even avoid school, social events, dating, or work out of fear of being judged for their looks.

When left untreated, BDD can lead to serious negative consequences. Over half of people with BDD are unmarried, and over 20% of people with body dysmorphia are unemployed. Around 20% of people with BDD are so distressed by their appearance that they attempt suicide.

If you think you may have BDD, talk to your healthcare provider. They can refer you to a mental health specialist who can make a diagnosis using the criteria in the DSM-5. If your worries about your looks are focused more on your body weight or size, you may be diagnosed with an eating disorder instead.

To be diagnosed with body dysmorphia, the preoccupation with your appearance must negatively affect your life and/or cause significant emotional distress. Your healthcare provider may also specify whether you have muscle dysmorphia, a type of body dysmorphia that involves worrying about appearing “too small” or not muscular enough.

During the diagnostic process, your mental health specialist may specify whether you have good, fair, or poor insight into your BDD symptoms.

According to the DSM-5 , some people with body dysmorphic disorder have “good” insight, which means they are aware that their beliefs about their body are not true. People with “fair” or “poor” insight aren’t aware that their worries are excessive or not based in reality.

The exact cause of body dysmorphia is unknown. Researchers believe that several factors may contribute to the development of BDD, including:

Genetics : In some cases, BDD may be inherited. According to twin studies, genetic factors account for about 44% of the variance in body dysmorphic disorder symptoms.
Trauma : People with a history of trauma have a higher chance of developing body dysmorphia. Many people with BDD report having been bullied by peers at school, and up to 79% of people with body dysmorphia experienced childhood abuse .
Personality traits : People with certain personality traits, such as perfectionism and sensitivity to aesthetics, are more likely to develop body dysmorphia.
Comorbid conditions : Many people with BDD have at least one other mental health condition at the same time. It’s especially common for someone with body dysmorphia to have obsessive-compulsive disorder (OCD), social anxiety disorder (SAD), or an eating disorder, such as anorexia nervosa (AN).

Treatment for body dysmorphia usually involves psychotherapy (talk therapy) and/or medication. Research suggests that the following approaches are effective in treating people with BDD:

Cognitive behavioral therapy (CBT) : CBT can help people with BDD learn to manage their anxiety and depression, gain insight into their beliefs, and resist the urge to perform compulsive behaviors.
Selective serotonin reuptake inhibitors (SSRIs) : Studies indicate that certain antidepressants , such as SSRIs, have been shown to be 53% to 70% effective in treating BDD. Many people with body dysmorphia have to take SSRIs on a long-term basis to reduce their symptoms.

If you have BDD, it’s important to build your self-esteem and reach out to others for support. In addition to seeking professional treatment, here are some ways to cope with the symptoms of body dysmorphia:

Joining an online or in-person peer support group for people with BDD
Spending time with loved ones
Practicing mindfulness techniques, such as meditation
Managing stress with relaxation techniques, such as deep breathing exercises
Writing your thoughts in a journal
Using positive affirmation statements to build your confidence
Participating in a new hobby or learning a new skill

If you or a loved one are struggling with body dysmorphic disorder, contact the Substance Abuse and Mental Health Services Administration (SAMHSA) National Helpline at 800-662-4357 for information on support and treatment facilities in your area.

If you are having suicidal thoughts, dial 988 to contact the 988 Suicide & Crisis Lifeline and connect with a trained counselor. If you or a loved one are in immediate danger, call 911 .

Body dysmorphic disorder (BDD), is a mental health disorder that involves an extreme preoccupation with minor or imagined flaws in one’s physical appearance. People with BDD feel overwhelmed by negative thoughts about their body or face. They may spend excessive amounts of time and/or money in attempts to conceal their imperfections or “fix” the way they look.

Researchers believe that BDD is caused by a combination of genetic and environmental factors. Many people with BDD have been bullied about their looks. A history of trauma, such as child abuse, also increases the likelihood of developing BDD. Treatment for BDD typically involves psychotherapy , medication, or both.

A Word From Verywell

If you worry excessively about your looks, you’re not alone. Body dymorphia is common, especially among young adults. Many people have low self-esteem and body image concerns. Talk to your healthcare provider about your options for treatment, support, and empowerment.

Many people are insecure about their looks. However, people with body dysmorphia are so concerned with certain aspects of their appearance that it interferes with their everyday life.

They may take extreme steps to change or hide particular body parts. They may also avoid going out at all because of their imagined physical flaws.

You may have body dysmorphic disorder if you are excessively preoccupied with minor or imagined flaws in your body and/or face. You may also perform repetitive actions, such as comparing yourself to others or grooming excessively, to address your perceived imperfections. Talk to your healthcare provider if you feel consumed or overwhelmed by negative thoughts about your appearance.

Body dysmorphic disorder is a fairly common mental health condition. According to estimates, between 0.6% to 4% of the population has body dysmorphia. It is even more common among people who get plastic surgery or visit a dermatologist regularly.

Research suggests that both biological and environmental factors contribute to the development of body dysmorphia. A history of trauma, including bullying and/or abuse, significantly increases the likelihood that someone will develop BDD. Twin studies indicate that genetics also plays a role, accounting for up to 44% of BDD cases.

If your friend or family member has body dysmorphic disorder, try to be an empathetic listener. Help to build their self-esteem and confidence by offering support and companionship.

If your loved one is open to professional help, reach out to a healthcare provider or support group. Remember to set boundaries and prioritize self-care to keep your communication healthy and effective.

Johns Hopkins Medicine. Body dysmorphic disorder .

American Psychological Association. Body dysmorphic disorder .

American Psychological Association. Obsessive-compulsive disorder .

Varma A, Rastogi R. Recognizing body dysmorphic disorder (dysmorphophobia) . J Cutan Aesthet Surg . 2015;8(3):165-168. doi:10.4103/0974-2077.167279

Substance Abuse and Mental Health Services Administration. DSM-5 changes: implications for child serious emotional disturbance; Table 23: DSM-IV to DSM-V body dysmorphic disorder comparison .

Singh AR, Veale D. Understanding and treating body dysmorphic disorder . Indian J Psychiatry . 2019;61(Suppl 1):S131-S135. doi:10.4103/psychiatry.IndianJPsychiatry_528_18

Krebs G, Fernández de la Cruz L, Mataix-Cols D. Recent advances in understanding and managing body dysmorphic disorder . Evid Based Ment Health . 2017;20(3):71-75. doi:10.1136/eb-2017-102702

Schieber K, Kollei I, de Zwaan M, Müller A, Martin A. Personality traits as vulnerability factors in body dysmorphic disorder . Psychiatry Res . 2013;210(1):242-246. doi:10.1016/j.psychres.2013.06.009

Hartmann AS, Staufenbiel T, Bielefeld L, et al. An empirically derived recommendation for the classification of body dysmorphic disorder: findings from structural equation modeling . PLoS One . 2020;15(6):e0233153. doi:10.1371/journal.pone.0233153

NHS. Body dysmorphic disorder (BDD) .

By Laura Dorwart Dr. Dorwart has a Ph.D. from UC San Diego and is a health journalist interested in mental health, pregnancy, and disability rights.

Body Dysmorphic Disorder falls under the Mental Health category.

Body Dysmorphic Disorder

Fact-checked

Body dysmorphic disorder (BDD) (sometimes informally called “body dysmorphia”) is a condition in which a person has an obsessive preoccupation with their physical appearance. These obsessions are triggered by perceived flaws in appearance.

Last Updated: October 24, 2023

What is body dysmorphic disorder?

The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) classifies body dysmorphic disorder (BDD) under the category of obsessive-compulsive and related disorders, alongside obsessive-compulsive disorder (OCD), hoarding disorder, and other conditions.

People with BDD usually experience an intense preoccupation with perceived defects in their physical appearance, defects that can sometimes be insignificant or unnoticeable to others. Individuals with BDD often exhibit repetitive and time-consuming behaviors (e.g., mirror checking, skin picking), and/or they constantly compare their appearance to others, which in turn may cause distress and have a negative impact on their social, personal, and professional lives. BDD is also linked with a high rate of suicidal thoughts and behaviors. [1] [2]

Although any part of the body can be a cause for concern in individuals with BDD, certain areas — like skin, hair, and nose — are more commonly affected. [3] Furthermore, a specific subtype of BDD, muscle dysmorphia (MD), is characterized by preoccupation with the size and muscle composition of the entire body. [4]

Is body dysmorphic disorder the same as being insecure?

What are the main signs and symptoms of body dysmorphic disorder?

Typical signs and symptoms of body dysmorphic disorder include the following: [5] [1]

Constant preoccupation with one or more physical characteristics
Repetitive behaviors (e.g., mirror checking, skin picking, excessive grooming, frequent changing of clothes, reassurance seeking, counting hair loss)
Difficulties in making friends, dating, or engaging in romantic relationships
Poor concentration leading to an impaired performance at work or school

Depression is also frequently observed in people affected by BDD, either as a pre-existing condition or as a direct consequence of body dysmorphia. Clinicians must screen patients for conditions that share symptoms with BDD (e.g., OCD , social phobia , depression, eating disorders) and which may confound the diagnosis of body dysmorphia. [5] [3]

How is body dysmorphic disorder diagnosed?

BDD is often overlooked and undiagnosed. Individuals who experience BDD are often overwhelmed with feelings of shame and embarrassment and find it challenging to reach out to mental health professionals and discuss their thoughts and preoccupations. Unless clinicians use specific screening tools, such as the *Body Dysmorphic Disorder Questionnaire (BDDQ) or the Body Image Disturbance Questionnaire (BIDQ), they may mistake BDD for other conditions such as depression, OCD, or social anxiety, which may result in delayed treatment. [1] [6]

Similar questionnaires, such as the Cosmetic Procedures Screening (COPS) for BDD, may also be used before surgical cosmetic procedures to determine whether a referral is necessary or after a procedure to measure improvements in BDD symptoms. [7]

Additionally, the DSM provides specific criteria to assist clinicians in identifying cases of BDD. One criterion emphasizes the importance of differentiating between BDD and eating disorders, so if a patient’s primary concern revolves around their body weight, the possibility of an eating disorder should be considered instead. [2]

Other diagnostic tools are designed to identify subgroups of body dysmorphic disorder (e.g., muscle dysmorphia) and to measure an individual’s level of insight regarding their perceived defects.

What are some of the main medical treatments for body dysmorphic disorder?

The main treatments currently used for body dysmorphic disorder include cognitive behavioral therapy (CBT) and medications from the serotonin reuptake inhibitors (SRIs) class. This class comprises selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine, sertraline, and citalopram, as well as nonselective SRI drugs such as clomipramine. Clinicians may also consider off-label use of other medications with known effectiveness in similar conditions (e.g., OCD). However, further research is needed to establish their efficacy specifically for treating BDD. [8] [1]

Given the frequent presence of comorbidities in individuals with BDD, treatment approaches may need to be adjusted accordingly. The use of SRIs in BDD treatment often aligns well with overlapping conditions, such as OCD or social anxiety. Similarly, CBT has shown improvements both in BDD symptoms and comorbid depression. However, for individuals with BDD and bipolar disorder , the administration of mood stabilizers may be necessary before initiating SRIs because the latter can potentially exacerbate bipolar symptoms. In cases in which anorexia nervosa and BDD coexist, anorexia should be addressed as a primary concern. This highlights the complexities involved in establishing the appropriate treatment for BDD.

CBT, the main psychological treatment for BDD, is used to address specific issues, such as repetitive behaviors, distorted perception patterns, and misinterpretation of others' emotions (e.g., feeling judged by others). [8]

Have any supplements been studied for body dysmorphic disorder?

N-Acetylcysteine (NAC) has shown positive outcomes in the treatment of certain obsessive-compulsive and related disorders, such as OCD, nail biting, grooming disorder, skin picking, and trichotillomania (hair pulling). Although there are currently no specific studies assessing the effectiveness of NAC for treatment of BDD, clinicians have been prescribing it as an adjunct therapy alongside SRIs, yielding promising results. However, further research is needed to establish its safety, effectiveness, and appropriate dosage for BDD. [9]

How could diet affect body dysmorphic disorder?

It is well known that nutrition and diet can impact brain health. [10] However, there is currently a lack of nutritional studies specifically focused on BDD. As a result, there is limited knowledge regarding potential nutritional deficiencies and the related dietary adjustments that could be beneficial for individuals with BDD.

Although specific interventions for nutrition and diet in BDD are not yet available, research has shown that people with BDD are more likely to also have an unhealthy relationship with food, which may contribute to the presence of an eating disorder. It is important to note that eating disorders are distinct from BDD and can occur as a consequence or symptom of body dysmorphia. [11] Furthermore, individuals with muscle dysmorphia often adhere to very strict diets that are typically high in protein and low in fats, and some individuals may also use supplements and/or anabolic steroids in an attempt to achieve their desired body shape more quickly. [12] All of these unhealthy eating patterns can potentially result in nutritional deficiencies and correlated issues, which should be addressed alongside BDD signs and symptoms.

Are there any other treatments for body dysmorphic disorder?

Online and smartphone-based cognitive behavioral therapy is currently being explored as a potential intervention for body dysmorphic disorder, and some studies have demonstrated improvements in symptoms. These technological approaches may particularly benefit individuals living in rural areas or those who are hesitant to engage in face-to-face interactions with physicians. However, further research is needed to compare the effectiveness of app-based CBT with traditional in-person CBTy. [8]

Can exercise improve symptoms of body dysmorphic disorder?

What causes body dysmorphic disorder?

Body dysmorphic disorder typically manifests during adolescence. It is not yet clear what exactly causes BDD, and it’s likely that multiple factors contribute to the development of the disorder.

Research suggests a genetic (and thus hereditary) component in BDD because individuals are more susceptible to the disorder if they have a family member affected by BDD or OCD. So far, only a few gene mutations have been identified as potentially contributing to the development of BDD, and these mutations are located on the gamma-aminobutyric acid (GABA)A-γ2 gene and the serotonin transporter gene. [13] [14] [15] [16]

Developmental factors (e.g., child emotional and/or physical abuse) and social factors (e.g., being bullied about a specific body flaw) may also contribute to the development of BDD, according to some studies. [17]

Additionally, functional magnetic resonance imaging (fMRI) has been used to scan BDD subjects while they perform a photo match task. In these fMRI studies, participants with BDD showed altered activity in the right hemisphere of the brain, compared to participants without BDD, and hypoactivity in the visual cortical systems and occipital regions, which may affect visual perception and/or visuospatial processing. [18] [19] Another study also detected a dysfunction in the frontal-striatal circuits of the brain, which are responsible for the perception and manipulation of information, among other functions. [20] Further studies on the brain morphometry of participants with BDD displayed some differences compared to control participants without BDD, but the results across studies were inconsistent, and more research is needed. [17]

Furthermore, the involvement of the serotonin system in BDD is under investigation, with some studies showing that by modulating the serotonin response, BDD symptoms may be exacerbated or attenuated. However, a direct causal relationship between serotonin and BDD has yet to be established. [17]

Can social media have an impact on body dysmorphic disorder?

Frequently asked questions

Having BDD and being insecure about one’s physical appearance are not the same thing. People who are affected by BDD have an irrational and persistent preoccupation with specific body characteristics that has a substantial negative impact on their daily lives. Feeling insecure or having low self-esteem or low confidence is common; however, this commonly occurs from time to time, and it’s not considered a mental health condition.

Although physical activity has been widely recognized for its positive effects on physical and mental health, prescribing exercise for individuals with Body Dysmorphic Disorder (BDD) may not always be appropriate. One specific subtype of BDD, known as muscle dysmorphia (MD), is characterized by an excessive preoccupation with body muscle mass. Individuals with MD are often self-conscious about their muscle appearance, leading them to engage in excessive exercise, and in some cases, to take supplements and/or steroids to enhance muscle growth. In this context, overexercising becomes an obsessive behavior rather than a healthy habit, and healthcare professionals may need to oversee exercise patterns for people affected by MD. [21] [22]

For body dysmorphic disorders other than muscle dysmorphia, some individuals report subjective benefits from exercise, such as improved self-esteem and a reduction in associated feelings of anxiety and depression. However, there is currently limited scientific evidence explicitly examining the impact of exercise on individuals with BDD. Nevertheless, unless exercising becomes an obsessive behavior in itself, people are generally encouraged to incorporate regular physical activity into their daily routine to support overall physical and mental well-being.

Constant exposure to carefully crafted images and the pressure to achieve an unattainable perfect appearance can lead to dissatisfaction with one's own body and distortions in self-perception. Studies have found that the use of social media platforms, although they offer opportunities for connection and self-expression, can also produce negative effects on body image and self-perception and can play a role in exacerbating feelings associated with BDD. [23]

A study in Saudi Arabia revealed that approximately 4.2% of participants who used social media had BDD, and those affected by body dysmorphia were also more likely to spend more time on social media platforms. [24] Furthermore social media has been proven to have a negative impact on many BDD comorbidities such as depression or eating disorders. [23]

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^ Singh AR, Veale D Understanding and treating body dysmorphic disorder. Indian J Psychiatry . ( 2019-Jan )
^ Administration Table 23, DSM-IV to DSM-5 Body Dysmorphic Disorder Comparison ( 2016-06 )
^ Phillips KA, Menard W, Fay C, Weisberg R Demographic characteristics, phenomenology, comorbidity, and family history in 200 individuals with body dysmorphic disorder. Psychosomatics . ( 2005 )
^ Leone JE, Sedory EJ, Gray KA Recognition and treatment of muscle dysmorphia and related body image disorders. J Athl Train . ( 2005 )
^ Phillips KA Body dysmorphic disorder: recognizing and treating imagined ugliness. World Psychiatry . ( 2004-Feb )
^ Krebs G, Fernández de la Cruz L, Mataix-Cols D Recent advances in understanding and managing body dysmorphic disorder. Evid Based Ment Health . ( 2017-Aug )
^ Veale D, Ellison N, Werner TG, Dodhia R, Serfaty MA, Clarke A Development of a Cosmetic Procedure Screening Questionnaire (COPS) for Body Dysmorphic Disorder. J Plast Reconstr Aesthet Surg . ( 2012-Apr )
^ Castle D, Beilharz F, Phillips KA, Brakoulias V, Drummond LM, Hollander E, Ioannidis K, Pallanti S, Chamberlain SR, Rossell SL, Veale D, Wilhelm S, Van Ameringen M, Dell'Osso B, Menchon JM, Fineberg NA Body dysmorphic disorder: a treatment synthesis and consensus on behalf of the International College of Obsessive-Compulsive Spectrum Disorders and the Obsessive Compulsive and Related Disorders Network of the European College of Neuropsychopharmacology. Int Clin Psychopharmacol . ( 2021-Mar-01 )
^ Oliver G, Dean O, Camfield D, Blair-West S, Ng C, Berk M, Sarris J N-acetyl cysteine in the treatment of obsessive compulsive and related disorders: a systematic review. Clin Psychopharmacol Neurosci . ( 2015-Apr-30 )
^ Gómez-Pinilla F Brain foods: the effects of nutrients on brain function. Nat Rev Neurosci . ( 2008-Jul )
^ S. Ruffolo et al. Comorbidity of body dysmorphic disorder and eating disorders: Severity of psychopathology and body image disturbance Int. J. Eat. Disord. . ( 2006-01 )
^ Contesini N, Adami F, Blake Md, Monteiro CB, Abreu LC, Valenti VE, Almeida FS, Luciano AP, Cardoso MA, Benedet J, de Assis Guedes de Vasconcelos F, Leone C, Frainer DE Nutritional strategies of physically active subjects with muscle dysmorphia. Int Arch Med . ( 2013-May-26 )
^ Feusner JD, Yaryura-Tobias J, Saxena S The pathophysiology of body dysmorphic disorder. Body Image . ( 2008-Mar )
^ Li W, Arienzo D, Feusner JD Body Dysmorphic Disorder: Neurobiological Features and an Updated Model. Z Klin Psychol Psychother (Gott) . ( 2013 )
^ Bienvenu OJ, Samuels JF, Riddle MA, Hoehn-Saric R, Liang KY, Cullen BA, Grados MA, Nestadt G The relationship of obsessive-compulsive disorder to possible spectrum disorders: results from a family study. Biol Psychiatry . ( 2000-Aug-15 )
^ Phillips KA, Kaye WH The relationship of body dysmorphic disorder and eating disorders to obsessive-compulsive disorder. CNS Spectr . ( 2007-May )
^ Feusner JD, Neziroglu F, Wilhelm S, Mancusi L, Bohon C What Causes BDD: Research Findings and a Proposed Model. Psychiatr Ann . ( 2010-Jul-01 )
^ Jamie D Feusner, Jennifer Townsend, Alexander Bystritsky, Susan Bookheimer Visual information processing of faces in body dysmorphic disorder Arch Gen Psychiatry . ( 2007 Dec )
^ Feusner JD, Moody T, Hembacher E, Townsend J, McKinley M, Moller H, Bookheimer S Abnormalities of visual processing and frontostriatal systems in body dysmorphic disorder. Arch Gen Psychiatry . ( 2010-Feb )
^ Mataix-Cols D, van den Heuvel OA Common and distinct neural correlates of obsessive-compulsive and related disorders. Psychiatr Clin North Am . ( 2006-Jun )
^ Segura-García et al. Body Uneasiness, Eating Disorders, and Muscle Dysmorphia in Individuals Who Overexercise The Journal of Strength & Conditioning Research . ( 2010-11 )
^ Corazza O, Simonato P, Demetrovics Z, Mooney R, van de Ven K, Roman-Urrestarazu A, Rácmolnár L, De Luca I, Cinosi E, Santacroce R, Marini M, Wellsted D, Sullivan K, Bersani G, Martinotti G The emergence of Exercise Addiction, Body Dysmorphic Disorder, and other image-related psychopathological correlates in fitness settings: A cross sectional study. PLoS One . ( 2019 )
^ Laughter et al. Psychology of aesthetics: Beauty, social media, and body dysmorphic disorder Clinics in Dermatology . ( 2023-03 )
^ Alsaidan MS, Altayar NS, Alshmmari SH, Alshammari MM, Alqahtani FT, Mohajer KA The prevalence and determinants of body dysmorphic disorder among young social media users: A cross-sectional study. Dermatol Reports . ( 2020-Dec-22 )

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Five Questions Answered About Body Dysmorphia

While standing in front of a mirror, it’s natural to zero in on that one annoying flaw. But if that casual dislike has become more of an obsession, you may be among the millions of Americans living with body dysmorphic disorder (BDD), or body dysmorphia.

People with body dysmorphia typically agonize over one specific body part and have difficulties thinking about anything else. The all-consuming obsession can interfere with work, relationships, and daily functioning. The good news is that BDD is treatable. Here’s what you need to know to get on the path to healing.

What Is BDD?

BDD is a mental health condition characterized by compulsive and intrusive obsessions over an imagined or slight defect in one's appearance. Bodily features that are most often found at fault include hair, skin, nose, chest, and stomach.

“Body dysmorphia means that someone sees their body, or a feature of their body, differently than it is in reality,” says Kristin Francis , MD, an assistant professor and psychiatrist at Huntsman Mental Health Institute at University of Utah Health. “When people who suffer from eating disorders have body dysmorphia, they often misperceive their size and overly focus on perceived flaws such as how their stomach looks.”

Repetitive behaviors associated with BDD include:

Obsessively examining your “flaw” in front of the mirror
Repetitively grooming yourself to conceal a perceived flaw
Incessantly seeking assurance from others
Believing that others are mocking your appearance
Constantly comparing yourself to others

Do I Have BDD or OCD?

BDD has much in common with obsessive-compulsive Disorder (OCD), which entails a cluster of disorders characterized by intrusive thoughts and compulsive self-soothing behaviors. Both conditions can occur together, yet they are not the same. One difference is that BDD patients are more likely to lack insight, meaning they aren’t able to accept and/or recognize the severity of their disorder. Without treatment, Francis says this unhealthy fixation can escalate to dangerous levels.

“People with this condition can become focused on changing their bodies to a degree that it becomes unhealthy,” Francis says. “Some examples include seeking surgery or taking medicines to change their muscle size.”

What Causes BDD?

BDD, which affects both males and females, typically presents itself around puberty and continues into adolescence. Biological risk factors include a history of anxiety or depression or having a parent or sibling with BDD or OCD.

External forces—particularly mainstream media and social media—also contribute to the manifestation of BDD and intensify symptoms.

“Our society puts a lot of focus on how someone looks on the outside, and the images perpetuated by the media often portray an unrealistic body standard,” Francis says. “When we compare ourselves to these impossible standards, we increasingly feel bad about ourselves and lose sight of what is important and realistic.”

How Do I Treat BDD?

Left untreated, BDD can take a significant toll on your quality of life, robbing you of your time, joyous occasions with friends and loved ones, and even your livelihood. Without medical intervention, obsessive thoughts and compulsive behaviors could intensify and lead to serious complications, such as eating disorders , physical pain and disfigurement, social phobia, and suicidal thoughts.

The most effective line of defense for BDD are SSRIs (antidepressants and antianxiety medications) and certain types of psychotherapy such as cognitive behavioral therapy (CBT) or acceptance and commitment therapy (ACT). ACT is a common treatment that can help patients with BDD learn how to tolerate anxiety-provoking triggers by incorporating the core concepts of mindfulness, acceptance, and value-based living into their daily lives. These practices give patients the support they need to live more in the present and better manage their emotions.

Where Can I Find Help?

Living with BDD can feel isolating and overwhelming. But you’re not alone. The first step is seeking help as soon as possible . Free online resources are available to access therapist directories, support groups, and educational materials. Despite the extreme suffering you may be experiencing with this disorder, it is possible to learn to cope and even fully recover.

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Body dysmorphic disorder

Body dysmorphic disorder is a mental health condition in which you can't stop thinking about one or more perceived defects or flaws in your appearance — a flaw that appears minor or can't be seen by others. But you may feel so embarrassed, ashamed and anxious that you may avoid many social situations.

When you have body dysmorphic disorder, you intensely focus on your appearance and body image, repeatedly checking the mirror, grooming or seeking reassurance, sometimes for many hours each day. Your perceived flaw and the repetitive behaviors cause you significant distress and impact your ability to function in your daily life.

You may seek out numerous cosmetic procedures to try to "fix" your perceived flaw. Afterward, you may feel temporary satisfaction or a reduction in your distress, but often the anxiety returns and you may resume searching for other ways to fix your perceived flaw.

Treatment of body dysmorphic disorder may include cognitive behavioral therapy and medication.

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Signs and symptoms of body dysmorphic disorder include:

Being extremely preoccupied with a perceived flaw in appearance that to others can't be seen or appears minor
Strong belief that you have a defect in your appearance that makes you ugly or deformed
Belief that others take special notice of your appearance in a negative way or mock you
Engaging in behaviors aimed at fixing or hiding the perceived flaw that are difficult to resist or control, such as frequently checking the mirror, grooming or skin picking
Attempting to hide perceived flaws with styling, makeup or clothes
Constantly comparing your appearance with others
Frequently seeking reassurance about your appearance from others
Having perfectionist tendencies
Seeking cosmetic procedures with little satisfaction
Avoiding social situations

Preoccupation with your appearance and excessive thoughts and repetitive behaviors can be unwanted, difficult to control and so time-consuming that they can cause major distress or problems in your social life, work, school or other areas of functioning.

You may excessively focus over one or more parts of your body. The bodily feature that you focus on may change over time. The most common features people tend to fixate about include:

Face, such as nose, complexion, wrinkles, acne and other blemishes
Hair, such as appearance, thinning and baldness
Skin and vein appearance
Breast size
Muscle size and tone

A preoccupation with your body build being too small or not muscular enough (muscle dysmorphia) occurs almost exclusively in males.

Insight about body dysmorphic disorder varies. You may recognize that your beliefs about your perceived flaws may be excessive or not be true, or think that they probably are true, or be absolutely convinced that they're true. The more convinced you are of your beliefs, the more distress and disruption you may experience in your life.

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, see your health care provider or a mental health professional.

Body dysmorphic disorder usually doesn't get better on its own. If left untreated, it may get worse over time, leading to anxiety, extensive medical bills, severe depression, and even suicidal thoughts and behavior.

If you have suicidal thoughts

Suicidal thoughts and behavior are common with body dysmorphic disorder. If you think you may hurt yourself or attempt suicide, get help right away:

In the U.S, call 911 or your local emergency number immediately.
Contact a suicide hotline. In the U.S., call or text 988 to reach the 988 Suicide & Crisis Lifeline , available 24 hours a day, seven days a week. Or use the Lifeline Chat . Services are free and confidential.
Call your mental health professional.
Seek help from your primary care provider.
Reach out to a close friend or loved one.
Contact a minister, spiritual leader or someone else in your faith community.

It's not known specifically what causes body dysmorphic disorder. Like many other mental health conditions, body dysmorphic disorder may result from a combination of issues, such as a family history of the disorder, negative evaluations or experiences about your body or self-image, and abnormal brain function or abnormal levels of the brain chemical called serotonin.

Risk factors

Body dysmorphic disorder typically starts in the early teenage years and it affects both males and females.

Certain factors seem to increase the risk of developing or triggering body dysmorphic disorder, including:

Having blood relatives with body dysmorphic disorder or obsessive-compulsive disorder
Negative life experiences, such as childhood teasing, neglect or abuse
Certain personality traits, such as perfectionism
Societal pressure or expectations of beauty
Having another mental health condition, such as anxiety or depression

Complications

Complications that may be caused by or associated with body dysmorphic disorder include, for example:

Low self-esteem
Social isolation
Major depression or other mood disorders
Suicidal thoughts or behavior
Anxiety disorders, including social anxiety disorder (social phobia)
Obsessive-compulsive disorder
Eating disorders
Substance misuse
Health problems from behaviors such as skin picking
Physical pain or risk of disfigurement due to repeated surgical interventions

There's no known way to prevent body dysmorphic disorder. However, because body dysmorphic disorder often starts in the early teenage years, identifying the disorder early and starting treatment may be of some benefit.

Long-term maintenance treatment also may help prevent a relapse of body dysmorphic disorder symptoms.

Body dysmorphic disorder. In: Diagnostic and Statistical Manual of Mental Disorders DSM-5. 5th ed. American Psychiatric Association; 2013. https://dsm.psychiatryonline.org. Accessed Aug. 17, 2021.
Body dysmorphic disorder (BDD). Office on Women's Health. https://www.womenshealth.gov/mental-health/mental-health-conditions/body-dysmorphic-disorder. Accessed Aug. 18, 2021.
Body dysmorphic disorder. Merck Manual Professional Version. https://www.merckmanuals.com/professional/psychiatric-disorders/obsessive-compulsive-and-related-disorders/body-dysmorphic-disorder?query=Body%20Dysmorphic%20Disorder#. Accessed Aug. 18, 2021.
Hong K, et al. Pharmacological treatment of body dysmorphic disorder. Current Neuropharmacology. 2019; doi:10.2174/1570159X16666180426153940.
Krebs G, et al. Recent advances in understanding and managing body dysmorphic disorder. Evidence Based Mental Health. 2017; doi:10.1136/eb-2017-102702.
Dong N, et al. Pharmacotherapy in body dysmorphic disorder: Relapse prevention and novel treatments. Expert Opinion on Pharmacotherapy. 2019; doi:10.1080/14656566.2019.1610385.
Lifeline Chat. National Suicide Prevention Lifeline. https://suicidepreventionlifeline.org/chat/. Accessed Aug. 18, 2021.
For people with mental health problems. MentalHealth.gov. https://www.mentalhealth.gov/talk/people-mental-health-problems. Accessed Aug. 18, 2021.
Mental Health: Managing stress. National Alliance on Mental Illness. https://www.nami.org/Your-Journey/Individuals-with-Mental-Illness/Taking-Care-of-Your-Body/Managing-Stress. Accessed Aug. 18, 2021.
Sawchuk CN (expert opinion). Mayo Clinic. Aug. 30, 2021.

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Patient information: See related handout on body dysmorphic disorder , written by the authors of this article.

Author disclosure: Nothing to disclose.

Body dysmorphic disorder is an increasingly recognized somatoform disorder, clinically distinct from obsessive-compulsive disorder, eating disorders, and depression. Patients with body dysmorphic disorder are preoccupied with an imagined deficit in the appearance of one or more body parts, causing clinically significant stress, impairment, and dysfunction. The preoccupation is not explained by any other psychiatric disorder. Patients present to family physicians for primary care reasons and aesthetic or cosmetic procedures. Cosmetic correction of perceived physical deficits is rarely an effective treatment. Pharmacologic treatment with selective serotonin reuptake inhibitors and nonpharmacologic treatment with cognitive behavior therapy are effective. Body dysmorphic disorder is not uncommon, but is often misdiagnosed. Recognition and treatment are important because this disorder can lead to disability, depression, and suicide.

Italian physician Enrique Morselli first described body dysmorphic disorder (BDD) in 1891 by using the term “dysmorphophobia,” defined as the fear of having a deformity. 1 The American Psychiatric Association classified BDD as a distinct somatoform disorder in 1987. 2 BDD has received particular attention in the media and in clinical research over the past 10 years.

Patients with BDD are preoccupied with a perceived physical defect, and this disrupts their lives by causing them considerable social distress and occupational dysfunction. They may seek care for their perceived defects from many subspecialties, including dermatology, 3 cosmetic surgery, 4 dentistry, 5 psychiatry, and family medicine. These patients often want cosmetic and aesthetic procedures, which have become more affordable and available than ever before. Therefore, family physicians who perform in-office aesthetic procedures (e.g., botulinum toxin type A injections [Botox]; filler injections [collagen and hyaluronic acid]; mesotherapy; micro-dermabrasion) may encounter patients with BDD. However, cosmetic procedures rarely improve the symptoms of patients with BDD, and often add to their psychic distress; therefore, considering the presence of this disorder before performing aesthetic procedures has been recommended. Furthermore, numerous reports have documented patients with BDD committing violent acts toward physicians who perform procedures on them. 6


Treatment of BDD with cosmetic procedures is not recommended.	C	,	Rarely improves symptoms, adds to psychic distress
BDD should be considered in patients before performing aesthetic procedures.	C	, ,
Treatment with high dosages of SSRIs has been shown to be effective for BDD.	B	–	See
Cognitive behavior therapy has been shown to be effective in patients with BDD.	B	–

Demographics

It is estimated that 1 percent of adults in the general population have BDD. 1 The disorder is more prevalent in patients undergoing cosmetic procedures and in those who have psychiatric comorbidities ( Table 1 3 , 7 – 10 ). Persons with BDD have higher rates of major depression, 11 suicide, 12 and disability than the general population. 1 , 3 BDD is reported worldwide, with most large studies coming from the United States, Italy, and England. 13 Clinical features of BDD are similar across many cultures, but some manifestations are culturally specific. 13 For instance, Japanese case reports discuss eyelids as the focus of concern, which is a rare complaint in Western cultures.


Anorexia nervosa	39
Atypical depression	14 to 42
Obsessive-compulsive disorder	8 to 37
Social anxiety	11 to 13
Dermatology and cosmetic surgery patients	6 to 15
Female college students	2 to 5

Persons with BDD worry about a large range of body parts, which may include hair, noses, freckles, chests, breasts, skin, muscles, buttocks, genitalia, hands, and feet. The types of bodily concerns tend to vary with gender ( Table 2 ) 14 , 15 ; however, similarities include single marital status (75 percent) and living with one's parents (25 percent).


Body part focus	Body build Genitalia Thinning hair	Breasts Buttocks Excessive hair Nose Skin Stomach Teeth Thighs Weight
Behavior	Substance use disorder Weight lifting	Camouflaging techniques (e.g., baggy clothing, hats, wigs, makeup) Eating disorder Skin picking

Demetrius is a 16-year-old Greek-American male who was admitted to the adolescent inpatient unit following an automobile collision. Demetrius has a history of major depression, school absences, and declining grades. His depression began at the onset of puberty. He reported that his automobile crash was not intentional, but that he was looking at his nose and acne in the rearview mirror when he lost control of his car on the freeway. No one else was with him; he has no friends and prefers to stay at home with his parents because he feels that his nose is hideous. He has never dated, avoids school functions, does not participate in sports, and believes that others laugh at the size of his nose. Demetrius is six feet tall, lanky, and thin. He has a full head of curly brown hair, a large nose, severe acne, and a pleasant demeanor.

While on the adolescent psychiatric unit, Demetrius spent a lot of time in the bathroom picking at his face, looking at his nose in reflective surfaces, and trying to manipulate his way out of group activities. He often had his hand over his nose and insisted on wearing a large hat and glasses on field trips. In spite of these behaviors, he was well-liked by others on the unit. Dermatology was consulted and his acne improved. Later that year, he had a rhinoplasty and his outlook was more positive. Two years later, he was readmitted following a suicide attempt after a breakup with his first girlfriend. At the second admission, he became convinced that he would be more appealing to women if he had cosmetic dentistry and began a bodybuilding regimen to achieve more definition of the muscles in his arms. At a five-year follow-up, Demetrius had quit high school and was living at home with his parents, not working, and on psychiatric disability.

Many theories have been proposed to explain the possible root causes of BDD, but no definitive etiology has been identified to date. Some popular theories include unrealistic societal standards and expectations, parental pressure, poor self-esteem, and neurotransmitter imbalances. 1 , 16 Cultural, social, and psychological components seem to play a role. One proposed model is similar to other psychiatric diagnoses that include genetic, cultural, and psychological factors 1 that manifest after a triggering event. For example, BDD may be triggered in a person genetically predisposed to anxiety who has been teased throughout high school about some distinguishing physical characteristic. One small study found that serotonin transporter promoter genes tend to be shorter in persons with BDD compared with the general population. 1 A 20 percent concordance rate of BDD among first-degree relatives has been described. 15

BDD is commonly missed, dismissed, and misdiagnosed in most medical settings. 3 Numerous studies have illustrated the rarity of a BDD diagnosis being included on a patient's problem list, even when looking at mental health records. 17 Successful treatment requires physician awareness of the disorder and a timely and accurate diagnosis. Table 3 2 lists diagnostic criteria for BDD.

A person is preoccupied with an imagined deficit in appearance. If a slight physical anomaly is present, the person's concern is markedly excessive

The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

The preoccupation is not better accounted for by another mental disorder (e.g., anorexia nervosa)

Patients are often reluctant or ashamed to admit to the problem or seek help for it. Important clinical features physicians should look for include: impairment in social functioning, such as avoidance of school, work, or other social situations; poor performance at school or work; and lateness caused by time spent grooming or camouflaging. Bodybuilders and patients with eating disorders also may have BDD. Muscle dysmorphia, considered by many to be a subtype of BDD, is characterized by excessive preoccupation and insecurity with one's musculature, resulting in excessive weight lifting, anabolic steroid use, and impaired social functioning. 18 Comorbid diagnoses such as obsessive-compulsive disorder (OCD), anorexia nervosa, and depression have also been well described. 19 , 20 However, BDD is a clinically distinct entity and its treatment differs in several important ways. Therefore, physicians should have a high index of suspicion for this disorder. Risk of depression and suicidality should be considered in patients with BDD because of the high correlation between these disorders. 11 , 12

To rule out an eating disorder, ask the patient if his or her main appearance-related concern is with not being thin enough. If not, BDD screening questions to ask the patient should cover the level of preoccupation and pervasiveness of thoughts related to the appearance of the body part; how much time is spent on these thoughts per day (e.g., less than one hour; one to three hours or longer); and how these thoughts have affected aspects of the patient's life (e.g., distress levels, social life impairment, productivity at school or work, avoidance behaviors, impact on friends and family). 1 A positive screen should include answers from the patient that indicate a high level of concern about the body part, which includes thinking about it for at least one hour per day and having at least one apsect of daily life significantly affected by this preoccupation. 1

One approach to treating patients with BDD is to change their appearance. However, procedures aimed at treating the underlying physical “defect,” usually performed by a plastic surgeon, dermatologist, or other medical subspecialist, have proved unsuccessful in patients with BDD. 21 , 22 The altered appearance may fall short of patient expectations and fail to relieve psychic distress, and additional changes may be sought. Before long, such patients may be seen as hypochondriacs or as having Munchausen syndrome. Consequently, the most important management point is to help patients with BDD to avoid surgical “corrections,” which only address a derivative symptom and leave the underlying ideation unchanged.

Whereas definitive treatments for BDD are unknown, pharmacologic interventions may be modeled on approaches to related disorders. Several classes of psychotropic medications have been tried since BDD was classified as a mental illness. Antipsychotics, monoamine oxidase inhibitors, and tricyclic antidepressants have been used; although anecdotal reports of treatment success appear in the literature, no randomized controlled trials (RCTs) are on record. In hindsight, it seems most likely that the treatment successes occurred in patients who had comorbid conditions such as major depression or an anxiety disorder, or in cases where the diagnosis should have been somatic delusional disorder.

Newer medications were tried when the central role of serotoninergic neurotransmission in the manifestation of obsessive thinking and compulsive behavior became clearer. Selective serotonin reuptake inhibitors (SSRIs) have been shown to effectively treat OCD. 23 This observation suggested the potential effectiveness of SSRIs for treatment of BDD, and led to several small-scale, open-label studies and a few RCTs. 24 – 29 The most rigorous of the RCTs used fluoxetine (Prozac). 24 The SSRIs were shown to reduce symptoms and subjective distress in 63 to 73 percent of patients. Dosages were higher than customarily used in the treatment of depressive disorders, and treatment response often took up to 12 weeks. 10 , 24 – 29 None of these agents are currently approved for the treatment of BDD; therefore, the prescription is off-label. It is unknown how long medication needs to be continued after BDD has gone into remission. Table 4 24 – 29 lists effective dosages of medications for BDD treatment.


Citalopram (Celexa)	50 mg per day
Clomipramine (Anafranil)	140 mg per day
Escitalopram (Lexapro)	30 mg per day
Fluoxetine (Prozac)	80 mg per day
Fluvoxamine (Luvox; brand only available in extended-release capsules)	More than 200 mg per day

The limitations of SSRIs are evident, but they may provide relief in combination with psychotherapy. Promising psychotherapeutic approaches include cognitive behavior therapy (CBT), which appears to be a particularly useful adjunct to pharmacotherapy. 30 There are no data on record to document the comparative effectiveness of pharmacologic treatments and CBT. In CBT, the therapist assists the patient to correct (or “restructure”) cognitive distortions, putting the patient's negative self-perception into a different perspective to develop less negative beliefs about his or her appearance. This may involve helping the patient see an offensive body part in the context of his or her ethnic heritage or family connections. CBT methods have been employed in individual therapy arrangements 31 – 33 and group therapy formats. 34

When referring to a therapist, it is important to locate one with CBT training who has experience treating patients with eating disorders, OCD, and depression. Collaboration among psychiatrists and primary care physicians is essential. Table 5 lists resources that offer additional information about BDD.

:
Los Angeles Body Dysmorphic Disorder Clinic
	Research Studies
	Web site:
BioBehavioral Institute, New York
	Web site: http://www.biobehavioralinstitute.com
Body Image Program at Butler Hospital
	Web site:
Harvard Medical School and Massachusetts
	General Hospital
	Web site:

Phillips KA. The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder . New York, NY: Oxford University Press; 2005.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders . 4th ed. Washington, DC: American Psychiatric Association; 2002:510.

Wilson JB, Arpey CJ. Body dysmorphic disorder: suggestions for detection and treatment in a surgical dermatology practice. Dermatol Surg. 2004;30(11):1391-1399.

Sarwer DB, Whitaker LA, Pertschuk MJ, Wadden TA. Body image concerns of reconstructive surgery patients: an underrecognized problem. Ann Plast Surg. 1998;40(4):403-407.

Herren C, Armentrout T, Higgins M. Body dysmorphic disorder: diagnosis and treatment. Gen Dent. 2003;51(2):164-166.

Cotterill JA. Body dysmorphic disorder. Dermatol Clin. 1996;14(3):457-463.

Sarwer DB, Cash TF, Magee L, et al. Female college students and cosmetic surgery: an investigation of experiences, attitudes, and body image. Plast Reconstr Surg. 2005;115(3):931-938.

Bohne A, Keuthen NJ, Wilhelm S, Deckersbach T, Jenike MA. Prevalence of symptoms of body dysmorphic disorder and its correlates: a cross-cultural comparison. Psychosomatics. 2002;43(6):486-490.

Cansever A, Uzun O, Dönmez E, Ozsahin A. The prevalence and clinical features of body dysmorphic disorder in college students: a study in a Turkish sample. Compr Psychiatry. 2003;44(1):60-64.

Grant JE, Phillips KA. Recognizing and treating body dysmorphic disorder. Ann Clin Psychiatry. 2005;17(4):205-210.

Phillips KA, Didie ER, Menard W. Clinical features and correlates of major depressive disorder in individuals with body dysmorphic disorder. J Affect Disord. 2007;97(1–3):129-135.

Phillips KA, Menard W. Suicidality in body dysmorphic disorder: a prospective study. Am J Psychiatry. 2006;163(7):1280-1282.

Phillips KA. Body dysmorphic disorder: recognizing and treating imagined ugliness. World Psychiatry. 2004;3(1):12-17.

Phillips KA, Menard W, Fay C. Gender similarities and differences in 200 individuals with body dysmorphic disorder. Compr Psychiatry. 2006;47(2):77-87.

Phillips KA, Menard W, Fay C, Weisberg R. Demographic characteristics, phenomenology, comorbidity, and family history in 200 individuals with body dysmorphic disorder. Psychosomatics. 2005;46(4):317-325.

Slaughter JR, Sun AM. In pursuit of perfection: a primary care physician's guide to body dysmorphic disorder. Am Fam Physician. 1999;60(6):1738-1742.

Zimmerman M, Mattia JI. Body dysmorphic disorder in psychiatric outpatients: recognition, prevalence, comorbidity, demographic, and clinical correlates. Compr Psychiatry. 1998;39(5):265-270.

Pope CG, Pope HG, Menard W, Fay C, Olivardia R, Phillips KA. Clinical features of muscle dysmorphia among males with body dysmorphic disorder. Body Image. 2005;2(4):395-400.

Frare F, Perugi G, Ruffolo G, Toni C. Obsessive-compulsive disorder and body dysmorphic disorder: a comparison of clinical features. Eur Psychiatry. 2004;19(5):292-298.

Ruffolo JS, Phillips KA, Menard W, Fay C, Weisberg RB. Comorbidity of body dysmorphic disorder and eating disorders: severity of psychopathology and body image disturbance. Int J Eat Disord. 2006;39(1):11-19.

Crerand CE, Phillips KA, Menard W, Fay C. Nonpsychiatric medical treatment of body dysmorphic disorder. Psychosomatics. 2005;46(6):549-555.

Phillips KA, Grant J, Siniscalchi J, Albertini RS. Surgical and nonpsychiatric medical treatment of patients with body dysmorphic disorder. Psychosomatics. 2001;42(6):504-510.

Williams J, Hadjistavropoulos T, Sharpe D. A metaanalysis of psychological and pharmacological treatments for body dysmorphic disorder. Behav Res Ther. 2006;44(1):99-111.

Phillips KA, Albertini RS, Rasmussen SA. A randomized placebo-controlled trial of fluoxetine in body dysmorphic disorder. Arch Gen Psychiatry. 2002;59(4):381-388.

Phillips KA, Najjar F. An open-label study of citalopram in body dysmorphic disorder. J Clin Psychiatry. 2003;64(6):715-720.

Phillips KA. An open-label study of escitalopram in body dysmorphic disorder. Int Clin Psychopharmacol. 2006;21(3):177-179.

Hollander E, Allen A, Kwon J, et al. Clomipramine vs desipramine crossover trial in body dysmorphic disorder: selective efficacy of a serotonin reuptake inhibitor in imagined ugliness. Arch Gen Psychiatry. 1999;56(11):1033-1039.

Phillips KA, Dwight MM, McElroy SL. Efficacy and safety of fluvoxamine in body dysmorphic disorder. J Clin Psychiatry. 1998;59(4):165-171.

Perugi G, Giannotti D, Di Vaio S, Frare F, Saettoni M, Cassano GB. Fluvoxamine in the treatment of body dysmorphic disorder (dysmorphophobia). Int Clin Psychopharmacol. 1996;11(4):247-254.

Neziroglu F, Khemlani-Patel S. A review of cognitive and behavioral treatment for body dysmorphic disorder. CNS Spectr. 2002;7(6):464-471.

McKay D. Two-year follow-up of behavioral treatment and maintenance for body dysmorphic disorder. Behav Modif`. 1999;23(4):620-629.

Rosen JC, Reiter J, Orosan P. Cognitive-behavioral body image therapy for body dysmorphic disorder [published correction appears in J Consult Clin Psychol . 1995;63(3):437]. J Consult Clin Psychol. 1995;63(2):263-269.

Veale D, Gournay K, Dryden W, et al. Body dysmorphic disorder: a cognitive behavioral model and pilot randomised controlled trial. Behav Res Ther. 1996;34(9):717-729.

Wilhelm S, Otto MW, Lohr B, Deckersbach T. Cognitive behavior group therapy for body dysmorphic disorder: a case series. Behav Res Ther. 1999;37(1):71-75.

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Questions to Help Uncover Hidden Body Dysmorphic Disorder

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While persons with body dysmorphic disorder (BDD) are preoccupied with their imagined defects in appearance, they often hide their concerns from the outside world, making detection of the disorder a real challenge.

BDD affects an estimated 1% to 2% of the general population, and symptoms can be severe and their distressing and impairing preoccupation with imagined defects in appearance interferes with work and relationships. Comorbidity with major depressive disorder, substance use disorder, obsessive-compulsive disorder (OCD), and social phobia is common. For patients with eating disorders, shape, or weight preoccupation that is consistent with the disorder doees not constitute BDD. Criteria C for BDD states, “the preoccupation is not better accounted for any another mental disorder, such as dissatisfaction with shape and weight in Anorexia Nervosa.”

Nearly all patients with BDD have few or no friends and often avoid social interactions; some studies have reported that these patients’ quality of life is poorer than that of patients with OCD alone. In addition, 80% of patients with BDD report a history of suicidal ideation and about a fourth have attempted suicide. Results of one study noted that the rate of successful suicide among these patients is higher than in nearly all other mental disorders ( Am J Psychiatry 2006; 163:1280).

Barriers to the diagnosis

Patients with BDD usually are embarrassed and ashamed about BDD and thus hide their symptoms. In addition, many BDD patients believe their problems are physical and do not recognize that their beliefs are caused by an underlying psychological or psychiatric problem. Thus, clinicians need to specifically ask about symptoms, using focused questioning, according to the authors. Also, BDD symptoms need to be differentiated from other disorders with similar symptoms. For example, social phobia and avoidant personality disorder share the symptoms of self-consciousness and anxiety in social settings—in BDD, fears of negative feedback are due to concerns about physical appearance.

Dr. Katherine A. Phillips of Brown University, Providence, RI, and colleagues at UCLA School of Medicine and Harvard Medical School recently offered some key questions to help clinicians diagnose BDD ( Am J Psychiatry 165:9, 2008).

According to the authors, an important first step is engaging the patient and establishing an alliance, so that he or she is willing to consider psychiatric treatment. Often patients think cosmetic treatment is all they need, and would rather see a surgeon or dermatologist than a psychiatrist. However, patients with BDD usually eventually recognize that their quality of life is not good. Empathizing with their concerns about finding a better quality of life may help them make the decision to seek psychiatric help.

Questions to help make the diagnosis

Dr. Phillips and colleagues suggest a series of questions that may help lead clinicians to make a diagnosis of hidden BDD.

“Are you very worried about your appearance in any way? Or “Are you unhappy with the way you look?”
“What don’t you like about the way you look?” or “Can you tell me about your concerns?”
“Are you unhappy about any other aspects of your appearance?”
“About how much time do you spend each day thinking about your appearance?”
“How much distress do these concerns cause you?” It is helpful to ask specifically about any resulting anxiety, social anxiety, depression, and feelings of panic, as well as any suicidal ideas.
“Do these concerns interfere with your life or cause problems in any way?” Note effects on work, caring for children, intimacy, social activities and other types of interference in the person’s life.

The researchers also suggest that although the absence of compulsive behaviors does not rule out the diagnosis, it’s helpful to ask patients about behaviors such as: frequently comparing oneself to others, checking oneself in the mirror, excessive grooming, frequently touching the disliked body area(s), changing clothing often, skin-picking, tanning, dieting, excessive exercise or excessive weight-lifting.

Eating Disorders Review

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Social Media Use and Body Image Disorders: Association between Frequency of Comparing One’s Own Physical Appearance to That of People Being Followed on Social Media and Body Dissatisfaction and Drive for Thinness

Barbara jiotsa.

1 Addictology and Liaison Psychiatry Department, Nantes University Hospital, 44000 Nantes, France; [email protected] (B.J.); [email protected] (B.N.); [email protected] (B.R.)

Benjamin Naccache

Mélanie duval.

2 Public Health Department, Nantes University Hospital, 44000 Nantes, France; [email protected]

Bruno Rocher

Marie grall-bronnec.

3 Inserm UMR 1246, Nantes and Tours Universities, 44200 Nantes, France

Associated Data

The data presented in this study are available on request from the corresponding author.

(1) Summary: Many studies have evaluated the association between traditional media exposure and the presence of body dissatisfaction and body image disorders. The last decade has borne witness to the rise of social media, predominantly used by teenagers and young adults. This study’s main objective was to investigate the association between how often one compares their physical appearance to that of the people they follow on social media, and one’s body dissatisfaction and drive for thinness. (2) Method: A sample composed of 1331 subjects aged 15 to 35 (mean age = 24.2), including 1138 subjects recruited from the general population and 193 patients suffering from eating disorders, completed an online questionnaire assessing social media use (followed accounts, selfies posted, image comparison frequency). This questionnaire incorporated two items originating from the Eating Disorder Inventory Scale (Body Dissatisfaction: EDI-BD and Drive for Thinness: EDI-DT). (3) Results: We found an association between the frequency of comparing one’s own physical appearance to that of people followed on social media and body dissatisfaction and drive for thinness. Interestingly, the level of education was a confounding factor in this relationship, while BMI was not. (4) Discussion: The widespread use of social media in teenagers and young adults could increase body dissatisfaction as well as their drive for thinness, therefore rendering them more vulnerable to eating disorders. We should consequently take this social evolution into account, including it in general population prevention programs and in patients’ specific treatment plans.

1. Introduction

Body image is defined as one’s perception, thoughts, and emotions revolving around one’s own body. It is the depiction of one’s body representation, including their mirror reflection, and it reflects social constructs, which depend on a society’s culture and norms. This conception is created using body ideals, substantially communicated via media, family, and peers.

For the last 30 years, media have been over-exposing people to thinness ideals, starting from a young age [ 1 ], turning this ideal into a new reference standard [ 2 ]. Young women, who are most sensitive to thinness ideals, tend to liken them to beauty and success [ 3 ]. Thus, etiologic models incorporating environmental factors consider social pressure about physical appearance to be a determining factor in developing eating disorders (EDs) [ 4 , 5 ].

However, even though this social pressure is indisputable, not all people are vulnerable to it. It is the degree with which they will relate to these thinness standards, namely how they internalize this ideal, that will help to predict the risk of developing an ED [ 6 ]. Indeed, internalizing thinness standards can lead to an alteration in body image, resulting in body dissatisfaction and exaggerated concerns about body and weight [ 4 ]. Body dissatisfaction is characterized by an inconsistency between one’s real body and the idealized body. It is one of the most studied psychological constructs in body image disorders literature [ 4 , 7 , 8 , 9 ]. According to the literature, it is often linked to psychological distress [ 10 , 11 ] and is a proven risk factor for developing an ED [ 12 , 13 ], through, in particular, the implementation of food restriction that can lead to anorexia nervosa (AN) [ 14 , 15 ] or to the onset of binge eating episodes (with or without compensatory behaviors to prevent weight gain). According to several authors, body dissatisfaction found in AN patients differs from that of control subjects by a greater feeling of inconsistency between their actual body and the desired body [ 16 ]. Indeed, in addition to overestimating the size of their actual shape, AN patients seek to resemble an ideal significantly thinner than subjects without EDs do. People with AN and bulimia nervosa share the same body image obsession, with the pervasive fear of gaining weight [ 4 ]. Finally, subjects with binge eating disorders tend to be overweight, or even obese, which can reinforce body dissatisfaction [ 17 ].

Social comparison, combined with the internalization of ideals, is one of the main mechanisms participating in one’s body image perception. These two mechanisms are instrumental in developing body dissatisfaction [ 1 , 18 , 19 ]. Several studies have shown that individuals who compare their physical appearance to that of others they considered to be more attractive than them, such as models or celebrities, had a higher chance of being dissatisfied with their body image and developing an ED [ 20 , 21 , 22 , 23 ].

Although historically speaking, body norms have been mainly conveyed through traditional media (TV, radio, newspaper, magazines), the last few years have borne witness to the rise and expansion of social media use. The term “social media” refers to every website and online mobile app with user-generated content. They enable their users to participate in online exchanges, broadcast self-made content, and join virtual communities. They are mostly used by teenagers and young adults, and the most common ones are Facebook, Instagram, Snapchat, and Twitter. Several studies have suggested that social media exposure could foster body dissatisfaction and result in risky eating behaviors by broadcasting thinness ideals individuals thus long for [ 18 , 24 , 25 ]. Among the identified mechanisms that explain this outcome, the most common ones are social comparison based on physical appearance and thinness ideals’ internalization through daily exposure to idealized bodies. Indeed, physical appearance holds a central place in social media today [ 26 ].

There is, to this day, a lack of scientific data, and in particular French data, about the association between the use of social media and risky eating behaviors [ 27 ]. In this context, this study’s main objective was to study the association between, on one hand, daily exposure to idealized bodies through social media and, on the other hand, the presence of two dimensions fostering body image disorders: body dissatisfaction and drive for thinness. A secondary objective was to compare two populations, one with a risk of suffering from ED, and the other one free of that risk, using different variables. The hypothesis was that at-risk participants were more dissatisfied with their physical appearance, had a higher drive for thinness, and compared themselves more often to social-media-conveyed images.

2. Materials and Methods

2.1. study design and ethics statements.

This is a transversal observational study. Participants had to answer a questionnaire available online. Since it was an investigation involving the health field, but with an objective that did not involve the developing of biological or medical knowledge, it not fit in the French Jardé legal framework (and thus, approval from an ethics committee was not required). Data collection was made anonymously, was digitalized, and was realized outside of a care setting. Answering the questionnaire was interpreted as consent for data use, as it displayed that the results would be used in a survey, but that the participation would be anonymous, and that there were no data that would lead them to be recognized should they decide to participate.

2.2. Participants Recruitment

The study’s general population participants were enlisted via a social media publication (Facebook, Instagram, Twitter) and via posters in gyms. These posters were also sent to health workers with a practice in Nantes and in different French cities (psychiatrists, GPs, psychologists, etc.), who were tasked with informing their ED patients about this study. The Fédération Française Anorexie Boulimie (FFAB, French Federation for Anorexia and Bulimia), which is an association regrouping professionals working in the ED field, helped to broadcast the questionnaire using mailing lists, social media, and websites. Recruitment occurred between September 2019 and December 2019.

The inclusion criteria were as follows: using their Facebook and/or Instagram account daily and being 15 to 35 years old. This age range was chosen in light of the current literature, which shows that use of social media and body image concerns involved mainly teenagers and young people [ 28 , 29 ]. Moreover, participants recruited via a health professional had to register their ED diagnosis for which they were treated.

2.3. Evaluation

2.3.1. general data.

The questionnaire’s first part was designed to register sex, age, degrees, and current height and weight to measure body mass index (BMI).

2.3.2. Social Media Use

The questionnaire’s second part interrogated the participants about their use of social media: platform, frequency (number of uses per day), time spent (hours per day), frequency of comparing one’s physical appearance to that of people followed on social media, and the frequency of posting “selfies” (a photograph that you take of yourself).

2.3.3. Body Image

The questionnaire’s third part evaluated body image perception, using the Eating Disorder Inventory-2 (EDI-2) scale, translated and adapted in French [ 30 , 31 ]. It is a self-rated questionnaire evaluating psychological characteristics and symptoms associated with ED, using 11 subscales. We used the “Drive for Thinness” subscale (EDI-DT), composed of 7 questions (score of 0 to 21), and “Body Dissatisfaction” subscale (EDI-BD), composed of 9 questions (score of 0 to 27). The subscales are presented in Table 1 .

Drive for Thinness and Body Dissatisfaction subscales of Eating Disorder Inventory-2.

Drive for Thinness	Always (=3)	Usually (=2)	Often (=1)	Sometimes (=0)	Seldom (=0)	Never (=0)
1—I eat sweets and carbohydrates without feeling nervous
2—I think about dieting
3—I feel extremely guilty after overeating
4—I am terrified of gaining weight
5—I exaggerate or magnify the importance of weight
6—I am preoccupied with the desire to be thinner
7—If I gain a pound, I worry that I will keep gaining

1—I think that my stomach is too big (+)
2—I think that my thighs are too large (+)
3—I think that my stomach is just the right size (−)
4—I feel satisfied with the shape of my body (−)
5—I like the shape of my buttocks (−)
6—I think my hips are too big (+)
7—I think that my thighs are just the right size (−)
8—I think my buttocks are too large (+)
9—I think that my hips are just the right size (−)

2.3.4. ED Screening

The questionnaire’s last part aimed at screening ED, using the Sick-Control-One Stone-Fat-Food (SCOFF) self-questionnaire. It is a simple survey of 5 questions used to screen eating disorders in general population [ 32 ]. The French validation depicted this questionnaire to be as efficient and relatable as the original, with a great sensitivity and specificity in diagnosing ED when a patient has a score of 2 or over [ 33 ]. It enabled us to sort the population sample into two groups depending on their risk of having an ED: when their score was ≥2, they were sorted in the “SCOFF positive” group, and when their score was <2, in the “SCOFF negative” group. The SCOFF questionnaire is presented in Table 2 .

Sick-Control-One Stone-Fat-Food (SCOFF) questionnaire.

	Yes	No
1—Do you make yourself sick because you feel uncomfortably full?	□	□
2—Do you worry you have lost control over how much you eat?	□	□
3—Have you recently lost over 1 stone (14 lb) in a 3-month period?	□	□
4—Do you believe yourself to be fat when others say you are too thin?	□	□
5—Would you say that food dominates your life?	□	□

Yes = 1 point; score of ≥2 suggests an eating disorder.

2.4. Statistical Analysis

A descriptive statistical analysis was conducted for the entire sample. Continuous variables are described by means and standard deviations, while categorical variables are presented as numbers and percentages.

We asked all participants to complete the SCOFF questionnaire, so that they were sorted into two groups depending on their results: the “SCOFF+” group gathering all participants with a SCOFF score of 2 or over, and therefore with the risk of suffering from an ED, and the “SCOFF−” group gathering all participants with a SCOFF score under 2. These two groups were then compared based on all collected variables. We applied a Student’s t -test for quantitative variables (“age”, “EDI-BD”, “EDI-DT”, and “average BMI”), a Chi-squared test for qualitative variables (“sex”, “level of education”, “social media use frequency”, “time spent”, “body comparison”, “groups of BMI”), and Fisher exact test for multimodal qualitative variables whose theoretical headcount did not allow the use of the Chi-squared test (“posting selfies”).

Then, we looked for an association between the frequency of comparing one’s own physical appearance to that of people followed on social media and the scores measured using the EDI Body Dissatisfaction and Drive for Thinness subscales. We thus performed two linear regressions with adjustment for two potential confounding factors (BMI and level of education). Confounding factor status was assessed by searching for an association of the two variables with EDI subscores on the one hand and with the frequency of comparing one’s own physical appearance to that of people followed on social media on the other hand.

The significance threshold for all these analyses was set at p = 0.05 (α risk of 5%).

Statistical analyses were done using the SPSS software (Statistical Package for Social Science, IBM, Armonk, NY, USA).

3.1. Population Description

In total, 1407 questionnaires were completed, and 1331 were analyzed. A total of 1138 subjects were from the general population, and 193 were ED patients recruited via health workers. Seventy-six completed questionnaires (5.4%) were excluded from the analysis because they did not match the age criteria or because their ED diagnosis was not communicated (for ED patients recruited via health workers). Figure 1 represents the study’s flowchart.

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Object name is ijerph-18-02880-g001.jpg

Flow chart of subjects’ inclusion.

The participants’ age ranged from 15 to 35 (M = 24.2, σ = 4.2). Most were women (97.7%). They had, for the most part, a Bachelor’s degree. Mean BMI was 22.3 (σ = 4.2).

Table 3 presents the final sample’s characteristics.

Final sample characteristics and comparison between SCOFF+ and SCOFF− groups.

	Final Sample ( = 1331)		SCOFF− ( = 378)		SCOFF+ ( = 953)		Value
	Mean or Number of Participants	Standard Deviation or Percentage	Mean or Number of Participants	Standard Deviation or Percentage	Mean or Number of Participants	Standard Deviation or Percentage

	24.2	4.2	25.1	4.2	23.9	4.2	<0.001 ***
							(Student’s -test)
							0.012 *
Female	1300	97.7%	363	96.0%	937	98.3%	(Chi-squared test)
Male	31	2.3%	15	4.0%	16	1.7%
							<0.001 ***
Less than Level 12	71	5.3%	16	4%	55	6%	(Chi-squared test)
Level 12	229	17.2%	62	16%	167	18%
Level 12 + 2 years	208	15.6%	50	13%	158	17%
Level 12 + 3 (Bachelor’s degree)	320	24.0%	89	24%	231	24%
Level 12 + 5 (Master’s degree)	380	0.285	96	25%	284	30%
Degree over Level 12 + 5	123	0.092	65	17%	58	6%

							<0.001 ***
Max. once a day	64	5%	17	4%	47	5%	(Chi-squared test)
2 to 10 times a day	578	43%	194	51%	384	40%
10 to 20 times a day	439	33%	115	30%	324	34%
Over 20 times a day	250	19%	52	14%	198	21%
							0.010 **
Less than 1 h	232	17%	81	21%	151	16%	(Chi-squared test)
Between 1 and 5 h	1048	79%	289	76%	759	80%
Over 5 h	51	4%	8	2%	43	5%
							<0.001 ***
Never	33	2%	18	5%	15	2%	(Chi-squared test)
Seldom	114	9%	56	15%	58	6%
Sometimes	317	24%	130	34%	187	20%
Often	523	39%	133	35%	390	41%
Always	344	26%	41	11%	303	32%
							<0.001 ***
Never	457	34%	146	39%	311	33%	(Fisher exact test)
1 or 2 times a month	756	57%	199	53%	557	58%
Once a week	93	7%	24	6%	69	7%
3 to 4 times a week	18	1%	7	2%	11	1%
Daily	7	1%	2	1%	5	1%

	12.4	7.5	7.9	6.6	14.2	7	<0.001 ***
							(Student test)
	8.9	6	4.1	4.2	10.8	5.5	<0.001 ***
							(Student test)
	22.3	4.2	22.2	3.5	22.3	4.5	0.575
							(Student test)
							<0.001 ***
<17.5	96	7.2%	9	2.4%	87	9.1%	(Chi-squared test)
[17.5–25]	981	73.7%	306	81.0%	675	70.8%
≥25	254	19.1%	63	16.7%	191	20.0%

Note. BDI: body mass index; EDI-IC: Eating Disorder Inventory—Body Dissatisfaction; EDI-RM: Eating Disorder Inventory—Drive for Thinness. *: p < 0.05; **: p < 0.01; ***: p < 0.001. According to the International Classification of Diseases, anorexia nervosa is associated with a BMI < 17.5.

Most participants declared using Facebook (93%) and Instagram (92.8%). Other social media were less frequently used: Snapchat (68.4%), Twitter (29.1%), and Tiktok (2.5%).

In total, 57.3% of participants had a private account and 42.7% an account open to the public. Users declared that they used social media mainly to “like posts” (82.7%) and to “observe content, as ghost followers (bots or inactive accounts)” (65.4%). In total, 92.7% said that they used social media to “follow friends and acquaintances”, “follow healthy food content” (68%), “follow the news” (67%), and “follow fitness content” (61.2%).

Regarding participants recruited via health workers for whom data were analyzed (N = 193), the most frequently reported ED was anorexia nervosa restricting type (41%), followed by anorexia nervosa purging type (28%), binge eating disorder (16%), bulimia nervosa (12%), and unspecified feeding or eating disorder (9%).

3.2. Comparing Participants Based on Their ED Screening

The final sample was sorted into two groups according to the SCOFF’s results ( n = 953 in the SCOFF+ group; n = 378 in the SCOFF− group). These groups were compared using all described variables, and the results are showcased in Table 3 .

SCOFF+ group subjects had a significantly higher social media use (regarding both frequency and time spent), a significantly higher frequency of comparing their physical appearance to that of people they followed, and of posting selfies.

In addition, they declared having significantly higher EDI-BD and EDI-DT scores than SCOFF− subjects ( p < 0.001), and they more frequently had BMI both in the lower and higher ranges.

3.3. Association between the Frequency of Comparing One’s Own Physical Appearance to That of People Followed on Social Media and EDI Body Dissatisfaction and Drive for Thinness

In the search for confounding factors associated with both the frequency of comparing one’s own physical appearance to that of people followed on social media and EDI-BD and EDI-DT scores, we found a significant association between the level of education and the frequency of comparing one’s own physical appearance to that of people followed on social media ( Table 4 ). Similarly, we observed an association between the modality “Level of education ≥12” and EDI-BD: participants with a level of education ≥12 had a mean EDI-BD score 2.5 points lower compared to that of participants with a level of education <12 ( Table 5 ). We also found a similar association between the modality “Level of education ≥12” and EDI-DT: participants with a level of education ≥12 had a mean EDI-DT score 3 points lower compared to that of participants with a level of education <12 ( Table 6 ).

Association between level of education and frequency of comparing one’s own physical appearance to that of people followed on social media.

	Chi-Squared Test	-Value
Frequency of comparing one’s own physical appearance	38.165	0.008 **

Note. **: p < 0.01.

One-way ANOVA results looking for a link between EDI-BD score and level of education.

	Estimates	-Value
Intercept	13.620	<2 × 10 ***
Studies level: Less than level 12
Studies level: Level 12	−0.672	0.507
Studies level: Level 12 + 2 years	−0.778	0.447
Studies level: Level 12 + 3 (Bachelor’s degree)	−1.560	0.110
Studies level: Level 12 + 5 (Master’s degree)	−1.307	0.175
Degree over Level 12 + 5	−2.538	0.022 *

Global p -value = 0.1338. Note: The modality “Less than level 12” was chosen as the reference modality for this analysis. *: p < 0.05; ***: p < 0.001.

One-way ANOVA results looking for a link between EDI-DT score and level of education.

	Estimates	-Value
Intercept	10.141	<2 × 10 ***
Studies level: Less than level 12
Studies level: Level 12	−0.730	0.368
Studies level: Level 12 + 2 years	−0.477	0.561
Studies level: Level 12 + 3 (Bachelor’s degree)	−1.328	0.090
Studies level: Level 12 + 5 (Master’s degree)	−1.451	0.061
Degree over Level 12 + 5	−3.019	0.0007 ***

Global p -value = 0.0016. Note: The modality “Less than level 12” was chosen as the reference modality for this analysis. ***: p < 0.001.

Furthermore, we did not find any significant association between BMI and the frequency of comparing one’s own physical appearance to that of people followed on social media ( Table 7 ). A significant but very weak correlation (<0.3) was found between the BMI and the two EDI subscores ( Table 8 ). In view of these results, we did not retain BMI as a confounding factor for the following analysis.

One-way ANOVA results looking for a link between BMI and frequency of comparing one’s own physical appearance to that of people followed on social media.

	Estimates	-Value
Intercept	21.109	<2 × 10 ***
Body comparison: Never
Body comparison: Seldom	1.002	0.233
Body comparison: Sometimes	1.049	0.177
Body comparison: Often	1.155	0.130
Body comparison: Always	1.384	0.074

Global p -value = 0.4368. Note: The modality “Never” was chosen as the reference modality for this analysis. ***: p < 0.001.

Results of association between BMI and EDI scores.

	Coefficient de Correlation de Pearson Avec son IC à 95%	-Value
EDI-DT	0.071 [0.017; 0.1239]	0.0099 **
EDI-BD	0.253 [0.202; 0.302]	<0.001 ***

Note. EDI-BD: Eating Disorder Inventory—Body Dissatisfaction. **: p < 0.01; ***: p < 0.001.

The results of the search for an association between the frequency of comparing one’s own physical appearance to that of people followed on social media and EDI Body Dissatisfaction and Drive for Thinness scores are presented in Table 9 and Table 10 . As showcased in Table 9 , the “Sometimes”, “Often”, and “Always” frequency of comparing modalities were significantly associated with the EDI-DT score. Participants who sometimes compared their own physical appearance to that of people followed on social media had a mean EDI-DT score 2.0 points higher than that of those who never compared themselves; those who often compared themselves had a mean EDI-DT score 5.3 points higher; and those who always compared themselves had a mean EDI-DT score 8.4 points higher.

Linear regression looking for a link between EDI-DT score and frequency of comparing one’s own physical appearance to that of people followed on social media.

	Estimates	-Value
Intercept	5.859	8.7 × 10 ***
Body comparison: Never
Body comparison: Seldom	0.438	0.678
Body comparison: Sometimes	2.021	0.038 *
Body comparison: Often	5.314	3.4 × 10 ***
Body comparison: Always	8.421	<2.2 × 10 ***
Studies level: Less than level 12
Studies level: Level 12	−1.399	0.053
Studies level: Level 12 + 2 years	−1.415	0.0539
Studies level: Level 12 + 3 (Bachelor’s degree)	−1.723	0.0138 *
Studies level: Level 12 + 5 (Master’s degree)	−1.999	0.0038 **
Degree over Level 12 + 5	−2.936	0.0002 ***

Global p -value <2.2 × 10 −16 ***. Note: Modalities “Less than level 12” and “Never” were chosen as the reference modalities for this analysis. *: p < 0.05; **: p < 0.01; ***: p < 0.001.

Linear regression looking for a link between EDI-BD score and frequency of comparing one’s own physical appearance to that of people followed on social media.

	Estimates	-Value
Intercept	9.087	1.1 × 10 ***
Body comparison: Never
Body comparison: Seldom	1.225	0.365
Body comparison: Sometimes	1.768	0.158
Body comparison: Often	5.564	6.5 × 10 ***
Body comparison: Always	9.226	2.4 × 10 ***
Studies level: Less than level 12
Studies level: Level 12	−1.437	0.122
Studies level: Level 12 + 2 years	−1.785	0.058
Studies level: Level 12 + 3 (Bachelor’s degree)	−1.986	0.027 *
Studies level: Level 12 + 5 (Master’s degree)	−1.940	0.029 *
Degree over Level 12 + 5	−2.471	0.016 *

Global p -value <2.2 × 10 −16 ***. Note: Modalities “Less than level 12” and “Never” were chosen as the reference modalities for this analysis. *: p < 0.05; ***: p < 0.001.

In addition, according to Table 10 , the “Often” and “Always” frequency of comparing modalities were significantly associated with the EDI-BD score. Participants who often compared their own physical appearance to that of people followed on social media had a mean EDI-BD score 5.6 points higher than that of those who did not, and those who always compared themselves to social media images had an average EDI-BD score 9.2 points higher than that of those who never did.

4. Discussion

4.1. discussing the main results.

Our survey aimed to study the links between social media use, body image disorders, and ED prevalence in a teenage and young adult population.

First, we found that ED or at-risk of ED subjects presented significantly different results concerning all social media use parameters. Using platforms such as Facebook and Instagram has been particularly associated with a higher body dissatisfaction and the appearance of ED symptoms [ 27 , 34 ]. As was expected, in ED or at-risk of ED patients, Body Dissatisfaction rates were higher, as was their Drive for Thinness. A common ED assumption is that ED patients develop a cognitive structure that focalizes on weight, combined with, most of the time, a mistaken perception of their own body image, especially in anorexia nervosa. These subjects tend to yearn for a thinner body ideal than the general population, thus creating a substantial inconsistency between what they think they look like and what they yearn to look like [ 35 ]. Leahey and her colleagues in 2011 [ 36 ] found that, in addition to increasing body dissatisfaction, social comparisons have an influence on negative effects, guilt, as well as diets and physical-activity-centered thoughts.

Participants in general were seldom prone to posting selfies. Ridgway and her colleagues [ 37 ] conducted in 2018 a study on Instagram and posting selfies, which showed that a higher body image satisfaction was associated with an increase in posting selfies. This could explain the low percentage of self-promoting subjects found in this study.

Second, we confirmed the existence of a significant association between, on one hand, the frequency of comparing one’s own physical appearance to that of people followed on social media and, on the other hand, Body Dissatisfaction and Drive for Thinness scores measured using the EDI scale. It seems that the more the subjects compared themselves to the images, the more they increased their body dissatisfaction and their drive for thinness. However, this association can work two ways. Indeed, it could be that the depth of body dissatisfaction and the drive for thinness increase the inclination to compare oneself to images. Our results are in accordance with those found in the literature, which identified a link between social media use and body image disorders [ 26 , 38 , 39 ]. It has also been found that subjects who often compared their physical appearance to that of idealized images were more dissatisfied with their body and had a higher drive for thinness than those who compared themselves less often [ 40 , 41 ]. Interestingly, the level of education was a confounding factor in this relationship, while BMI was not. Indeed, the relation between frequency of comparing one’s own physical appearance to that of people followed on social media on the one hand and EDI DT and BD subscores on the other hand is modified by the level of education, starting from a level corresponding to a Bachelor’s degree (>12 + 3 years).

Self-assessment is a fundamental reflexive analysis tool [ 42 ]. It plays an essential part in self-positioning among others and oneself. This self-evaluation must resort to social comparisons, which have a direct link to self-esteem. Body image’s sociocultural construct takes shape using body ideals that are broadcasted through, in particular, media, family, and peers and are thereafter internalized by individuals [ 43 ]. Reaching these body norms is usually perceived as proof of self-control and success, which leads one to stand out from the crowd in a positive way [ 44 ]. Internalizing body ideals thus creates an authentic concern for one’s physical appearance, which will be observed and judged by others [ 45 ]. This can trigger body dissatisfaction, which usually involves feeling inadequate in one’s body, estranged from the ideal one pursues [ 43 ]. Fear of gaining weight can be exacerbated when thinness is one of narcissism’s only tools. It can lead to behaviors such as food restriction, excessive physical activity, with the aim of modifying one’s appearance and thus fit into social standards. This excessive self-surveillance can bring about emotional and psychological consequences, including shame about one’s own body, self-bashing, anxiety, and depression, up to ED [ 46 ].

Finally, although estimating ED prevalence in a young adult population was not an objective determined beforehand, we must point out that most participants had a SCOFF+ result (71%), suggesting they might suffer from an ED. This questions whether a more systematic ED screening should be done in teenage and young adult populations, which are ED’s main targets. Several studies in which teenagers were interviewed have shown that they often are dissatisfied with their bodies, feeling like they are “too fat”, and most of them have already followed a diet [ 47 , 48 , 49 ]. These diets can include ingesting smaller portions, eating healthier food, up to major food restrictions and complete removal of some types of food, which can be found in ED.

4.2. Study’s Strengths and Weaknesses

There are several limits to this study. First, it is a transversal study, which cannot prove the existence of a causal relationship between the studied variables. Therefore, longitudinal studies are necessary in finding out how this association works. Second, the online questionnaire was not designed to collect data that could be considered as indicators of individual or family vulnerabilities for ED, which did not allow for stratified analyses. Third, measuring the time spent on social media and how often participants used it was done through self-reported data, which could induce a declaration bias, thus limiting the data’s precision. Future studies could use technologies such as data tracking (virtual counter measuring connection frequency and time spent) in order to have more precise data and thus be more confident in the data’s reliability. Fourth, the participants’ recruitment induced a selection bias. Indeed, having used daily use of social media as an inclusion criterion leads to selecting a certain type of population and renders irrelevant any extrapolation to the general population. Moreover, recruiting via gyms may have led to selecting individuals with a specific concern for their body image. We can assume that these subjects, who paid specific attention to their physical appearance, might have certain demands concerning themselves, which might involve body dissatisfaction and an exaggerated drive for thinness. The daily use of social networks could also be a reflection of excessive body concerns, which could lead to more body dissatisfaction and a more pronounced drive for thinness compared to subjects who are less exposed to these kinds of media. Fifth, our participants recruited via health workers may not be representative of all ED patients for several reasons: ED diagnosis was self-reported, anorexia nervosa restricting type was overrepresented in our sample, and the most severe patients may not be psychologically available to participate in a study like this one. Finally, the SCOFF questionnaire is a screening tool and not a diagnostic one. It does not enable discriminating between anorexia nervosa, bulimia nervosa, or binge eating disorder among participants, but we can assume that all types of ED were present in the SCOFF+ group, as the participants in this group more frequently had BMI both in the lower and higher ranges.

However, these limits are balanced by the study’s strengths. First, the sample rallied a significant number of participants, and their sorting into two groups after ED screening was quite proportionate, which ensured the statistical analyses’ power. Second, EDs were screened using a validated tool for the general population, and the Body Dissatisfaction and Drive for Thinness dimensions were evaluated using a self-questionnaire whose psychometric characteristics have been validated in clinical populations. Finally, to the extent of our knowledge, this type of study had never been conducted in France, thus bringing forth unprecedented data.

4.3. Perspectives

This study’s results open new avenues for clinicians to explore social media use and cognitive pathways in ED. Indeed, social media exposure and, in particular, exposure to edited and idealized images could contribute to inaccurate thought processes about body image, internalizing what is socially valued on social media as a personal goal. Since we know that cognitive pathways play an important part in ED development and continuation [ 50 ], it seems relevant to explore patients’ use of social media and the cognitions associated. This could contribute to increasing psychotherapy’s efficacy, enriching prevention programs using cognitive dissonance, therapies that have been proven to be effective in reducing ED symptoms’ intensity [ 51 ]. A way to implement this could be to encourage the development of the ability to question social media, encouraging patients to think of arguments that go against posting idealized photos on social media [ 27 ].

When considering the general population, when we see how important social comparison based on physical appearance is in developing body dissatisfaction, prevention programs could be useful. It seems relevant to encourage teenagers, particularly those with the tendency to compare themselves to their peers, to evaluate their body using health criteria instead of using other peoples’ bodies as a standard. Additionally, it would be interesting to intervene by deconstructing the “ideal body” myth, with the goal of diminishing the comparison to “idols”. Finally, it seems relevant to inform people that some role models’ BMI and body type are not representative of those of most of the population and that trying to reach their body type could be harmful. ED screening in this population should thus be more systematic.

5. Conclusions

To summarize, we found an association between the frequency of comparing one’s own physical appearance to that of people followed on social media and body dissatisfaction and drive for thinness. Interestingly, the level of education was a confounding factor in this relationship, while BMI was not. The widespread use of social media in teenagers and young adults could increase body dissatisfaction as well as their drive for thinness, therefore rendering them more vulnerable to eating disorders.

Acknowledgments

The authors would like to thank the French Federation for Anorexia and Bulimia (Fédération Française Anorexie-Boulimie (FFAB)), who allowed the broadcasting of the questionnaire to its members, ED-specialized health workers.

Author Contributions

Study concept and design: B.J., B.R., and M.G.-B. Analysis and interpretation of data: B.J., B.N., B.R., and M.G.-B. Statistical analysis: M.D. Study supervision: B.R. and M.G.-B. Investigation (data collection): B.J., B.R., and M.G.-B. Writing—original draft: B.J. and B.N. Critical revision: M.D., B.R., and M.G.-B. Writing—revised version of the manuscript: B.J., M.D., and M.G.-B. All authors have read and agreed to the published version of the manuscript.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Institutional Review Board Statement

Since the study was an investigation involving the health field, but with an objective that did not involve the development of biological or medical knowledge, it not fit in the French Jardé legal framework. The approval from an ethics committee was not required according to the current French legislation.

Informed Consent Statement

Data collection was made anonymously. According to the current French legislation, answering the questionnaire was interpreted as consent for data use.

Data Availability Statement

Conflicts of interest.

The authors declare no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Social Media Use and Body Image Disorders: Association between Frequency of Comparing One’s Own Physical Appearance to That of People Being Followed on Social Media and Body Dissatisfaction and Drive for Thinness