Body dysmorphic disorder is a preoccupation with a perceived flaw in appearance that other people cannot see or think is slight. It is not vanity, and it is not the ordinary dissatisfaction almost everyone has about something.
What separates it is how much of the day it takes and what it makes you do. Hours of preoccupation, and repetitive checking or concealing that is genuinely hard to stop, are the features that matter. [dsm5tr-bdd]
What the condition actually involves
The condition involves a preoccupation with one or more perceived defects, distress or impairment that follows from it, and repetitive behaviours performed in response. All three parts are required. The third is the one people most often do not realise belongs in the picture.
Skin, hair, nose and body build are the most commonly reported focuses, though any feature can be involved. It is a separate condition from the eating disorders it is most often confused with, where the concern centres on weight and shape and drives eating behaviour. The behaviours are consistent across whichever feature it is: checking in mirrors or avoiding them entirely, excessive grooming, camouflaging with clothing, makeup or posture, comparing with other people, and seeking reassurance that never quite settles anything.
How it differs from ordinary appearance concern
The difference is not how much you dislike the feature but how much of your life it occupies. Almost everyone has something they would change. That near-universal dissatisfaction is not what this describes.
A schematic of the distinctions described in this article and in the diagnostic criteria, not measured data.
Notice that the bottom bar is high in both. Disliking a feature is where the two overlap almost completely, which is why comparing the strength of the dislike tells you nothing. The three bars above it are where they separate.
Is this taking more of your day than you thought?
These are the features that distinguish the condition from ordinary appearance concern. Tick anything that has been true over the past month.
0 of 6 ticked
Most of this is familiar to you, which is worth raising with a doctor or therapist. This is a prompt to have a conversation, not an assessment of anything.
A couple of these are familiar. Worth watching how much of your day it is taking, and worth mentioning if you are already speaking to somebody.
Little here matches the condition. Ordinary dissatisfaction with a feature is extremely common and is not what this article describes.
This is not a screening tool and no self-assessment on this site measures this condition. Only a clinician can assess it.
Why cosmetic procedures rarely resolve it
Procedures rarely help because the distress is produced by the preoccupation rather than by the feature. Change the feature and the preoccupation is still there, so it either settles back onto the same area or moves to a new one, which is a well-documented pattern.
This is the most consequential thing to know before booking anything irreversible. Ask first. People with the condition are substantially over-represented among those seeking cosmetic treatment, and considerably more likely than other patients to be dissatisfied afterwards. A surgeon who declines to operate and suggests an assessment instead is not dismissing you.
Who it affects
It affects an estimated 1.8 percent of the general population, across all genders. [buhlmann-bdd-prevalence] The common assumption that this is a condition of young women is wrong, and the assumption itself is part of why it goes unrecognised in everybody else.
Onset is usually in adolescence, and the average gap between onset and diagnosis is long. Shame is the main reason. The concern feels superficial to the person experiencing it, so it goes unmentioned even in appointments arranged for something else. Nobody thinks it is a reasonable thing to bring up, which is exactly why so few clinicians hear about it.
What treatment works
Cognitive behavioural therapy adapted specifically for this condition is the recommended first-line psychological treatment, usually including exposure and response prevention to reduce the checking, camouflaging and reassurance seeking. [nice-cg31-bdd] Generic talking therapy is not the same thing, so it is worth asking whether the therapist has worked with this particular condition.
Guidelines describe a stepped approach in which the intensity of treatment follows severity, and a selective serotonin reuptake inhibitor is an option where symptoms are more severe or where therapy alone has not been sufficient. Treatment works. The obstacle is that people do not raise the problem, not that the problem resists treatment.
When to seek help
Speak to a doctor if a concern about your appearance is taking up more than an hour a day, is changing what you do, or has led you to consider a cosmetic procedure. That last one matters most. It is the decision hardest to reverse, so get an assessment before you book anything.
Two things make the conversation easier. Say how much time it takes rather than describing the feature, because time and interference are what a clinician is listening for. And say what you do about it: the checking and concealing behaviours are the part that most clearly identifies the condition, and they are the part people are least likely to volunteer.
How MyFreud can help
MyFreud’s daily tracking is useful for the thing this condition hides best, which is how much of your day it takes. Most people substantially underestimate it until they log it, and having a fortnight of that record is far more useful in an appointment than trying to describe the feature that worries you.
Download MyFreud and start today: App Store or Google Play.