AKT · Psychiatry/Anxiety & stresslow yield

Body dysmorphic disorder

Overview

An OCD-spectrum disorder of preoccupation with a perceived defect in appearance that is unnoticeable or slight to others, driving repetitive behaviours (mirror-checking, camouflaging, reassurance-seeking) and significant distress/impairment.

Recognise

Preoccupation with a perceived appearance flaw (often skin, nose, hair) that others cannot see
Repetitive behaviours: mirror-checking or avoidance, camouflaging, comparing, reassurance-seeking, skin-picking
Marked distress; may seek repeated cosmetic procedures; high suicide risk

Red flags

High suicide risk; repeated requests for cosmetic surgery (rarely satisfying)

Differentials & how to tell them apart

Obsessive-compulsive disorderobsessions/compulsions not focused specifically on appearance

Eating disorderspreoccupation is with weight/shape and eating behaviour, not a specific appearance defect

Phobias (including agoraphobia)cued fear of an object/situation, not a perceived bodily defect

Delusional disorderif the belief is held with delusional (no insight) intensity

Investigations

Clinical; screen for depression and suicide risk; ask specifically (often concealed through shame).

Management

1CBT (with exposure and response prevention) ± SSRI, mirroring OCD treatment.Gate: Cosmetic procedures rarely help and often worsen BDD → direct to psychological/psychiatric care instead
2Higher-dose/longer SSRI course; manage suicide risk; specialist referral if severe.

SSRI (often higher dose) — as for OCD; e.g. fluoxetine

CBT with ERP — exposure/response prevention is first-line

Key points

On the OCD spectrum — treated like OCD (SSRI + ERP). Patients often present to dermatology/cosmetic services rather than psychiatry.

Monitor & prognosis

Symptom severity, suicide risk, response to SSRI/CBT.

Improves with SSRI + ERP; chronic if untreated.

Source: NICE CG31 (OCD/BDD)