Body dysmorphic disorder: symptoms, causes and treatment

Key points

• Body dysmorphic disorder, or BDD, is a preoccupation with a flaw in appearance that others cannot see or think slight [1][5]. Body dysmorphia is the everyday word for it [1].
• Repetitive behaviours define it as much as the worry: mirror checking or avoidance, camouflaging, comparing, reassurance seeking, skin picking [1][3].
• ICD-11 and NICE both group BDD with OCD, which guideline CG31 covers together [2][10].
• Cosmetic procedures are often sought, rarely settle the concern, and the preoccupation commonly moves to another feature [6].
• NICE recommends CBT including exposure and response prevention adapted for BDD, with an SSRI as impairment increases [2].

What body dysmorphic disorder is

Body dysmorphic disorder is a mental health condition in which a person spends a long time worrying about a flaw in their appearance that other people cannot see, or think is minor [1]. The worry comes with repeated behaviours such as mirror checking, camouflaging or comparing. Most people call it body dysmorphia.

If you need help now. Samaritans: call 116 123, free, 24/7. Shout: text SHOUT to 85258. NHS 111, then choose the mental health option. Call 999 if anyone is in immediate danger.

In ICD-11, the World Health Organization’s current classification, BDD sits with the obsessive-compulsive and related disorders [10]. NICE covers OCD and BDD in one guideline, CG31, because they share features and treatment [2].

No reliable UK population figure exists. Community studies put the rate near 0.7%, and more recent estimates suggest 2% to 3% of adults [5][6]. Between 5% and 15% of cosmetic surgery patients meet criteria [6]. It usually starts around 16 to 18, and up to 15 years can pass before a person reaches mental health services [8].

Symptoms

BDD combines a preoccupation with appearance and behaviours to check, hide or correct it.

The preoccupation

• Worry about one feature, most often the skin, nose, hair, eyes, chin or lips [1][8]
• Appearance on the mind for hours a day, with over an hour counted as excessive by NICE [4]

Repetitive behaviours

• Mirror checking, in mirrors or reflective surfaces [3]
• Mirror avoidance, covering or removing mirrors [1]
• Camouflaging with make-up, hair, clothing or posture [3][6]
• Comparing the feature with other people’s, in person and in photographs [1]
• Reassurance seeking, asking repeatedly how the feature looks [3]
• Skin picking to smooth the skin, which can damage it [1][6]

Social situations, photographs and intimacy are often avoided, and some people become housebound [1][3][6].

Why the behaviours continue. Checking, camouflaging and reassurance lower distress briefly, then the doubt returns and the behaviour repeats [3][6]. Treatment therefore targets the behaviours rather than the appearance, using exposure and response prevention, as in OCD [1][2].

Commonly confused with. Ordinary dissatisfaction with appearance, OCD, social anxiety disorder and eating disorders. In BDD the focus is one perceived flaw, in an eating disorder weight and shape overall, though both can be present [5][7].

Types

BDD has no formal subtypes in ICD-11, but several presentations are recognised [10].

• Muscle dysmorphia. The belief that the body is too small or not muscular enough, mostly affecting men, and recorded in the American manual DSM-5 as a specifier [5]. It can lead to heavy training, restrictive eating and steroid use [7].
• BDD by proxy. The preoccupation is with someone else’s appearance, usually a partner or child [9]. Behaviours are the same, and the same treatment appears to work, though research is limited [9].
• By level of impairment. NICE separates mild, moderate and severe impairment, which decides what is offered [2].

Causes and risk factors

No single cause has been identified. BDD is understood as developing from a mix of inherited traits and experience [1].

• A family history of BDD or related conditions [1]
• Being teased, bullied or abused in childhood [1]
• Depression, social phobia and OCD, which often occur alongside BDD [3]

BDD is not vanity. On a quality of life measure, people with BDD reported distress worse than that reported in depression, diabetes or bipolar disorder [6].

Suicide risk. NICE states that the risk of suicide is high in people with BDD [2]. In one series of 33 children and adolescents, 21% reported suicidal thoughts or an attempt [3]. Anyone struggling to stay safe can use the numbers above now.

How it is diagnosed

A GP is the usual starting point, and people in England can refer themselves to NHS Talking Therapies without a GP referral [1]. A diagnosis is normally recorded by a psychiatrist registered with the GMC, a clinical psychologist registered with the HCPC, or another qualified professional.

NICE suggests five identification questions covering the specific concerns, hours a day spent on them, and the effect on work and friendships [4].

Assessment is a conversation, not a physical examination. It covers how long the concern has lasted, which behaviours happen and how often, what is avoided, previous cosmetic treatment, and mood and safety. NICE recommends that anyone with suspected BDD seeking cosmetic surgery or dermatology is first assessed by a mental health professional with BDD expertise [4].

A diagnosis names a recognised pattern and opens access to treatment. It does not mean the distress was imagined.

Treatment

NICE recommends psychological therapy first, with medication offered alongside or instead as impairment increases [2].

• Mild impairment. CBT including ERP addressing the key features of BDD, individually or in a group [2]. For OCD the same guideline starts lower, with brief self-help based CBT [2].
• Moderate impairment. A choice of an SSRI or more intensive individual CBT including ERP [2].
• Severe impairment. Combined SSRI and CBT including ERP [2].
• Children and young people. CBT including ERP involving the family or carers, adapted to the child’s age, as first-line treatment [2][4].

Medication. NICE names fluoxetine as the first SSRI choice, because the evidence for it in BDD is stronger than for other SSRIs [2]. SSRIs can take up to 12 weeks to affect symptoms [1], and NICE advises at least 12 months of treatment [2]. Decisions about medicine are for a GP or prescriber.

If treatment does not work, NICE recommends review by a team with BDD expertise, further CBT from a different team, or adding buspirone to an SSRI, with closer monitoring because suicide risk is high [2].

Cosmetic procedures. Many people with BDD seek cosmetic surgery or dermatology first, and in one clinic series 26% had obtained one or more operations [6]. Outcomes are poor: in one study 82.6% reported symptoms the same or worse afterwards, and after half of all procedures the preoccupation moved elsewhere on the body [6]. Having had a procedure is not a failure and does not stop treatment helping.

Living with body dysmorphic disorder

Management follows the same principle as therapy: reduce the behaviours that keep it going.

• Record checking, comparing, camouflaging and reassurance requests for a week, then cut them in steps [2]
• Use mirrors for a set purpose and time, rather than long sessions or total avoidance [1]
• Agree one calm, repeated answer with family for reassurance questions
• Reduce what prompts comparing, such as appearance-focused feeds and photo editing apps [2]
• Delay cosmetic procedure decisions until you have had a BDD assessment [4]

You do not have to tell an employer or university your diagnosis. Occupational health or student support can arrange adjustments without clinical detail being passed on. Mind and the BDD Foundation provide UK information and support [7][8]. Any private therapist should be registered with HCPC, BPS, BACP, UKCP or GMC.

When to speak to a professional

Speak to a GP, or self-refer to NHS Talking Therapies in England, if:

• Appearance has been on your mind for more than an hour a day for weeks [4]
• Checking, camouflaging or comparing affects work, study, sleep or relationships
• You are avoiding people, photographs or going out because of how you look
• You are picking your skin, or training or eating in a way that causes harm
• You are planning or repeating cosmetic procedures and any relief does not last

Contact your GP the same day, or call NHS 111 and choose the mental health option, if you cannot manage daily tasks. If you are having thoughts of ending your life, or cannot keep yourself safe, call Samaritans on 116 123, text SHOUT to 85258, or call 999 if anyone is in immediate danger.

Common questions

Is body dysmorphia the same as body dysmorphic disorder?

Yes. Body dysmorphia is the everyday term, and body dysmorphic disorder is the clinical name used in NHS records and NICE guidance [1][2].

Is BDD an eating disorder?

No, although the two can occur together. In BDD the preoccupation is with one perceived flaw, often in the face, while an eating disorder centres on weight and shape overall [5][7]. Where criteria for both are met, both are diagnosed [5].

Does cosmetic surgery help BDD?

Usually not. Most report no improvement, and the preoccupation often moves to another feature [6]. NICE recommends mental health assessment before cosmetic treatment where BDD is suspected [4].

What treatment does the NHS offer for BDD?

NICE recommends CBT including exposure and response prevention adapted for BDD, with an SSRI as an alternative or addition depending on impairment [2]. Children are offered family-involved CBT first [2].

Clinical review pending

References

1. NHS. Body dysmorphic disorder (BDD). NHS, 2026. https://www.nhs.uk/mental-health/conditions/body-dysmorphia/
2. National Institute for Health and Care Excellence. Obsessive-compulsive disorder and body dysmorphic disorder: treatment. Clinical guideline CG31, recommendations, 2005. https://www.nice.org.uk/guidance/cg31/chapter/Recommendations
3. National Collaborating Centre for Mental Health. Obsessive-compulsive disorder and body dysmorphic disorder, chapter 2 (NICE clinical guideline 31 full guideline). NCBI Bookshelf, 2006. https://www.ncbi.nlm.nih.gov/books/n/nicecg31/ch2/
4. National Collaborating Centre for Mental Health. Summary of recommendations, chapter 10 (NICE clinical guideline 31 full guideline). NCBI Bookshelf, 2006. https://www.ncbi.nlm.nih.gov/books/n/nicecg31/ch10/
5. Body Dysmorphic Disorder. StatPearls, NCBI Bookshelf. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK555901/
6. Veale D. Body dysmorphic disorder. Postgraduate Medical Journal, 80(940), 2004. https://pmj.bmj.com/content/80/940/67
7. Mind. Body dysmorphic disorder (BDD): about BDD. Mind. https://www.mind.org.uk/information-support/types-of-mental-health-problems/body-dysmorphic-disorder-bdd/about-bdd/
8. BDD Foundation. What is BDD? BDD Foundation. https://bddfoundation.org/information/what-is-bdd/
9. BDD Foundation. BDD by proxy. BDD Foundation. https://bddfoundation.org/information/bdd-by-proxy/
10. World Health Organization. Clinical descriptions and diagnostic requirements for ICD-11 mental, behavioural and neurodevelopmental disorders. WHO, 2024. https://www.drugsandalcohol.ie/41519/1/WHO_Clinical_descriptions_and_diagnostic_requirements_ICD-11.pdf