body dysmorphia research questions

• Research article
• Open access
• Published: 15 June 2021

Body dysmorphic disorder and self-esteem: a meta-analysis

• Nora Kuck 1 ,
• Lara Cafitz 1 ,
• Paul-Christian Bürkner 2 ,
• Laura Hoppen 1 ,
• Sabine Wilhelm 3 &
• Ulrike Buhlmann 1  

BMC Psychiatry volume  21 , Article number:  310 ( 2021 ) Cite this article

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Body dysmorphic disorder (BDD) is associated with low self-esteem. The aim of this meta-analysis was to examine the strength of the cross-sectional relationship between BDD symptom severity and global self-esteem in individuals with BDD, mentally healthy controls, community or student samples, and cosmetic surgery patients. Moreover, the role of depressive symptom severity in this relationship and other moderating factors were investigated.

A keyword-based literature search was performed to identify studies in which BDD symptoms and global self-esteem were assessed. Random effects meta-analysis of Fisher’s z-transformed correlations and partial correlations controlling for the influence of depressive symptom severity was conducted. In addition to meta-analysis of the observed effects, we corrected the individual correlations for variance restrictions to address varying ranges of BDD symptom severity across samples.

Twenty-five studies with a total of 6278 participants were included. A moderately negative relationship between BDD symptom severity and global self-esteem was found ( r  = −.42, CI  = [−.48, −.35] for uncorrected correlations, r  = −.45, CI  = [−.51, −.39] for artifact-corrected correlations). A meta-analysis of partial correlations revealed that depressive symptom severity could partly account for the aforementioned relationship ( pr  = −.20, CI  = [−.25, −.15] for uncorrected partial correlations, pr  = −.23, CI  = [−.28, −.17] for artifact-corrected partial correlations). The sample type (e.g., individuals with BDD, mentally healthy controls, or community samples) and diagnosis of BDD appeared to moderate the relationship only before artifact correction of effect sizes, whereas all moderators were non-significant in the meta-analysis of artifact-corrected correlations.

Conclusions

The findings demonstrate that low self-esteem is an important hallmark of BDD beyond the influence of depressive symptoms. It appears that negative evaluation in BDD is not limited to appearance but also extends to other domains of the self. Altogether, our findings emphasize the importance of addressing self-esteem and corresponding core beliefs in prevention and treatment of BDD.

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Introduction

Body dysmorphic disorder (BDD) is characterized by a preoccupation with perceived appearance defects and repetitive behaviors intended to hide, fix or check them. The perceived flaws are not observable or only appear minimal to others. Affected individuals may excessively check their body areas of concern, seek reassurance, camouflage or groom, compare their own physical appearance to that of others, exercise to the point of injury, or even seek cosmetic surgery [ 1 ]. The symptoms frequently lead to marked impairment in social functioning and reduced quality of life [ 2 ].

In general, BDD is associated with low self-esteem [ 3 ]. Rosenberg defined self-esteem as one’s positive or negative attitudes towards the self. Accordingly, persons may have favourable or unfavourable opinions about themselves and self-esteem is an overall evaluation of one’s value [ 4 ]. Thus, the question arises how strongly the negative evaluation in the domain of physical appearance in BDD is accompanied by general feelings of unworthiness and a low self-esteem. Several studies have investigated self-esteem in BDD (e.g., [ 3 , 5 , 6 ]). The samples comprised clinical samples (e.g., [ 7 ]), combined samples of patients and healthy control participants (e.g., [ 8 ]), non-clinical community (e.g., [ 9 , 10 ]) or student samples (e.g., [ 11 , 12 , 13 ]). Moreover, data on self-esteem and BDD symptoms in cosmetic surgery settings have been collected (e.g., [ 14 , 15 , 16 ]). Altogether, more pronounced BDD symptoms were related to lower self-esteem in these studies. However, the reported effect sizes varied from r  = − .04 to r  = − .52, or d  = 0.66 to d  = 2.26. In addition, various authors assessed BDD symptoms and self-esteem but did not report effect sizes, and so far, no meta-analysis or review has systematically analyzed and integrated these studies.

A frequent comorbid disorder in BDD is major depression [ 17 ]. Summers et al. demonstrated the interconnectedness of BDD symptoms and depressive symptoms in a network analysis of BDD and major depressive disorder [ 18 ]. Elevated levels of depressive symptoms were found in adolescents with high appearance anxiety [ 19 ]. This shows that, regardless of the diagnostic categories, BDD and depressive symptoms tend to co-occur. Moreover, depression is linked to low self-esteem [ 20 ]. Feelings of worthlessness are among the diagnostic criteria for major depression [ 1 ]. According to a meta-analysis by Sowislo and Orth, low self-esteem represents a risk factor for depressive symptoms rather than a consequence [ 21 ]. Still, low self-esteem and depressive symptoms might reciprocally affect each other [ 20 ]. The connection of depressive symptoms to self-esteem and BDD may have consequences for the relationship between BDD symptoms and self-esteem. More precisely, the co-occurrence of BDD symptoms and low self-esteem may either be specific to BDD or may be caused by high levels of comorbid depressive symptoms. In this regard, Cerea et al. already pointed to the relevance of clarifying the relationship between BDD and self-esteem [ 9 ]. So far, only two studies reported partial correlations and suggested that depressive symptoms might contribute to the relationship between BDD symptoms and self-esteem. A study by K. A. Phillips et al. revealed a zero-order correlation of r  = − .38 and a partial correlation of pr  = −.16 [ 3 ]. Bartsch et al. found an uncontrolled correlation of r  = − .48 and a partial correlation of pr  = −.32 [ 22 ]. Besides, several studies measured depressive symptoms alongside with BDD symptoms and self-esteem but did not provide a partial correlation. Analyzing these studies with meta-analytic techniques and gathering corresponding effect sizes can shed light on the role of depressive symptoms.

Another relevant question is whether the strength of the relationship between BDD symptoms and self-esteem varies systematically between different subgroups. On the one hand, low self-esteem might particularly act as a risk factor for BDD in certain groups such as adolescence. Adolescence is a developmental phase in which body image concerns are common [ 23 ]. BDD most frequently begins in this period [ 24 ]. Also, adolescence is characterized by declining self-esteem [ 25 , 26 , 27 ]. Furthermore, decreased self-esteem appears to be strongly related to dysmorphic concern in adolescents [ 28 ]. Thus, if low self-esteem represented a risk factor for BDD, it could have a more severe impact in a vulnerable period such as adolescence. On the other hand, BDD symptoms might result in lower self-esteem in adolescence and young adulthood than in middle and old age. The concept of contingent self-esteem refers to the degree to which self-esteem depends on achievements and feedback in different domains such as appearance, academic success, relationships, or virtue [ 29 ]. A study by Meier et al. suggested that self-esteem might become less contingent on interpersonal conflicts across the life course [ 25 ]. If contingent self-esteem also decreased in other domains, a preoccupation with perceived defects in appearance might have a larger effect on self-esteem in adolescence and young adulthood compared to middle and old age. Further, some studies found that women tend to have more contingent self-esteem than men, particularly in the domain of appearance [ 25 , 30 ]. Hence, BDD symptoms might possibly affect self-esteem more strongly in women than in men. Alternatively, it is possible that the effects of appearance concerns on self-esteem are stronger in individuals with (vs. without) a clinical diagnosis of BDD given that - according to our clinical observation - individuals with clinical BDD build their self-esteem predominantly on how they look. So far, there has been a lack of longitudinal studies on BDD symptoms and self-esteem, and therefore we do not know whether low self-esteem could cause BDD. Also, the current studies did not investigate moderators of the cross-sectional relationship between BDD symptoms and self-esteem. However, meta-analytic studies allow for a closer investigation of systematic variation in effect sizes. Thus, insights on the influence of age, gender, or sample type on the relationship between BDD symptoms and self-esteem can be gained.

In summary, the aims of the current meta-analysis were as follows:

Examine the strength of the cross-sectional relationship between BDD symptom severity and global self-esteem in BDD patients, healthy controls, community or student samples, and cosmetic surgery patients.

Investigate whether the aforementioned relationship between BDD symptom severity and self-esteem persists beyond the influence of depressive symptoms.

Explore potential systematic differences in the magnitude of the correlations regarding participants’ mean age, percentage of females, the sample type (e.g., student sample or BDD patients), the diagnostic method (self-report versus clinician-administered measures of BDD symptoms), and BDD diagnosis (whether BDD was diagnosed by a clinician prior to or during study participation).

Altogether, the three research questions could further our understanding of associated features in BDD and offer valuable insights for the prevention and treatment of BDD.

A preprint of the manuscript was uploaded to psyarxiv ( https://psyarxiv.com/ ). The extracted data used for the meta-analysis are available at our Open Science Framework (OSF) data repository ( https://osf.io/z52fc/ ). A PRISMA checklist concerning the documentation of the meta-analysis can be retrieved in the Appendix (Additional file  1 ) [ 31 ]. The meta-analysis was not pre-registered.

Study selection

Studies were selected if they fulfilled the following eligibility criteria. BDD symptom severity had to be measured with a questionnaire or interview that captures symptoms as described in the fifth or fourth edition of the Diagnostic and Statistical Manual of Mental Disorders , DSM-5 or DSM-IV [ 1 , 32 ]. This comprised detailed measures of BDD symptom severity as well as shorter screening measures for BDD symptoms. Alternatively, categorial diagnostic measures of BDD based on DSM-IV or DSM-5 were also considered. Hence, the Yale-Brown Obsessive Compulsive Scale for Body Dysmorphic Disorder (BDD-YBOCS) [ 33 ], the self-report and clinician-administered versions of the Body Dysmorphic Disorder Examination (BDDE) [ 34 ], the Body Dysmorphic Symptoms Inventory (Fragebogen körperdysmorpher Symptome; FKS) [ 35 ], the Questionario sul Dismorfismo Corporeo (QDC) [ 36 ], the Dysmorphic Concern Questionnaire (DCQ) [ 37 ], the Body Dysmorphic Disorder Questionnaire (BDDQ) [ 38 ], and the Body Dysmorphic Disorder Diagnostic Module (BDD-DM) [ 39 ] were included in this meta-analysis. Measures of body image or body dissatisfaction were excluded. Also, measures which specifically address muscle dysmorphia were not included, as we intended to investigate BDD symptoms in general and because of the overlap between muscle dysmorphia and eating disorders. This meta-analysis relied on the definition and operationalization of self-esteem by Rosenberg [ 4 ]. Thus, self-esteem needed to be assessed via the Rosenberg Self-Esteem Scale (RSES), the most widely used self-report measure for global self-esteem [ 4 ]. For inclusion in the meta-analysis of partial correlations, studies were required to use a questionnaire or interview for the assessment of depressive symptom severity. The Beck Depression Inventory (BDI) [ 40 , 41 , 42 ], the Hamilton Depression Rating Scale (HAMD) [ 43 ], the depression subscale of the Depression Anxiety Stress Scales (DASS) [ 44 ], the depression subscale of the Hospital Anxiety and Depression Scale (HADS) [ 45 ], the depression subscale of the Symptom Checklist-90 (SCL-90) [ 46 ], and the Patient Health Questionnaire-9 Depression module (PHQ-9) [ 47 ] were used in the studies.

Clinical, subclinical, and non-clinical samples were examined. Studies could target BDD patients, mentally healthy control participants, students, community persons, and cosmetic surgery patients. Participants were allowed to have secondary comorbid mental disorders. However, samples with another primary mental disorder (e.g., eating disorders, social anxiety disorder) were excluded. Studies that were recruited according to the presence or absence of a physical condition (e.g., rheumatic arthritis, obesity) were not included in this analysis. Also, samples that were selected according to related factors (e.g., body dissatisfaction) were not considered. No restrictions concerning age or gender of the sample were applied. Studies could be designed as correlational surveys or intervention studies. Since we investigated the cross-sectional relationship, data on all our variables of interest had to be collected at a single measurement point. In the case of more than one measurement point, baseline measures were analyzed. Case studies were omitted. For inclusion, manuscripts were required to be written in English or German.

Several sources were used to identify relevant studies. The databases PubMed , PsycInfo , PsycArticles , Medline , Web of Science , Psyndex , and Dissertation Abstracts International were searched for eligible studies. Furthermore, ongoing trials were found in the http://ClinicalTrials.gov  registry, the Cochrane Central Register of Controlled Trials ( CENTRAL ), the WHO International Clinical Trials Registry Platform ( ICTRP ), and the ISRCTN registry. We also tried to obtain unpublished data by searching OpenGrey ( http://www.opengrey.eu ). The keyword-based literature search was carried out by the second author in April 2017. Subsequently published or registered studies were identified in January 2019, August 2019, and in May 2020. The following search term was applied: (body dysmorphic AND self-esteem) or (dysmorphophobia AND self-esteem) or (dysmorphophobic AND self-esteem) or (body dysmorphic AND self-worth) or (dysmorphophobia AND self-worth) or (dysmorphophobic AND self-worth). The corresponding German search terms were: (körperdysmorphe AND Selbstwert) or (Dysmorphophobie AND Selbstwert) or (dysmorphophobe AND Selbstwert). Additionally, 24 well-known researchers in the field of BDD were contacted for unpublished studies in September 2019.

In a first step, the abstracts of identified studies were screened. The abstract screening of studies which were published after April 2017 was performed by two research assistants. The abstracts were required to suggest that BDD symptoms and self-esteem were captured in the study. Subsequently, a full text assessment was conducted by the second author (or a research assistant for studies with dates of publication after April 2017) according to the eligibility criteria described above.

Data collection

A coding scheme for extraction of relevant data was developed. The coding scheme contained the following information: First, the sample was described with regard to the number of participants (in total and in the subgroups), clinical status, age, sex, education, ethnicity, sample type (e.g., students, cosmetic surgery patients), comorbidities, and other study-specific inclusion criteria (e.g., a certain cut-off on a BDD questionnaire). Second, the assessment of BDD symptom severity was specified. The interview or questionnaire used to examine BDD symptoms, diagnostic criteria, the diagnostic method (self-report vs. clinician-administered), as well as means and standard deviations of the diagnostic measure in the sample were coded. Additionally, the range of BDD symptom severity (e.g., only clinical participants) and whether the study compared two extreme groups (e.g., BDD patients versus healthy controls) were rated. Third, mean and standard deviation of the RSES in the total sample were gathered. Fourth, information on the assessment of depressive symptoms was collected. This included the measure for depressive symptom severity, the applied diagnostic criteria, the diagnostic method, as well as mean and standard deviation of the measure for depressive symptoms. Fifth, the reported effect size data were compiled. Preferably, the correlations between BDD symptom severity and self-esteem, between BDD symptom severity and depressive symptom severity, and between self-esteem and depressive symptom severity were gathered. Additionally, we coded whether the correlation was reported in the study or obtained by the authors afterwards. The type of correlation and the number of participants, for whom the correlation was calculated, were also coded. Alternatively, Cohen’s d for the difference in self-esteem and depressive symptoms of participants with BDD compared to participants without BDD were entered. If Cohen’s d was not reported, the mean and standard deviation of self-esteem and depressive symptom severity, and the number of participants in each comparison group were collected.

Data were coded independently by the first and second author. Interrater agreement was 97% and consensus was achieved after discussion of divergent coding. If studies did not report all data that were needed for the meta-analysis, authors were asked for the missing information. Altogether, 30 authors were contacted (concerning 35 studies) and 17 authors provided the required information (for 20 studies).

The effect sizes in the individual studies might have been subject to bias. We considered the selection of the sample (e.g., clinical BDD patients versus non-clinical students) and the diagnostic method for assessing BDD symptoms (self-report versus clinician-administered) as possible sources of bias. Consequently, these aspects were included in our coding scheme and controlled for in moderator analysis. Furthermore, we dealt with potential selective reporting by contacting all authors of studies which assessed our variables of interest without reporting an effect size for the relationship between BDD symptoms and self-esteem.

Data analysis

Effect sizes for the relationship between BDD symptom severity and self-esteem were calculated in three ways depending on the level of measurement of BDD symptom severity. For the majority of studies ( k  = 21), Fisher’s z transformed Pearson correlations between BDD symptom severity and self-esteem were analyzed. If effect sizes could not be based on a continuous measure of BDD symptom severity, we either used the pointbiseral correlation ( k  = 1) between BDD (coded 1 for BDD and 0 for healthy controls) and self-esteem or Cohen’s d ( k  = 1) which was transformed to Fisher’s z [ 48 , 49 ]. In this case Cohen’s d described the difference in mean self-esteem between participants with BDD compared to participants without BDD. This categorial effect size is not based on the individual values of participants but rather on the group means. Thus, it mirrors the relationship between BDD symptom severity and self-esteem on a less precise group level. Nevertheless, we preferred to integrate these categorial effect sizes in the meta-analysis to achieve an extensive overview of the field and to avoid complete loss of the information. Two studies [ 12 , 50 ] followed an ordinal approach and reported correlations between the number of items endorsed on the BDDQ and self-esteem. As this represents a gain in information compared to mere nominal data, this procedure was applied for studies which used the BDDQ.

If possible, an effect size for the total sample (instead of separate effect sizes for the subgroups) was gathered. Still, samples with varying ranges of BDD symptom severity were examined. In some cases, this may have caused underestimation of the true effect, whereas in others the magnitude of the relationship might have been overestimated [ 51 ]. Restriction of range in samples with reduced variance of BDD symptom severity (e.g., only clinical BDD participants) may have led to underestimation of the true effect. Enhancement of range and corresponding overestimation of effect sizes may have been produced by comparison of extreme groups (BDD patients versus healthy controls). A meta-analysis without artifact correction was conducted to describe the actual observed effects. Additionally, we attempted to correct for the artifacts. Thereby, we intended to achieve an estimate of the effect scaled on the general population without variance restrictions. For this purpose, studies with potentially restricted or enhanced range of BDD symptom severity were identified on the basis of theoretical assumptions concerning the sample. The individual correlations of these studies were adjusted before conducting a meta-analysis using standard corrections for variance restrictions [ 52 ]. For the adjustment, an estimate of the standard deviation of the BDD symptom severity measure in the general population was used and applied to all studies included. If possible, this was drawn from studies with large community samples.

For the calculation of partial correlations between BDD symptom severity and self-esteem controlling for depressive symptom severity, Pearson correlations between BDD symptom severity and depressive symptom severity, as well as between self-esteem and depressive symptom severity were conducted and preprocessed in the same manner as described above. The partial correlations controlling for depressive symptom severity were also Fisher’s z transformed for a subsequent meta-analysis. A meta-analysis of (z-transformed) partial correlations was also conducted with and without artifact correction.

A random effects meta-analysis was chosen to account for heterogeneity in effect sizes across studies. The computation was performed in R [ 53 ] using the metafor package [ 54 ] . For the assessment of effect size variability I 2 and τ were used. A moderator analysis was conducted to examine the influence of participants’ mean age, percentage of females, sample type, diagnostic method, and BDD diagnosis on effect sizes. An alpha level of α = .05 was applied. To visualize a potential publication bias, we created funnel plots.

Study characteristics

The process of study selection with the number of records screened and excluded at each stage is presented in the PRISMA flow diagram in Fig.  1 [ 31 ]. Altogether, 25 studies (and 27 effect sizes) with a total number of 6278 participants were included in the meta-analysis. The mean age was 26.35 with a mean percentage of females of 69.62%. Regarding the sample type, four samples were drawn from individuals with clinical BDD ( n  = 239), three from mentally healthy control participants and individuals with clinical BDD ( n  = 128), and five from cosmetic surgery settings ( n  = 614). Further, nine student samples ( n  = 3463), two community samples ( n  = 423), and three community samples with large proportions of students ( n  = 1310) were analyzed. For nine studies BDD was diagnosed by a clinician either prior to or during study participation. Twelve effect sizes were based on clinician-rated measures of BDD symptoms whereas 14 relied on self-report measures (for one study no precise information was available whether the BDD-YBOCS was administered by a clinician or applied as a self-report questionnaire). Seventeen studies assessed depressive symptoms and could be included in the meta-analysis of partial correlations. Table  1 provides an overview of the study characteristics and effect sizes which were extracted from the studies.

PRISMA flow diagram illustrating the process of study selection

Meta-analysis of zero-order correlations

The meta-analysis of uncorrected zero-order correlations between BDD symptom severity and self-esteem yielded an overall effect size of r  = −.42, CI  = [−.48, −.35]. The Fisher’s z-transformed effect estimates and confidence intervals for the individual studies as well as the Fisher’s z-transformed overall effect size are illustrated in Fig.  2 . With regard to heterogeneity, I 2 amounted to 85.87% and τ was .17, indicating substantial variability of effect sizes.

Forest plot of Fisher’s z-transformed correlations between BDD symptom severity and self-esteem

When correcting for variance restriction and enhancement of BDD symptom severity, a mean weighted correlation of r  = −.45, CI  = [−.51, −.39] was observed. The artifact-corrected Fisher’s z-transformed zero-order correlations and the corresponding overall effect size estimate are visualized in Fig.  3 . The I 2 of 82.38% and τ = .14 implied considerable heterogeneity. The standard deviation estimates for the BDD symptom severity measures which were used for artifact correction can be found in the appendix (Additional file  2 ).

Forest plot of Fisher’s z-transformed correlations between BDD symptom severity and self-esteem (corrected for variance restriction and enhancement of BDD symptom severity)

Meta-analysis of partial correlations

In the meta-analysis of uncorrected partial correlations between BDD symptom severity and self-esteem controlling for depressive symptom severity a mean weighted effect size of pr  = −.20, CI  = [−.25, −.15] was achieved. The forest plot of Fisher’s z-transformed partial correlations and confidence intervals for the individual studies and the total estimate are displayed in Fig.  4 . Investigation of heterogeneity resulted in I 2  = 37.28% and τ = .06.

Forest plot of Fisher’s z-transformed partial correlations between BDD symptom severity and self-esteem controlling for depressive symptom severity

Basing the meta-analysis on the artifact-corrected partial correlations revealed a mean weighted effect size of pr  = −.23, CI  = [−.28, −.17]. Fisher’s z transformed coefficients and confidence intervals are presented in Fig.  5 . This analysis produced an I 2 of 40.33% and τ = .06.

Forest plot of Fisher’s z-transformed partial correlations between BDD symptom severity and self-esteem controlling for depressive symptom severity (corrected for variance restriction and enhancement of BDD symptom severity)

Moderator analysis

The results of the moderator analysis for the meta-analysis of uncorrected zero-order correlations are presented in Table  2 . The mean age of the sample, the percentage of females, and the diagnostic method did not show a significant influence on the magnitude of effect sizes in any of the analyses. The sample type turned out to be a significant moderator in the meta-analysis of uncorrected zero-order correlations ( F (3, 22) = 4.83, p  < .01). The weighted effect size estimates were z  = −.40, CI  = [−.58, −.22] for clinical BDD samples, z  = −.83, CI  = [− 1.06, −.60] for combined samples of mentally healthy control participants and individuals with clinical BDD, z  = −.39, CI  = [−.46, −.32] for student and community samples (which were analyzed as one category in the moderator analysis), and z  = −.40, CI  = [−.54, −.25] for the cosmetic surgery samples. The effect sizes for combined samples of clinical BDD and mentally healthy control participants differed significantly from the clinical BDD samples when contrasted in a dummy-coded moderator analysis (cf., Table 2 ). However, the moderation effect of the sample type was no longer significant for the artifact-corrected zero-order correlations. The weighted effect size estimates for the artifact-corrected zero-order correlations amounted to z  = −.59, CI  = [−.80, −.38] for clinical BDD samples, z  = −.67, CI  = [−.97, −.37] for combined samples of mentally healthy control participants and individuals with clinical BDD, z  = −.46, CI  = [−.55, −.37] for student and community samples, and z  = −.45, CI  = [−.63, −.27] for the cosmetic surgery samples. Regarding the partial correlations, the moderation effect of the sample type was no longer significant. Even more so, effect sizes for the different sample types were very much aligned after artifact correction ( z  = −.24, CI  = [−.45, −.04] for clinical BDD samples, z  = −.27,. CI  = [−.52, −.02] for combined samples of mentally healthy control participants and individuals with clinical BDD, z  = −.23, CI  = [−.30, −.15] for student and community samples, z  = −.21, CI = [−.37, −.05] for the cosmetic surgery samples) compared to the uncorrected weighted partial correlations ( z  = −.16, CI  = [−.36, .03] for clinical BDD samples, z  = −.32, CI  = [−.54, −.11] for combined samples of mentally healthy control participants and individuals with clinical BDD, z  = −.20, CI  = [−.27, −.14] for student and community samples, z  = −.18, CI  = [−.32, −.03] for the cosmetic surgery samples). BDD diagnosis emerged as a significant moderator in the meta-analysis of uncorrected zero-order correlations (cf., Table 2 ). More precisely, studies in which BDD was diagnosed by a clinician prior to or during study participation appeared to have higher negative correlations between BDD symptom severity and self-esteem compared to studies without clinician-rated BDD diagnoses. However, this was no longer significant in all other analyses ( b  = −.118, CI  = [−.278, .043], p  = .144 for corrected zero-order correlations). In an attempt to explore other factors which could explain the heterogeneity of effect sizes, we additionally conducted moderator analysis with the year of publication and examined differences between different measures of BDD symptom severity. None of these analyses had significant explanatory value.

Publication bias

The funnel plots were rather symmetrical and did not point to any publication bias. Single effect sizes were positioned outside of the funnel which was in line with the heterogeneity of effect sizes, in particular with regard to the effect of the sample type. The funnel plots are attached as supplementary information (Additional files 3 , 4 , 5 , 6 ).

We examined the relationship between BDD symptom severity and global self-esteem, while also investigating the role of depressive symptoms and other moderating factors. Regarding our three research questions, the following results were obtained: First, a moderate negative relationship between BDD symptom severity and self-esteem was revealed in meta-analyses of uncorrected and corrected zero-order correlations. Thus, the current state of research suggests that with increasing BDD symptoms self-esteem appears to be lowered. This is in line with previous findings from individual studies suggesting that BDD is often accompanied by low self-esteem (e.g., [ 3 ]). Thus, it appears negative evaluation in BDD is not limited to appearance but also extends to other domains of the self. Our results corroborate the role of appearance as an idealized value and dominating aspect in defining the self. Our results also provide an empirical basis for negative core beliefs (e.g., “I am worthless.”, “If my appearance is defective then I am worthless.”) that are often described as part of cognitive-behavioral models of BDD [ 62 , 63 , 64 ]. Furthermore, our findings are consistent with studies on other disorders that have also found a relationship between self-esteem and psychopathology [ 65 ].

Second, the negative relationship between BDD symptom severity and global self-esteem was only partly explained by depressive symptom severity. The meta-analyses of uncorrected and corrected partial correlations demonstrated that there was still a negative, though smaller, relationship beyond the influence of depressive symptoms. Thus, higher levels of BDD symptoms appear to be associated to lower levels of self-esteem even after controlling for depressive symptoms. This might be interpreted as a connection between appearance concerns and global self-esteem which is maintained after partialling out the distress and impairment due to depressive symptoms. It corresponds to findings on the association between body image or body dissatisfaction and self-esteem (e.g., [ 66 , 67 ]). Moreover, the results could imply that individuals suffering from BDD symptoms and comorbid depressive symptoms might have particularly low self-esteem.

Third, the relationship between BDD symptom severity and self-esteem turned out to be stable across samples with varying mean age of participants and percentage of females. However, it should be noted that the mean age was rather young in most of the samples and the majority of samples consisted of more female than male participants. Consequently, there might have been too less variation to examine potential effects of these two moderators. Further, the overall effect size was robust regardless of the diagnostic method for the assessment of BDD symptom severity. This suggests that self-report and clinician-administered instruments for the assessment of BDD symptoms were equally capable of capturing the effect. With regard to the sample type, the combined samples of individuals with clinical BDD and mentally healthy control participants showed high negative uncorrected correlations compared to moderate negative uncorrected correlations for the other sample types. However, estimates of corrected correlations were more similar across samples types. Particularly for combined samples of individuals with BDD and mentally healthy controls the correlation was reduced after artifact correction, whereas it was noticeably raised in clinical BDD samples. This suggests that the effect of the sample type was caused by variance restriction and enhancement and not by actual differences between the sample types. Regarding the mean weighted partial correlations, effect sizes for the different sample types were very much aligned after artifact correction. The significant effect of the moderator BDD diagnosis on the uncorrected zero-order correlations might suggest that samples which included participants with diagnosed BDD tended to demonstrate higher negative correlations than student or community samples without clinical diagnostics. However, as this effect was much smaller and not significant for the corrected correlations, it is likely that range restriction/enhancement artifacts also contributed to this finding.

We observed substantial variations in effect sizes with regard to the meta-analyses of zero-order correlations. One explanation for this heterogeneity may be the influence of depressive symptom severity on the relationship between BDD symptom severity and self-esteem. The mean weighted partial correlations which were smaller than the mean weighted zero-order correlations and the substantially reduced amount of heterogeneity in the meta-analyses of partial correlations support this explanation. Other moderators that we considered to possibly have an impact on the systematic variation of effect sizes seemed to be not relevant or only in the context of a statistical artifact caused by relative range restrictions/enhancements. Since the included studies did not provide sufficient information on comorbidities, personality disorders, or medication, these variables could not be investigated. Also, we were not able to examine associated factors such as insight. Furthermore, cultural aspects might play a role and could not be controlled for in the analyses. For instance, the study by Ahmadpanah et al. [ 13 ] stands out with a correlation between BDD symptom severity and global self-esteem of only r  = −.04. This study was conducted in an Iranian sample in which according to the authors the face, hair, and body shape are often covered and not visible for others [ 13 ]. Thus, cultural effects need to be considered when trying to understand the relationship between BDD symptoms and self-esteem. Further, the use of social media or bullying experiences might also act as moderators and their impact should be clarified in future studies.

Limitations

The present meta-analysis has several limitations. First, we included studies using detailed clinician-administered measures of BDD symptom severity as well as shorter self-report screening instruments. These are of course not equally valid in assessing BDD symptom severity. For example, self-report measures might fail to differentiate BDD symptoms from preoccupation about actual defects (e.g., acne, scars) or weight-based concerns in the context of an eating disorder. Four of the 14 studies which applied self-report BDD measures tried to control for eating disorders. One of these studies excluded participants with elevated symptoms of an eating disorder [ 56 ], one study assessed comorbidities and reported that none of the participants were suffering from a comorbid eating disorder [ 6 ], one study excluded participants with a past or present eating disorder according to self-report [ 22 ], and one study ruled out the presence of any mental disorder according to self-report [ 11 ]. In order to address this limitation, we investigated the influence of the diagnostic method in moderator analysis. The diagnostic method appeared to have no systematic influence on the magnitude of effect sizes. On the one hand, this could imply that self-report measures were equally capable of capturing the relationship between BDD symptoms and self-esteem. On the other hand, this could signify that a preoccupation with actual appearance defects or weight-based concerns show a similar association with global self-esteem. Since this is the first meta-analysis on BDD and self-esteem we preferred to include all studies assessing BDD symptoms and self-esteem and controlled for the diagnostic method in moderator analysis.

Second, concerning the assessment of global self-esteem, this meta-analysis relied on the Rosenberg Self-esteem Scale [ 4 ] and considered the level of self-esteem only. Thus, we cannot determine whether other definitions and operationalizations of self-esteem demonstrate the same pattern of results. We were not able to examine contingencies and instability of self-esteem and their associations with BDD symptoms, since most of the primary studies did not assess these aspects of self-esteem.

Third, no causal inference can be drawn from our correlational findings. It remains unclear whether low self-esteem represents a vulnerability for BDD or develops as a consequence of the disorder (cf., [ 3 ]). Orth and Robins described different models for linking low self-esteem to depression [ 20 ] and these models might also apply to the relationship between BDD and self-esteem. Apart from unidirectional pathways, reciprocal relations or a common cause (e.g., bullying experiences) of both variables are possible. Moreover, a diathesis-stress model might be appropriate in which only under certain conditions low self-esteem leads to elevated BDD symptoms. Also, if low self-esteem predisposed BDD symptoms, mediating (e.g., social avoidance) and moderating variables (e.g., instability of self-esteem) might have an effect. Schulte et al. investigated the temporal dynamics of insight, affect, and self-esteem in BDD over six consecutive days and found that the cross-lagged effect of state self-esteem on insight was stronger than the effect of insight on state self-esteem [ 68 ]. Altogether, more studies are required to investigate causal directions.

Fourth, we included studies with varying ranges of BDD symptom severity. This may have led to overestimation of effect sizes for extreme group comparisons and underestimation of the effect in clinical samples. We tried to adjust effect sizes using variance corrections. However, in the absence of standard deviation norms for the individual BDD measures in the general population, we used standard deviation estimates from community samples if these were available or had to rely on student samples. Therefore, the results of the meta-analysis of corrected correlations have to be interpreted with caution, and the corrections need to be regarded as an imperfect attempt to deal with the heterogeneous samples.

Fifth, we were only able to exploratively investigate moderators for which sufficient information was provided in the studies. For instance, we could not control for effects of medication, comorbidities, or personality disorders. Hence, moderator analysis should be replicated in the future with a larger number of studies and variability of moderators.

Future directions

Future studies may examine causal directions concerning the relationship between BDD symptom severity and self-esteem. Furthermore, future research may seek to identify subgroups in which BDD symptoms are associated with particularly low self-esteem, as these groups might benefit from self-esteem interventions. In this regard, it could be important to consider different developmental phases and the impact of depressive symptoms. It might also be helpful to examine whether low self-esteem can help to distinguish individuals with BDD from individuals without BDD among cosmetic surgery patients. Moreover, future studies should focus on different aspects of self-esteem. For instance, Buhlmann et al. investigated implicit self-esteem [ 5 , 6 ], whereas B. Phillips et al. examined contingent self-esteem in BDD [ 10 ]. More research on contingencies and stability of self-esteem in BDD is required. With regard to prevention and therapy of BDD, an important step will be to evaluate the specific effects of interventions targeting self-esteem. In their network analysis of BDD and major depressive disorder Summers et al. revealed a high centrality of feelings of worthlessness and discussed implications for treatment such as addressing maladaptive core beliefs about self-worth [ 18 ]. Hence, future work may further try to determine the role of feelings of worthlessness in etiology, maintenance, and treatment of BDD. Furthermore, future trials may compare the effects of interventions intended to boost self-esteem and enhance self-compassion. In particular, focusing on self-compassion may entail certain benefits because it appears to be independent of personal achievements and success and thereby may result in more stable self-evaluations and reduced processes of comparing oneself to others (e.g., in the domain of appearance) [ 69 ]. Higher levels of self-compassion were associated with fewer BDD symptoms in a sample of adolescents [ 70 ]. Veale and Gilbert proposed to improve current treatments for BDD by developing a functional and evolutionary understanding of the BDD symptoms and by learning to relate to oneself and others with compassion and kindness [ 71 ]. These strategies from compassion-focused therapy [ 72 , 73 ] might complement or enhance cognitive approaches.

Altogether, our findings demonstrate that low self-esteem appears to be an important feature in BDD, particularly when not controlling for depressive symptoms. Consequently, addressing self-esteem and corresponding core beliefs is of high importance in the treatment of BDD. This emphasizes the value of cognitive restructuring and interventions such as the self-esteem pie by which one tries to reduce the overidentification with appearance and develop a more balanced basis of one’s self-esteem [ 63 ]. In this regard, a study by Rosen and Reiter found that decreases in BDD symptoms (as measured by the BDDE) after cognitive-behavioral therapy were associated with improvements in self-esteem [ 34 ]. Furthermore, depending on whether low self-esteem acts as a risk factor or as a consequence of BDD, self-esteem interventions might play a crucial role in the prevention of BDD. Low self-esteem during adolescence predicted adult psychopathology in a longitudinal birth cohort development study [ 74 ]. Consequently, BDD prevention programs might benefit from interventions targeted at cognitive and social determinants of low self-esteem (cf., [ 75 ]). This might buffer against the development of a negative bias in evaluating oneself which appears to be present in adolescents with high appearance anxiety [ 19 ]. Taken together, our results show that BDD is characterized by low self-esteem and highlight the importance of interventions targeting low self-esteem.

Availability of data and materials

The extracted data used for the meta-analysis are available at our Open Science Framework (OSF) data repository ( https://osf.io/z52fc/ ).

Abbreviations

• Body dysmorphic disorder

4th edition of the Diagnostic and Statistical Manual of Mental Disorders

5th edition of the Diagnostic and Statistical Manual of Mental Disorders

Yale-Brown Obsessive Compulsive Scale for Body Dysmorphic Disorder

Body Dysmorphic Disorder Examination

Body Dysmorphic Symptoms Inventory (Fragebogen körperdysmorpher Symptome)

Questionario sul Dismorfismo Corporeo

Dysmorphic Concern Questionnaire

Body Dysmorphic Disorder Questionnaire

Body Dysmorphic Disorder Diagnostic Module

Rosenberg Self-Esteem Scale

Beck Depression Inventory

Hamilton Depression Rating Scale

Depression subscale of the Depression Anxiety Stress Scales

Depression subscale of the Hospital Anxiety and Depression Scale

Depression subscale of the Symptom Checklist-90

Patient Health Questionnaire-9 Depression module

Cochrane Central Register of Controlled Trials

WHO International Clinical Trials Registry Platform

Body Dysmorphic Disorder Examination - Self Report

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Acknowledgements

We would like to thank Laura Brockhoff and Martje Kohlhoff for their assistance in literature search and study selection.

The first author was partly supported by a PhD fellowship from the German Academic Scholarship Foundation. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Open Access funding enabled and organized by Projekt DEAL.

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Conceptualization: NK UB. Data Curation: NK LC PCB. Formal Analysis: PCB NK. Funding Acquisition: NK UB. Investigation: NK LC. Methodology: NK UB PCB. Project Administration: NK. Resources: UB. Software: PCB. Supervision: UB. Validation: NK PCB LC. Visualization: PCB NK. Writing – Original Draft: NK. Writing – Review & Editing: NK UB SW PCB LH. The authors read and approved the final manuscript.

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SW is a presenter for the Massachusetts General Hospital Psychiatry Academy in educational programs supported through independent medical education grants from pharmaceutical companies; she has received royalties from Elsevier Publications, Guilford Publications, New Harbinger Publications, Springer, and Oxford University Press. SW has also received speaking honoraria from various academic institutions and foundations, including the International Obsessive Compulsive Disorder Foundation, Tourette Association of America, and Brattleboro Retreat. In addition, she received payment from the Association for Behavioral and Cognitive Therapies for her role as Associate Editor for the Behavior Therapy journal, as well as from John Wiley & Sons, Inc. for her role as Associate Editor on the journal Depression & Anxiety. SW has also received honorarium from One-Mind for her role in PsyberGuide Scientific Advisory Board. SW has received salary support from Novartis and Telefonica Alpha, Inc. All other authors do not have any competing interests.

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Additional file 1..

PRISMA Checklist.

Additional file 2.

Standard deviation estimates for the BDD symptom severity measures used for artifact correction.

Additional file 3.

Funnel plot for the meta-analysis of uncorrected zero-order correlations.

Additional file 4.

Funnel plot for the meta-analysis of artifact-corrected zero-order correlations.

Additional file 5.

Funnel plot for the meta-analysis of uncorrected partial correlations.

Additional file 6.

Funnel plot for the meta-analysis of artifact-corrected partial correlations.

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Kuck, N., Cafitz, L., Bürkner, PC. et al. Body dysmorphic disorder and self-esteem: a meta-analysis. BMC Psychiatry 21 , 310 (2021). https://doi.org/10.1186/s12888-021-03185-3

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• Joel P. Diaz-Fong   ORCID: orcid.org/0000-0002-2108-6830 1 , 2 &
• Jamie D. Feusner   ORCID: orcid.org/0000-0002-0391-345X 1 , 2 , 3 , 4  

Part of the book series: Current Topics in Behavioral Neurosciences

Phenomenological observations of individuals with body dysmorphic disorder (BDD), coupled with evidence from neuropsychological, psychophysical, and neuroimaging studies, support a model of aberrant visual perception characterized by deficient global/holistic, enhanced detail/local processing, and selective visual-attentional biases. These features may contribute to the core symptomatology of distorted perception of their appearance, in addition to misinterpretation of others’ facial expressions and poor insight regarding their misperceived appearance defects. Insights from visual processing studies can contribute to the development of novel interventions, such as perceptual retraining and non-invasive neuromodulation. However, much remains to be understood about visual perception in BDD. Future research should leverage brain imaging modalities with high temporal resolutions and employ study designs that induce conflicts in multisensory integration, thereby advancing our mechanistic understanding of distorted visual perception observed in BDD.

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Diaz-Fong, J.P., Feusner, J.D. (2024). Visual Perceptual Processing Abnormalities in Body Dysmorphic Disorder. In: Current Topics in Behavioral Neurosciences. Springer, Berlin, Heidelberg. https://doi.org/10.1007/7854_2024_472

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

Affiliations.

• 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].
• PMID: 35182708
• DOI: 10.1016/j.clindermatol.2022.02.015
• Body Dysmorphic Disorders* / diagnosis
• Psychiatric Status Rating Scales
• Social Media*

• Patient Care & Health Information
• Diseases & Conditions
• 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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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. For more mental health resources, see our National Helpline Database .

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.

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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Frequently Asked Questions

Can i recover from bdd.

Individuals with body dysmorphic disorder who are motivated to improve their quality of life can most definitely reduce their BDD symptoms and achieve a higher quality of life. This includes a significant increase in school and work capacity, and most importantly, much improved interpersonal and intimate relationships.

Do you use cognitive behavioral therapy (CBT)?

You probably have read the research data stating that cognitive behavioral therapy is utilized for the treatment of body dysmorphic disorder. Although behavioral therapy, specifically ERP (exposure and response prevention) is an important component of BDD treatment, one treatment modality does not fit every individual. There are some individuals who require more behavioral therapy, while other individuals may respond better with other appropriate therapeutic modalities. Behavioral therapy in itself, without the support of other psychotherapeutic techniques, is usually insufficient for long term BDD symptom remission.

Do you treat other disorders along with body dysmorphic disorder?

Most definitely..

In my many years working with body dysmorphic disorder, I have found that the vast majority of individuals with BDD have dual diagnoses.  As a result, I have found that it is imperative to concurrently address these other ailments while simultaneously treating the BDD. Please see Related Disorders & Dual Diagnoses .

Do you work with clients that live outside of California?

My psychotherapy practitioner license is only valid within the State of California thus a client would need to live within the state to work with me. However, if an individual is located in California temporarily, I can work with them for as long as they are in the state.

What does recovery look like?

Recovery from body dysmorphic disorder is a process; there is no quick fix, however, symptoms can be significantly decreased leading to a significantly higher quality of life. The trajectory of one’s recovery depends on a multitude of factors including the severity of the body dysmorphic disorder when entering treatment as well as co-morbid diagnoses that may need to be addressed simultaneously. Personality traits can also determine the length of time for symptom remission, for instance, avoidant personalities often have more trepidation about the recovery process and may take longer to fully engage in essential aspects of treatment.

Do I need to take medication?

Many individuals with body dysmorphic disorder benefit from treatment with psychiatric medication, as this has been demonstrated in open-label and controlled research studies. The psychiatrists that I refer to are experienced in treating BDD as well as related disorders and dual diagnoses. I do not require clients to take medications, and although it may be recommended, the final decision is always made by the client.

Do you take my insurance?

I am not in network with any insurance providers. However, upon request, I can provide you with a super-bill receipt at the end of each month that in turn you can submit to your insurance company to petition for reimbursement. The amount of reimbursement you receive for out of network services will depend upon your insurance benefits and coverage.

How much does treatment cost?

Please call me at 310-741-2000 for all enquiries regarding fees for treatment.

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The vast majority of individuals with BDD also have dual diagnoses.

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How To Deal With Body Dysmorphia In The Age Of Social Media, According To A Psychologist

S ocial media is an almost inescapable part of modern life. Unplugging from the internet doesn't offer much reprieve, as you'll still spot influencers on magazines and billboards throughout the day. For many, the pervasiveness of social media can be easily overlooked, but for those with body dysmorphic disorder, the superficial slant of social media and influencer culture may take a toll on their overall mental health .

Maybe you've heard about body dysmorphic disorder, also known as BDD, or perhaps you or a loved one struggle with dysmorphic thoughts. The effects of body dysmorphia extend beyond low self-esteem, severely impacting one's quality of life. Navigating the world with BDD has never been easy, but social media can present increased challenges for affected individuals. According to research published in The Psychology of Popular Media , cutting back on social media usage can significantly improve self-esteem and body image in teens and young adults.

Of course, those living with body dysmorphia may feel stuck between a rock and a hard place, finding it difficult to engage in online spaces without exacerbating negative thoughts or behaviors. Glam spoke exclusively to Dr. Talia Wiesel , cognitive psychologist and clinical assistant professor of psychology at Weill Cornell Medical College, to learn more about coping with body dysmorphia in the age of social media.

What Is Body Dysmorphia?

While body dysmorphia is slowly gaining more recognition, many remain confused about what it really is. So, what exactly is body dysmorphic disorder? According to Dr. Talia Wiesel, it's more complex than you might think. Roughly 40% of those with BDD are men, she says, and the condition can affect people of all ages. "People with BDD perceive themselves as looking ugly, abnormal, or disfigured when in reality, they look normal," Dr. Wiesel exclusively tells Glam. "People with BDD perform repetitive behaviors — i.e., 'rituals' and 'compulsions' – in response to their distress regarding their appearance."

For many people with BDD, even routine social activities can trigger these ritualistic or compulsive behaviors. You might think your friend is overdramatic when they complain about their looks after taking a group photo, but they may be struggling to hold back their dysmorphic thoughts. "The rituals — like comparing disliked body parts with others or checking disliked body areas in mirrors or taking selfies — are often difficult to resist or control," Dr. Wiesel explains. Everyone's experience with body dysmorphia is slightly different, but some common rituals include body checking , hiding perceived flaws with makeup or accessories, and talking negatively about their body . The experience of living with untreated body dysmorphia can lead to anxiety, isolation, and depression, and in some cases, social media usage can intensify these negative feelings.

How Social Media Impacts Body Dysmorphia

Body dysmorphia might be a hot topic in current conversations on mental health, but it's far from new. According to research published in the medical journal American Family Physician , dysmorphia was first identified by Italian physician Enrique Morselli in 1891, though BDD wasn't classified as a disorder by The American Psychiatric Association until 1987. As such, many public figures, from Sylvia Plath to Michael Jackson, are thought to have struggled with BDD prior to the APA's official recognition of it.

Dr. Talia Wiesel points out that body dysmorphia can develop due to numerous factors, from genetic predisposition and personality traits to "life experiences – like a history of bullying or abuse." In the face of social media, however, those with BDD may face unique challenges. "BDD has been and continues to be underrecognized and undertreated. Social media may not cause BDD, but it can worsen the condition," Dr. Wiesel exclusively tells us. "Social media exposure can worsen body image dissatisfaction and comorbidities of BDD, like depression and eating disorders."

Whereas past generations may have compared themselves to stars on film or in print, social media makes it easier than ever for those with BDD to engage in near-constant comparison with others from all walks of life. What's more, dysmorphia can hold people back socially and occupationally as self-promotion becomes increasingly high-stakes online. Even if your ambitions don't involve becoming an influencer, you may still dread routine tasks like attending video meetings or selecting a headshot for social network platforms.

Can Cosmetic Treatments Help Those With Dysmorphia?

With the widespread usage of cosmetic enhancements like fillers & surgery  plainly visible across social media, it can be tempting for those with BDD to explore aesthetic interventions to relieve their symptoms. Yet, according to Dr. Talia Wiesel, these procedures can have unintended effects on those with BDD. "Many people with BDD believe that if they get cosmetic treatment, it will change how they feel about their appearance. However, cosmetic treatment is not recommended for BDD. It is almost never helpful and can make BDD symptoms worse," Dr. Wiesel exclusively explains to Glam. "Furthermore, certain features are trendy, transient fads — such as sculpted high cheekbones or full, lush lips. The majority of patients (75%) often regret these procedures, and while some are reversible, like lip fillers, others are permanent, like buccal fat removal."

To make matters worse, social media has led to the emergence of countless new insecurities, often inspired by body-checking behaviors disguised as trends. On TikTok, users look for feedback on the profiles of their noses or outlines of their limbs, while Redditors engage in heated discussions over which physical traits are closest to perfection. "Excessive social media use can increase preoccupation with imagined defects among people with BDD leading them to pursue minimally invasive cosmetic and plastic surgery procedures," says Dr. Wiesel. "Celebrity plastic surgeons have a strong social media presence, posting videos of cosmetic procedures and before-and-after photos, which receive hundreds of thousands of views and likes."

Ways To Deal With Body Dysmorphia Effectively

Trying to manage body dysmorphia in a culture obsessed with social media can feel like an uphill battle, but fortunately, treatment is available. Whether you've struggled with dysmorphic thoughts for as long as you can remember or are just beginning to spot symptoms, there are clinically proven strategies that Dr. Talia Wiesel suggests trying first. "Selective serotonin reuptake inhibitors — high doses are often needed – is the first-line medication treatment," she exclusively tells Glam. Common SSRI medications include Prozac, Zoloft, Effexor, and Lexapro, and they can help ease the recurrent negative thoughts associated with body dysmorphic disorder and are available by prescription only. To find out more, speak to a trusted healthcare professional like your primary care provider or therapist, who can help select the best treatment for you.

From there, Dr. Wiesel recommends seeking cognitive-behavioral therapy, also known as CBT. Directories like Psychology Today can help you find a local mental health professional who specializes in CBT, but there are several at-home interventions you can use as well. Dr. Wiesel suggests reading " Feeling Good about the Way You Look " by Sabine Wilhelm, Ph.D., and " The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder " by Dr. Katharine Phillips. In addition to self-help books, those with BDD can explore online resources like The Body Dysmorphic Disorder Foundation and The International OCD Foundation . Though body dysmorphia is not the same as obsessive-compulsive disorder, research published in The Journal of Clinical Psychiatry suggests that the conditions have some similarities.

Overcoming Your Fear Of Posting On Social Media

The fear of rejection, ostracization, or abusive comments can lead many people with BDD to avoid posting anything on social media. Moreover, opening an app like Instagram and viewing others' posts can inspire anxiety in those with BDD due to social comparison and insecurity.

So, is it better to fight your fears and join in with other posters, or should you walk away from social media altogether if you have persistent dysmorphic thoughts? Well, that depends on where you are on your journey. "Most people with BDD struggle to take pictures, let alone post them online. I often recommend taking a break from social media if it is being used in an unhealthy way, like scrutinizing others and comparing themselves with friends or celebrities," Dr. Talia Wiesel tells Glam in our exclusive chat.

Nevertheless, taking a step back from social media doesn't have to be permanent. "As patients begin to improve and learn coping strategies to manage their BDD, we gradually start to confront anxiety-provoking situations that are difficult or avoided, like taking unfiltered pictures with others, and eventually, posting these pictures on social media," Dr. Wiesel tells Glam. The pressure to appear perfect — especially online, where filters run rampant — can feel overwhelming for those with body dysmorphia. That said, the era of airbrushed perfection may be coming to an end. An increasing number of individuals, influencers included, have recently shifted their focus toward producing authentic content that unabashedly depicts their flaws.

Using Social Media Positively With BDD

For all its faults, social media shows some promise in the fight against body dysmorphia. "Social media can help raise awareness about BDD and its treatment," Dr. Talia Wiesel exclusively tells Glam. "Celebrities have begun to discuss their struggles with BDD, like Robert Pattinson, Demi Lovato, and more recently, Meghan Fox. It can be helpful knowing people who are known for their beauty believe they struggle with BDD and aren't perceiving themselves accurately." Although no one's path is quite the same, it's important to understand you aren't alone in combating dysmorphia.

Ultimately, it's up to the individual to decide how to best interact with social media. As Dr. Wiesel points out, patients in earlier phases of treatment may need to take a break from online spaces before challenging themselves by sharing more. Above all, those struggling with body dysmorphia should know that healing can take time, but change is possible. Pursuing cognitive-behavioral therapy, challenging negative thoughts, and finding safe spaces in life and online are all steps in the right direction.

Read this next: All Of The Mental Health Resources You Need To Get And Give Help