CME

Body Dysmorphic Disorder and

Cosmetic Surgery
Canice E. Crerand, Ph.D.
Learning Objectives: After studying this article, the participant should be able
Martin E. Franklin, Ph.D. to: 1. Identify the diagnostic criteria and clinical features of body dysmorphic
David B. Sarwer, Ph.D. disorder. 2. Describe the prevalence of body dysmorphic disorder in cosmetic
Philadelphia, Pa. populations. 3. Identify appropriate treatment strategies for body dysmorphic
disorder.
Background: Body dysmorphic disorder is a relatively common psychiatric dis-
order among persons who seek cosmetic surgical and minimally invasive treat-
ments.
Methods: This article reviews the history of the diagnosis and the current
diagnostic criteria. Etiologic theories, clinical and demographic characteristics,
and comorbidity, including the relationship of body dysmorphic disorder to
obsessive-compulsive spectrum and impulse control disorders, are discussed.
The prevalence of body dysmorphic disorder in cosmetic populations is high-
lighted. Treatments for body dysmorphic disorder, including medical, psychi-
atric, and psychological interventions, are reviewed.
Results: Body dysmorphic disorder is an often severe, impairing disorder.
Among patients presenting for cosmetic treatments, 7 to 15 percent may suffer
from the condition. Retrospective outcome studies suggest that persons with
body dysmorphic disorder typically do not benefit from cosmetic procedures.
Pharmacotherapy and cognitive-behavioral psychotherapy, in contrast, appear
to be effective treatments for body dysmorphic disorder.
Conclusions: Because of the frequency with which persons with body dysmor-
phic disorder pursue cosmetic procedures, providers of cosmetic surgical and
minimally invasive treatments may be able to identify and refer these patients
for appropriate mental health care. Directions for future research are
suggested. (Plast. Reconstr. Surg. 118: 167e, 2006.)

PSYCHIATRIC DIAGNOSES IN of individuals. Such interest is by no means new

COSMETIC SURGERY PATIENTS and dates back over 40 years to the groundbreak-
ing work of Edgerton and colleagues.2– 4

T
he popularity of cosmetic procedures has
exploded over the past decade, with more We have previously categorized the literature
than 10 million cosmetic surgical and min- regarding the psychological aspects of cosmetic
imally invasive procedures performed in 2005.1 procedures into three generations of
Not surprisingly, both surgeons and mental research. 5–10 Studies from each generation
health professionals are interested in the psycho- shared a common purpose: to determine
logical characteristics of this growing population whether some patients present with psychiatric
disorders that make them inappropriate candi-
From the Department of Psychology, Division of Plastic and dates for surgery and to determine whether
Reconstructive Surgery, Children’s Hospital of Philadelphia; changes in physical appearance relate to postop-
Department of Psychiatry, Center for the Treatment and erative improvements in psychosocial function-
Study of Anxiety, and Department of Surgery, Division of ing. The first generation of studies (approxi-
Plastic Surgery, University of Pennsylvania School of Med-
mately 1950s to 1960s), which relied heavily on
icine; and Department of Psychiatry, Weight and Eating
Disorders Program, Edwin and Fannie Gray Hall Center for unstructured clinical interviews, implied that
Human Appearance. psychopathology was the norm among patients
Received for publication October 6, 2005; accepted February presenting for cosmetic surgery. Results regard-
6, 2006. ing postoperative psychological outcomes were
Copyright ©2006 by the American Society of Plastic Surgeons mixed; several studies reported postoperative
DOI: 10.1097/01.prs.0000242500.28431.24 benefits and other studies noted symptom

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 Plastic and Reconstructive Surgery • December 2006

exacerbations. 2– 4 Second-generation studies characterized by extreme appearance preoccu-

(1970s to 1980s), which often included reliable pation, may be of particular relevance to plastic
and valid psychometric measures, reported surgeons and other physicians who offer cos-
lower rates of psychopathology.11–18 Further- metic procedures. Thus, this article provides an
more, studies from this generation implied that overview of body dysmorphic disorder and its
surgery could lead to postoperative improve- relationship to cosmetic surgery. It includes a
ments in psychological functioning.19 description of the history of the diagnosis, the
Studies from the third generation of re- current diagnostic criteria, etiologic theories,
search, including most recent investigations, clinical and demographic features, and comor-
typically incorporated methodological im- bidity associated with the disorder. The article
provements, such as the use of established di- then focuses on the prevalence of body dysmor-
agnostic criteria, preoperative and postopera- phic disorder, particularly among persons who
tive assessments, and inclusion of appropriate seek cosmetic treatment. A review of the medi-
comparison groups. Clinical interview studies cal, pharmacologic, and psychotherapeutic treat-
found that 20 to 48 percent of patients present ments for body dysmorphic disorder is also pro-
for surgery with a formal psychiatric vided. The article concludes with suggestions for
diagnosis.20,21 However, these studies did not future research.
use well-structured, validated interviews, thus
calling into question the accuracy of the find- HISTORY OF AND DIAGNOSTIC
ings. Postoperative benefits (e.g., improve- CRITERIA FOR BODY DYSMORPHIC
ments in depressive and anxiety symptoms and DISORDER
quality of life) have been reported in studies
that used psychometric measures.22–29 Many History of the Diagnosis
third-generation studies also have focused on Body dysmorphic disorder was initially called
the body image concerns of cosmetic surgery “dysmorphophobia” when it first appeared in the
patients. Several studies suggest that cosmetic European medical literature in 1886.37 In other
surgery patients typically present with height- early descriptions, body dysmorphic disorder was
ened body image dissatisfaction before surgery termed “l’obsession de la honte du corps” (obses-
30 –34
and experience body image improvements sion with shame of the body)38 or “dysmorpho-
postoperatively.22–25,29,35 phobic syndrome.”39
Because of methodological problems from all In the United States, case reports in the cos-
three generations of research, coupled with the metic surgery and dermatology literature describ-
lack of any large-scale investigations of the rate ing symptoms consistent with body dysmorphic
of psychopathology in cosmetic surgery patients, disorder appeared before the disorder’s inclusion
it is difficult to draw firm conclusions regarding in the Diagnostic and Statistical Manual of Mental
the psychological characteristics of cosmetic sur- Disorders. Descriptions of “minimal deformity” and
gery patients and how they relate to postopera- “insatiable” patients were reported in the cosmetic
tive outcome. We, however, have drawn two ten- surgery literature in the 1960s.2,40 Case reports of
tative conclusions from the three generations of “dysmorphophobia” and “dermatological nondis-
research.6,7,9,36 First, persons presenting for cos- ease” were also described in the dermatology
metic treatments, like those in the general pop- literature.41 Similar to persons with body dysmor-
ulation, likely experience a wide range of psychi- phic disorder presenting for cosmetic treatments
atric symptoms and conditions. Second, today, these patients requested multiple proce-
although it appears that most patients experi- dures to improve slight or imagined defects, and,
ence improvements in body image following sur- typically, reported high levels of dissatisfaction
gery, there currently is not enough evidence to with their postoperative results.2
conclude that the majority of patients experi- Body dysmorphic disorder first appeared in
ence additional psychosocial improvements Diagnostic and Statistical Manual of Mental Disorders,
postoperatively. Third Edition in 1980, where it was described as an
All psychiatric disorders are likely to be repre- atypical somatoform disorder.42 Body dysmorphic
sented among the large population of persons disorder was included as a formal diagnosis and
presenting for cosmetic treatments. Disorders officially termed “body dysmorphic disorder” with
that involve an individual’s physical appearance the publication of the Diagnostic and Statistical
or body image, however, may be especially prev- Manual of Mental Disorders, Third Edition, Revised in
alent. Body dysmorphic disorder, a disorder 1987.43 Two variations of body dysmorphic disor-

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der were included in the Diagnostic and Statistical pears to be normative.30 –34 However, the degree
Manual of Mental Disorders, Third Revision, Revised: of distress and impairment in functioning may
nondelusional or delusional (or delusional disor- be the most useful indicator of body dysmorphic
der, somatic type). The differentiation between disorder in these patients. 10,50 For example, a
subtypes is less clear in both the Diagnostic and person who reports that his or her appearance
Statistical Manual of Mental Disorders, Fourth Edition concerns interfere with his or her ability to
44
and the Diagnostic and Statistical Manual of Mental maintain a job likely meets criteria for body
Disorders, Fourth Edition, Text Revision.45 This likely dysmorphic disorder. In contrast, the person
reflects the growing consensus that the nondelu- who denies significant disruption in occupa-
sional and delusional subtypes are variations of the tional or social functioning is unlikely to have
disorder.46 body dysmorphic disorder.

Diagnostic and Statistical Manual of Mental Disor- Etiology

ders, Fourth Edition, Text Revision Diagnostic Neurobiological, psychological, and sociocul-
Criteria tural factors are thought to play a role in the
Body dysmorphic disorder is currently cate- development of body dysmorphic disorder.51
gorized as a somatoform disorder.45 This classi- Neurobiological Factors
fication has been criticized, with some research- Although research is limited, there is some
ers asserting that body dysmorphic disorder evidence to suggest that body dysmorphic disor-
should be considered an obsessive-compulsive der has a genetic underpinning. Phillips et al.52
spectrum disorder47,48 or an affective spectrum reported that 20 percent of participants (n ⫽ 200)
disorder.48 in their naturalistic study of body dysmorphic dis-
Three diagnostic criteria are listed for body order had at least one first-degree family member
dysmorphic disorder in the Diagnostic and Statisti- with the disorder. Other studies suggest that body
cal Manual of Mental Disorders, Fourth Edition, Text dysmorphic disorder is more common in families
Revision: (1) a preoccupation with an imagined or of persons diagnosed with obsessive-compulsive
slight defect in appearance (if a slight physical disorder, suggesting that there may be a common
defect is present, the person’s degree of concern genetic link between the disorders.53
is extreme); (2) marked distress or impairment in Abnormal serotonin and dopamine function
social, occupational, or other areas of functioning are thought to play a role in the development of
resulting from the appearance preoccupation; body dysmorphic disorder, as evidenced by the
and (3) the preoccupation is not attributable to fact that patients seem to respond preferentially
the presence of another psychiatric disorder (e.g., to medications that alter levels of these
anorexia nervosa).45 As in previous versions of the neurotransmitters.54 Case reports suggest that
Diagnostic and Statistical Manual of Mental Disorders, body dysmorphic disorder may be triggered by
if the appearance preoccupations are held with medical illnesses involving inflammatory pro-
delusional intensity, a diagnosis of delusional dis- cesses that can interfere with serotonin
order, somatic type can also be applied. synthesis.55 Another case study reported that neu-
The application of the body dysmorphic dis- ral injury to the frontotemporal region of the
order diagnostic criteria to cosmetic surgery brain resulted in the onset of body dysmorphic
populations can be challenging.49 Applied in- disorder symptoms.56 A study of single-photon
dependently, the first diagnostic criterion likely emission computed tomographic brain scans con-
describes the majority of cosmetic surgery pa- ducted on six patients with body dysmorphic dis-
tients. Many individuals present for cosmetic order revealed deficits in the parietal region of
surgery to correct slight imperfections or to the brain, an area thought to be related to dis-
enhance “normal” features, and cosmetic sur- turbed body perception.57 Neuropsychological
geons, by virtue of their training, are skilled at testing of patients with body dysmorphic disorder
identifying and correcting these relatively mod- suggests deficits in verbal and nonverbal memory
est appearance imperfections. Thus, the classi- skills, and with organizational encoding
fication of a feature as “abnormal” or “correct- abilities.58 Such impairments may be indicative of
able” is often quite subjective. abnormalities in the frontostriatal and dopami-
Furthermore, in cosmetic surgery popula- nergic systems.54 A magnetic resonance imaging
tions, some degree of distress about the appear- study of eight women with body dysmorphic dis-
ance feature for which treatment is desired ap- order revealed abnormal asymmetry of the cau-

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date nucleus and increased white matter volume of onset for this disorder) and its accompanying
as compared with normal controls.59 Similar find- physical and psychological changes may also play
ings have been found among individuals with a role in the onset of body dysmorphic disorder,
obsessive-compulsive spectrum disorders. This particularly if a person is teased about his or her
study provides further evidence that body dys- appearance. For example, teasing could cause an
morphic disorder may be best classified as an individual to question the normality of his or her
obsessive-compulsive spectrum disorder rather appearance, even if it is not flawed. The increased
than as a somatoform disorder. emphasis on physical perfection in the media is yet
Psychologic Factors another potential factor in the cause of both gen-
The cause of body dysmorphic disorder has eral body image dissatisfaction and the appear-
been explained by at least two psychological the- ance preoccupations among persons with body
ories. Psychoanalytic explanations suggest that dysmorphic disorder.6,70,71
body dysmorphic disorder arises from an uncon-
scious displacement of sexual or emotional con- DEMOGRAPHIC AND CLINICAL
flict or feelings of inferiority, guilt, or poor self- CHARACTERISTICS
image onto a body part.60 There is, however, no Demographic Features
empirical evidence to support this theory. Expla- Age of Onset
nations from a cognitive-behavioral perspective Although most persons with body dysmorphic
suggest that the disorder arises from an interac- disorder do not seek treatment until their early
tion of cognitive, emotional, and behavioral thirties, the mean age of onset of body dysmorphic
factors.61– 63 disorder, as noted above, is late adolescence.72,73 In
Cognitive factors that appear to be instrumen- one of the largest studies of persons with body
tal in the development and maintenance of body dysmorphic disorder, the mean age of onset was
dysmorphic disorder include unrealistic attitudes 16.4 ⫾ 7.0 years, although dislike of appearance
about body image related to perfection and sym- began at 12.9 ⫾ 5.8 years.52 Symptom develop-
metry, selective attention to the perceived defect, ment may be sudden or gradual. It is not uncom-
increased self-monitoring for the presence of ap- mon for body dysmorphic disorder to be misdi-
pearance flaws, and misinterpretation of the facial agnosed, given its comorbid conditions (see
expressions of others as being angry or critical.62– 64 discussion below) and the reluctance of persons
Persons with body dysmorphic disorder tend to with body dysmorphic disorder to discuss their
perceive their actual appearance as being far less concerns with others.70,73
attractive than their ideal.65 They also may be more Course
sensitive to aesthetics compared with others. Two Body dysmorphic disorder tends to be contin-
studies have found associations between employ- uous rather than episodic.52 Symptom severity and
ment or education in the arts and body dysmor- degree of insight can fluctuate over the course of
phic disorder.66,67 the disorder. Complete remission of symptoms
From a behavioral perspective, body dysmor- appears to be rare, even after treatment.51,70,74 A
phic disorder is thought to arise from positive or naturalistic study of the course of body dysmor-
intermittent reinforcement of appearance char- phic disorder found that persons with severe symp-
acteristics and social learning (e.g., observing the toms of long duration, and those with personality
importance of appearance from the media or disorders, were less likely to experience partial or
peers).68 Cognitive factors (e.g., negative thoughts full remission at 1-year follow-up.74
about appearance) give rise to anxiety or other Gender Differences
negative emotions. Maladaptive behaviors (e.g., Somewhat counterintuitively, body dysmor-
excessive mirror checking) then may develop and phic disorder appears to affect men and women
persist as a means of reducing distress.62,68,69 with equal frequency.45,72 Some studies have re-
Sociocultural Factors ported higher frequencies among women52,73 or
Sociocultural theories derive explanations for men.20,47 Nevertheless, men and women tend to be
the cause of body dysmorphic disorder from the similar with respect to most demographic and clin-
social histories of patients. For example, being ical features.72,75 Male patients, however, may be
raised in a family that is rejecting, neglectful, and more likely to be unmarried.72
critical, particularly as related to issues of physical
appearance, may be associated with the develop- Clinical Features
ment of body dysmorphic disorder.60,70 The devel- To date, no large-scale epidemiologic studies
opmental period of adolescence (the typical age of body dysmorphic disorder have been com-

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pleted. However, retrospective studies72,73 and anxiety, they typically have the opposite effect.
baseline data from the first naturalistic prospec- Spending hours in front of the mirror often in-
tive study of the course of body dysmorphic creases the degree of preoccupation. Engaging in
disorder52 have provided rich descriptions of the skin picking as a means of improving the appear-
disorder’s clinical characteristics. ance of “blemishes” may create or exacerbate a
Preoccupation with Perceived Defects defect.79 Excessive application of corrective
Most frequently, persons with body dysmor- creams and makeup can also damage skin.
phic disorder become preoccupied with their Distress and Impairment of Functioning
skin, hair, and nose, although any body part can Body dysmorphic disorder symptoms often
be a source of concern.52,72,76 Men may become cause significant distress. Persons with body dys-
preoccupied with their genitals, height, hair, and morphic disorder report higher levels of depres-
body build, whereas women typically report con- sion, anxiety, and anger/hostility compared with
cerns with their weight, hips, legs, and breasts.72,75 other psychiatric outpatients and those free from
On average, persons with body dysmorphic disor- psychiatric disorders.80 Studies and case reports
der report preoccupation with five to seven body suggest that persons with body dysmorphic disor-
parts over the course of the disorder.52 Some may der may become physically violent toward
present with highly specific concerns (e.g., per- others.75,81,82 Some become so distressed about
ceived asymmetry of a body part), whereas others their appearance that they attempt “do-it-yourself”
may have vague complaints (e.g., concern that the cosmetic procedures.70,83
part does not “look right”).70 Body dysmorphic disorder often causes marked
Obsessive Thoughts impairment in psychosocial functioning.52,84 Almost
Persons with body dysmorphic disorder typi- all patients report inference with vocational or aca-
cally experience uncontrollable, intrusive demic performance, and 27 percent reported being
thoughts about their appearance. These thoughts housebound for more than 1 week at some point
may increase in situations where the person fears during the course of the disorder.52 Self-esteem and
that his or her “defect” will be evaluated by quality of life for persons with body dysmorphic
others.61 In severe cases, persons with body dys- disorder appear to be poor.84 – 87 The emotional suf-
morphic disorder may have difficulty thinking fering related to body dysmorphic disorder may
about anything aside from their “defect.” Insight lead some persons to contemplate or attempt sui-
tends to vary, but it is typically poor.52 Some per- cide. Up to 78 percent of persons with body dys-
sons admit that their concerns are exaggerated, morphic disorder report suicidal ideation and 17 to
whereas others hold their beliefs with delusional 33 percent report suicide attempts over the course
intensity.77 Up to 77 percent of persons with body of the disorder.72,73,78,79,88 Case reports of attempted
dysmorphic disorder held their appearance be- and completed suicides have been described in the
liefs with delusional intensity at some point dur- dermatology literature.41,89
ing the course of the disorder.52 Use of Cosmetic Treatments
Compulsive Behaviors Persons with body dysmorphic disorder fre-
Persons with body dysmorphic disorder often quently seek cosmetic surgery and other related
engage in compulsive, time-consuming behaviors treatments to improve their “flawed” appearance.
as a means of inspecting, improving, or camou- Veale et al.73 reported that nearly half of their
flaging their appearance concern.51,78 They may sample (n ⫽ 50) had sought cosmetic or derma-
spend hours each day examining their “defects” in tologic treatment, with 26 percent having under-
the mirror or other reflective surfaces, applying gone more than one surgical procedure. In a
makeup to camouflage their flaws, or using clothes larger sample (n ⫽ 188), 70 percent had sought
or body positions to hide areas of concern. Others and 58 percent had obtained cosmetic
may avoid mirrors and situations or clothing that treatments.72 Two recent studies suggest that 71
may expose their defect. In the largest study of to 76 percent sought and 64 to 66 percent re-
persons with body dysmorphic disorder, all par- ceived cosmetic treatments.76,90 Rhinoplasty, lipo-
ticipants reported engaging in at least one com- suction, and breast augmentation were among
pulsive behavior, including comparing themselves the most frequently sought surgical procedures.
to others, mirror checking, and skin picking.52 Receipt of minimally invasive (e.g., collagen in-
These behaviors can consume several hours each jections) and dental (e.g., tooth whitening) pro-
day and lead to impairment in relationships and cedures was also common.90
occupational functioning.61,78 Although these be- Somewhat encouragingly, providers often
haviors are undertaken with the goal of reducing refuse to perform procedures on persons with

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body dysmorphic disorder. In Phillips et al.’s76 is on appearance, whereas in hypochondriasis the

sample of 250 patients, 35 percent of all requested concerns relate to health status. Phillips et al.52
treatments (n ⫽ 785) were not provided, most found that only 2 percent of their body dysmor-
commonly because the physician deemed the phic disorder sample had comorbid hypochon-
treatment unnecessary. Similarly, in a sample of driasis.
200 patients, 21 percent of all sought procedures Trichotillomania is defined as repetitive pull-
(n ⫽ 528) were not received, primarily because the ing out of one’s hair, resulting in observable hair
provider refused to perform the procedure.90 A loss.45 The disorder is typically maintained by pos-
survey of 265 cosmetic surgeons found that 84 itive reinforcement rather than by negative
percent had refused to operate on a patient they reinforcement,94 which contrasts with body dys-
suspected of having body dysmorphic disorder.91 morphic disorder, where negative reinforcement
Nonetheless, patients may engage in “doctor shop- plays a much more prominent role in symptom
ping” until they find a provider who will perform maintenance. Although the prevalence of tricho-
the desired treatment.70 tillomania has not been examined in a body dys-
morphic disorder sample, Soriano et al.95 found
Comorbid Psychopathology that 26 percent of their small sample of trichotil-
lomania patients had body dysmorphic disorder.
Body dysmorphic disorder frequently occurs The comorbidity of body dysmorphic disorder
with other psychiatric disorders. In the largest with other obsessive-compulsive spectrum disor-
study of comorbidity among persons with body ders such as pathologic gambling, tic disorders,
dysmorphic disorder (n ⫽ 293), on average, par- and compulsive shopping has yet to be examined
ticipants met criteria for at least two lifetime co- systematically.
morbid Axis I diagnoses.92 Mood and anxiety dis-
orders, obsessive-compulsive spectrum disorder, Substance Use Disorders
substance use disorders, eating disorders, and per- Substance abuse and dependence frequently
sonality disorders were the most typical comorbid co-occur with body dysmorphic disorder. Gunstad
diagnoses. and Phillips92 reported that lifetime rates of sub-
stance abuse disorders ranged from 25 to 30 per-
Mood and Anxiety Disorders
cent, with rates as high as 47 percent being pre-
Major depression appears to be the most com-
viously reported.78 Current rates of substance
mon comorbid condition. More than 75 percent
abuse disorders range from 273 to 35 percent.72,92
of patients with body dysmorphic disorder had a
In a study of substance use disorders among per-
lifetime history of major depression, and over half
sons with body dysmorphic disorder, 49 percent
met criteria for current major depression.92 Anx-
had a lifetime history and 17 percent met current
iety disorders also frequently co-occur. Gunstad
criteria for a disorder.96 Alcohol dependence was
and Phillips92 reported that over 60 percent of
the most common lifetime substance use
patients had a lifetime history of an anxiety dis-
disorder.96 These findings suggest that some per-
order. The lifetime co-occurrence rate for social
sons with body dysmorphic disorder may use sub-
phobia is roughly 38 percent.72,92 Social phobia
stances to self-medicate distress.96
tends to predate the onset of body dysmorphic
disorder.92,93 Eating Disorders
Obsessive-Compulsive Spectrum Disorders Anorexia and bulimia appear to be relatively
Body dysmorphic disorder also frequently co- common in persons with body dysmorphic disor-
occurs with obsessive-compulsive disorder. Life- der. The lifetime comorbidity rate ranges from 7
time rates of obsessive-compulsive disorder among to 14 percent, with a current rate of 4 percent.92
persons with body dysmorphic disorder range In a study of 41 patients hospitalized for anorexia,
from 3092 to 78 percent,47 and current rates range 39 percent met criteria for body dysmorphic
from 673 to 30 percent.72,78,92 Body dysmorphic dis- disorder.97
order shares overlapping features with several Personality Disorders
other obsessive-compulsive spectrum disorders as The rate of personality disorders among per-
well. Data on their co-occurrence are mixed, mak- sons with body dysmorphic disorder appears to be
ing it difficult to establish strong connections be- quite high. In a study of Axis II comorbid diag-
tween the disorders. For example, body dysmor- noses (n ⫽ 148), 57 percent met criteria for at
phic disorder and hypochondriasis both involve least one personality disorder, most commonly
obsessional thinking and checking behaviors, but avoidant personality disorder.98 Paranoid, obses-
the focus of concern in body dysmorphic disorder sive-compulsive, and dependent personality disor-

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ders may also co-occur with body dysmorphic ies. Overall, studies suggest that body dysmorphic
disorder.73,98,99 disorder is not uncommon. Table 1 provides an
overview of the prevalence studies that have been
PREVALENCE conducted to date in a variety of populations.
Body Dysmorphic Disorder in the General Pop-
ulation Body Dysmorphic Disorder in Cosmetic Surgery
The prevalence of body dysmorphic disorder and Dermatology Populations
in the general population has yet to be firmly Body dysmorphic disorder was initially thought
established. However, body dysmorphic disorder to occur in approximately 2 percent of cosmetic
is estimated to affect approximately 1 to 2 percent surgery patients, a rate similar to that in the general
of the general population.45 Two large studies of population.109 However, empirical studies suggest
community samples both reported body dysmor- that the rate of body dysmorphic disorder among
phic disorder rates of 0.7 percent.100,101 Another cosmetic surgery and dermatology populations ap-
study of community samples reported that the rate pears to be higher than the reported rate in the
of body dysmorphic disorder ranged from 1 to 3 general population. In American cosmetic surgery
percent.53 A study of 566 high school students populations, 7 to 8 percent of patients met diagnos-
reported a rate of 2 percent.102 In college popu- tic criteria for body dysmorphic disorder.34,110 Inter-
lations, rates of body dysmorphic disorder range nationally, rates of body dysmorphic disorder
from 2.5 to 5 percent.103–106 Earlier studies of col- ranged from 6 to 53 percent among patients pre-
lege students suggested higher rates of body dys- senting for cosmetic surgery.20,111–115 However, sev-
morphic disorder (e.g., 13 to 28 percent).107,108 eral of these studies had significant methodological
However, the discrepancy in rates between early flaws, including small sample sizes, selection biases,
and more recent studies is likely attributable to the and the use of unstructured interviews. Two inter-
use of less rigorous assessments in the early stud- national studies that had larger samples and im-

Table 1. Studies of the Prevalence of BDD among Community, Student, Cosmetic Surgery, Reconstructive
Surgery, and Dermatology Samples
Authors Year Country No. Population Assessment Rate (%)

Community
Faravelli et al. 1997 Italy 673 Community sample Clinical interview 0.70
Bienvenu et al. 2000 United States 373 Community sample Clinical interview 1–3
Otto et al. 2001 United States 976 Community sample Clinical interview 0.70
Students
Fitts et al. 1989 United States 258 College students Self-report 28
Biby 1998 United States 102 College students Self-report 13
Mayville et al. 1999 United States 566 High school students Self-report 2.2
Bohne et al. 2002 Germany 133 College students Self-report 5.3
Bohne et al. 2002 United States 101 College students Self-report 4
Cansever et al. 2003 Turkey 420 College students Self-report, clinical interview 4.8
Sarwer et al. 2005 United States 559 College students Self-report 2.5
Cosmetic Surgery
Sarwer et al. 1998 United States 100 Cosmetic surgery Self-report 7
Ishigooka et al. 1998 Japan 415 Cosmetic surgery Clinical interview 15
Altamura et al. 2001 Italy 487 Aesthetic medical Clinical interview 6.3
Vargel et al. 2001 Turkey 20 Cosmetic surgery Clinical interview 20
Vindigni et al. 2002 Italy 56 Cosmetic surgery Clinical interview 53.6
Aouizerate et al. 2003 France 132 Cosmetic surgery Clinical interview 9.1
Veale et al. 2003 United Kingdom 29 Rhinoplasty Self-report 20.7
Crerand et al. 2004 United States 91 Cosmetic surgery Self-report 8
Castle et al 2004 Australia 137 Nonsurgical cosmetic Self-report 2.9
Reconstructive Surgery
Sarwer et al. 1998 United States 43 Reconstructive surgery Self-report 16
Crerand et al. 2004 United States 50 Reconstructive surgery Self-report 7
Dermatology
Phillips et al. 2000 United States 268 Dermatology Self-report 11.9
Dufresne et al. 2001 United States 46 Dermatology Self-report, clinical interview 15
Harth et al. 2001 Germany 13 Dermatology (hyperhidrosis) Clinical interview 23.1
Uzun et al. 2003 Turkey 159 Dermatology (acne) Clinical interview 8.8
BDD, body dysmorphic disorder.

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proved methodologies reported rates of 6.3 and 9 procedures, 7 to 16 percent reported appear-
percent, respectively, rates more consistent with ance concerns and distress consistent with body
those found in American studies.113,114 dysmorphic disorder. 110,121 Phillips reported
Two studies have investigated the rate of body that 4 percent of patients in a general medical
dysmorphic disorder among patients presenting clinic were found to have body dysmorphic
for nonsurgical cosmetic procedures. A small Ger- disorder.70 Case descriptions of body dysmor-
man study (n ⫽ 13) investigated “botulinophilia,” phic disorder have been reported in dental
a potential subtype of body dysmorphic disorder practices 1 2 2 , 1 2 3 and maxillofacial surgery
characterized by persistent demands for Botox in- clinics.124,125 A study of 30 patients presenting
jections to treat hyperhidrosis despite the absence for orthognathic surgery assessed body dysmor-
of symptoms, and suggested that 23 percent met phic disorder symptoms using a reliable and
Diagnostic and Statistical Manual of Mental Disorders, valid measure, but failed to report how many
Fourth Edition criteria.116 A recent study of 137 Aus- patients met criteria for body dysmorphic dis-
tralian patients presenting for nonsurgical cos- order preoperatively and postoperatively. 126
metic procedures (e.g., Botox injections, chemical Two studies have documented that persons with
peels) reported a rate of 2.9 percent.117 This rate body dysmorphic disorder seek and receive
is significantly lower than the rates reported treatments from orthodontists, ophthalmolo-
among cosmetic surgery patients. The lower rate gists, and paraprofessionals.76,90 Additional em-
reported in this sample may be attributable to piric studies are needed to document the prev-
selection bias (e.g., no information about those alence of body dysmorphic disorder among
who refused participation was collected). It is also these and other medical specialties.
possible that more people with body dysmorphic
disorder present for surgery rather than less in- TREATMENT
vasive procedures because they believe that their As noted above, persons with body dysmorphic
“defects” warrant more intensive intervention. Ad- disorder typically believe that the cause of their dis-
ditional study of the rate of body dysmorphic dis- tress is a “defective” appearance. Not surprisingly,
order among persons seeking nonsurgical cos- these patients often turn to plastic surgeons, derma-
metic interventions is needed. tologists, and other medical professionals for treat-
The rates of body dysmorphic disorder reported ment. Patients also present for psychiatric and psy-
in dermatology settings, ranging from 9 to 15 per- chological treatment, often with greater success.
cent, appear to be slightly higher than the rates
found in cosmetic surgery populations.118 –120 In the
largest study of body dysmorphic disorder in a der- Cosmetic Medical Treatments
matology setting (n ⫽ 268), 12 percent met criteria To date, no prospective studies of cosmetic
for body dysmorphic disorder.118 These patients medical treatment outcome among individuals
most frequently sought treatment for acne. with body dysmorphic disorder have been con-
In sum, 7 to 15 percent of patients who present ducted. Thus, what is known about the outcome of
for cosmetic surgical or dermatologic treatment such treatments has been gathered from retro-
may be suffering from body dysmorphic disorder. spective studies73,76,90 and reports from the cos-
Among patients presenting for nonsurgical cos- metic surgery literature of poor outcomes among
metic procedures, the rate of body dysmorphic patients thought to have body dysmorphic disor-
disorder appears to be lower, although this find- der symptoms.127 These investigations suggest that
ing awaits replication. Nonetheless, these rates cosmetic medical treatments typically produce no
suggest that it is important for treatment providers change or, even worse, an exacerbation of body
to be aware of body dysmorphic disorder and its dysmorphic disorder symptoms.76,90 In one of the
presentation in cosmetic populations.5–7 largest studies, 91 percent of procedures resulted
in no change in overall body dysmorphic disorder
symptoms.90 After treatment, some recipients
Body Dysmorphic Disorder in Other Medical thought that their defect looked better, but they
Populations continued to worry about the treated body part
The rate of body dysmorphic disorder in (e.g., concerns that the part would become de-
other medical populations has received less em- fective again).90 In other cases, new appearance
piric attention. However, there is evidence that concerns developed.90
the disorder occurs in other patient groups. Persons with body dysmorphic disorder who re-
Among persons seeking reconstructive surgical ceive cosmetic treatments typically report dissatisfac-

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tion with their treatment results.73 Of greater concern, terventions for persons with body dysmorphic dis-
there are reports of patients with body dysmorphic order. Until recently, knowledge regarding phar-
disorder who have threatened or executed lawsuits macotherapy for body dysmorphic disorder was
against their treatment providers.91,128,129 In a survey of limited to the results of case reports, retrospective
265 aesthetic surgeons, 29 percent reported that they chart reviews, and open-label trials.70,136 –141 De-
had been threatened legally by a patient with body spite their inherent methodological weaknesses,
dysmorphic disorder.91 The case of Lynn G v. Hugo these studies consistently suggested that selective
also underscored the potential malpractice risks asso- serotonin reuptake inhibitors were beneficial in
ciated with providing treatment to persons with body treating body dysmorphic disorder.
dysmorphic disorder.128 In this case, Dr. Hugo was Randomized, controlled trials have also pro-
sued by his former patient, Lynn G, who claimed that vided evidence for the efficacy of selective sero-
she had body dysmorphic disorder and therefore tonin reuptake inhibitors in the treatment of body
could not consent for treatment. As there was no dysmorphic disorder. Hollander et al.142 reported
evidence that Lynn G had body dysmorphic disorder, that the selective serotonin reuptake inhibitor clo-
the case was dismissed. Nonetheless, this case brought mipramine was more effective than desipramine,
to light the potential legal concerns associated with a nonselective serotonin reuptake inhibitor, in
treating persons with body dysmorphic disorder. their randomized, double-blind, crossover study.
In addition to the potential legal hazards associ- More recently, fluoxetine was found to be superior
ated with treating patients with body dysmorphic dis- to placebo in a randomized, controlled trial.143 In
order, reports suggest that these patients may become this study of 67 patients, 53 percent of those
violent toward their surgeons. A survey of aesthetic treated with fluoxetine had a favorable response
surgeons reported that 2 percent had been physically compared with 18 percent of those treated with
threatened by a patient with body dysmorphic disor- placebo. Patients who responded favorably to flu-
der; 10 percent reported that they had received threats oxetine experienced significant improvements in
of both violence and legal action.91 At least two sur- quality of life and daily functioning.86
geons have been murdered by patients who appeared Despite these promising results, many patients
to have symptoms consistent with body dysmorphic treated with selective serotonin reuptake inhibi-
disorder.129,130 Similar reports of violence have been tors experience only partial response to treat-
published in the dermatology literature.131 ment. Some patients need long trials of high dos-
Because of the legal and personal safety issues ages of the medication,139,144 whereas others need
associated with treating persons with body dysmorphic to switch to a different selective serotonin re-
disorder, coupled with the evidence that cosmetic uptake inhibitor.144 Augmentation studies of se-
treatments rarely improve body dysmorphic disorder lective serotonin reuptake inhibitors with antipsy-
symptoms, there is growing consensus that body dys- chotic medications such as olanzapine or
morphic disorder should be considered a contraindi- pimozide have yielded mixed results.139,145,146 De-
cation for cosmetic treatments.49,73,76,90,91,127,130,131 Given spite the fact that some patients may be delusional,
that persons with body dysmorphic disorder seek cos- the use of antipsychotic medications alone for the
metic medical treatments with great frequency, it is treatment of either body dysmorphic disorder
important that all patients be assessed for the potential variant has not been supported.46,144 The nonde-
presence of body dysmorphic disorder before under- lusional and delusional variants of body dysmor-
going treatment. A general psychological screening, phic disorder appear to respond equally well to
consisting of an assessment of patient motivations and selective serotonin reuptake inhibitors.140,142 Al-
expectations, psychiatric status and history, body im- though selective serotonin reuptake inhibitor
age concerns and body dysmorphic disorder symp- medications have produced the most favorable
toms, and an observation of the patient’s office behav- results thus far, a recent case report suggests that
ior, can identify persons for whom surgery may be bupropion, an atypical antidepressant, may also
inappropriate.132–135 Such a screening may include an improve body dysmorphic disorder symptoms.147
interview with the patient and/or use of self-report
assessments. Patients with suspected body dysmorphic
disorder can be referred to a mental health profes- Psychotherapeutic Treatment
sional for additional screening and treatment.7,133 Cognitive behavioral therapy is another com-
mon treatment approach. Cognitive behavioral ther-
Pharmacologic Treatment apy involves the identification and modification of
Unlike cosmetic treatments, pharmacologic problematic, appearance-related cognitions and be-
treatments appear to be much more effective in- haviors. Strategies used in cognitive behavioral ther-

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 Plastic and Reconstructive Surgery • December 2006

apy include self-monitoring of thoughts and behav- ences in demographic or clinical characteristics
iors related to appearance (e.g., monitoring the (e.g., symptom severity) in persons with body dys-
amount of time spent mirror gazing); cognitive tech- morphic disorder who had received or not re-
niques (e.g., challenging distorted thoughts about ceived cosmetic treatment. However, the retro-
one’s appearance); and behavioral exercises (e.g., spective design of this study limits the validity of
exposing the patient to a feared situation and pre- this finding. The willingness of some patients with
venting engagement in compulsive behaviors).69 body dysmorphic disorder to undertake the risks
Several studies, including two randomized, con- associated with surgery may be indicative of more
trolled clinical trials,61,62 suggest that cognitive be- severe symptomatology.
havioral therapy is an efficacious treatment for body Studies are also needed to determine effective
dysmorphic disorder.148 –150 treatments for body dysmorphic disorder. Clearly,
CONCLUSIONS AND DIRECTIONS FOR medications and psychotherapy appear to be
FUTURE RESEARCH promising interventions for this disorder, al-
though research in these areas is still in its infancy.
Body dysmorphic disorder is characterized by
extreme dissatisfaction and preoccupation with a Research is needed to identify other medications
perceived appearance defect that often leads to and implementation strategies that may help man-
significant functional impairment. Among pa- age body dysmorphic disorder symptoms effec-
tients presenting for cosmetic treatments, 7 to 15 tively. Also needed are studies that combine phar-
percent may suffer from body dysmorphic disor- macotherapy with psychotherapy.
der. Cosmetic treatment typically does not im- Cosmetic treatment as a potential intervention for
prove the appearance concerns of individuals with body dysmorphic disorder also warrants further atten-
body dysmorphic disorder and, in some cases, may tion. Retrospective studies suggest that persons with
exacerbate symptoms. Patients with body dysmor- body dysmorphic disorder do not benefit from cos-
phic disorder may also be more likely to become metic treatments. However, surgeons appear to be less
litigious or violent toward their treatment provid- convinced of this finding, given that only 30 percent of
ers. Because persons with body dysmorphic disor- surgeons in one survey reported that body dysmorphic
der frequently seek cosmetic procedures, provid- disorder was always a contraindication for surgery.91 It
ers may be able to identify and refer these patients is possible, however, that cosmetic treatments may ben-
for mental health treatment. efit some persons with body dysmorphic disorder. Edg-
Additional research is needed to further investi- erton et al.151suggested that some patients with severe
gate body dysmorphic disorder among cosmetic sur- psychological disturbances desiring cosmetic treat-
gery populations. The rate of body dysmorphic disor- ments could be managed successfully with combined
der among persons presenting for minimally invasive psychiatric and surgical treatment. Cosmetic treat-
procedures requires additional study. Investigations of ments in conjunction with appropriate psychiatric care
the rates of body dysmorphic disorder among specific may prove to be an effective treatment combination for
cosmetic surgery patient populations are also needed. body dysmorphic disorder, particularly in cases where
For example, it is unknown whether the rate of body
previous treatments have resulted in observable
dysmorphic disorder is higher among patients present-
damage.152 It is also possible that persons with mild
ing for facial procedures compared with those present-
ing for body procedures. The rate of body dysmorphic forms of the disorder may benefit from cosmetic treat-
disorder should also be examined among patients re- ments or a combination of cosmetic and psychiatric
questing atypical procedures (e.g., craniofacial proce- treatments. Clearly, there are ethical concerns to con-
dures, genital surgery) and among adolescents request- sider before conducting prospective studies such as
ing cosmetic treatment, given the age of onset of the these. However, such studies could potentially improve
disorder. Studies are also needed to identify the rate of the clinical care for persons with this often devastating
psychiatric disorders such as social anxiety disorder and disorder.
eating disorders in cosmetic surgery patients, given
their potential overlap with body dysmorphic disorder. David B. Sarwer, Ph.D.
At present, it is unclear whether persons with University of Pennsylvania School of Medicine
body dysmorphic disorder who receive cosmetic Edwin and Fannie Gray Hall Center for Human
Appearance
treatments differ with respect to demographic or 10 Penn Tower
clinical characteristics compared with persons 3400 Spruce Street
with body dysmorphic disorder who do not seek Philadelphia, Pa. 19104
cosmetic treatments. One study90 found no differ- [email protected]

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Volume 118, Number 7 • Body Dysmorphic Disorder

DISCLOSURE 17. Shipley, R. H., O’Donnell, J. M., and Bader, K. F. Personality

None of the authors reports any commercial associ- characteristics of women seeking breast augmentation.
Plast. Reconstr. Surg. 60: 369, 1977.
ations or financial disclosures that might pose or create 18. Wright, M. R., and Wright, W. K. A psychological study of
a conflict of interest with the information presented in patients undergoing cosmetic surgery. Arch. Otolaryngol.
this article. 101: 145, 1975.
19. Wengle, H. P. The psychology of cosmetic surgery: A critical
overview of the literature, 1960 –1982. Part I. Ann. Plast.
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dysmorphic disorder: An obsessive-compulsive spectrum
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morphic disorder: neurobiology and psychopharmacology. morphic disorder. Psychosomatics 42: 504, 2001.
In D. J. Castle and K. A. Phillips (Eds.), Disorders of Body 77. Phillips, K. A., and McElroy, S. L. Insight, overvalued ide-
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Pp. 139–155. der: Theoretical and treatment implications. J. Nerv. Ment.
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morphic disorder triggered by medical illness? Am. J. Psy- 78. Phillips, K. A., McElroy, S. L., Keck, P. E., et al. Body dys-
chiatry 159: 493, 2002. morphic disorder: 30 cases of imagined ugliness. Am. J. Psy-
56. Gabbay, V., Asnis, G. M., Bello, J. A., et al. New onset of body chiatry 150: 302, 1993.
dysmorphic disorder following frontotemporal lesion. Neu- 79. Phillips, K. A., and Taub, S. L. Skin picking as a symptom
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16: 357, 2004. sion, anxiety, anger, and somatic symptoms in patients with
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order. J. Int. Neuropsychol. Soc. 6: 673, 2000. and literature review. J. Forensic Psychiatry 13: 145, 2002.

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82. Albertini, R., and Phillips, K. A. Thirty-three cases of body 103. Bohne, A., Keuthen, N. J., Wilhelm, S., et al. Prevalence of
dysmorphic disorder in children and adolescents. J. Am. symptoms of body dysmorphic disorder and its correlates:
Child Adolesc. Psychiatry 38: 453, 1999. A cross-cultural comparison. Psychosomatics 43: 486, 2002.
83. Veale, D. Outcome of cosmetic surgery and ‘DIY’ surgery in 104. Bohne, A., Wilhelm, S., Keuthen, N. J., et al. Prevalence of
patients with body dysmorphic disorder. Psychiatr. Bull. 24: body dysmorphic disorder in a German college student
218, 2000. sample. Psychiatry Res. 109: 101, 2002.
84. Phillips, K. A., Menard, W., Fay, C., et al. Psychosocial func- 105. Cansever, A., Uzun, O., Donmez, E., et al. The prevalence
tioning and quality of life in body dysmorphic disorder. and clinical features of body dysmorphic disorder in college
Compr. Psychiatry 46: 254, 2005. students: A study in a Turkish sample. Compr. Psychiatry 44:
85. Phillips, K. A. Quality of life for patients with body dysmor- 60, 2003.
phic disorder. J. Nerv. Ment. Dis. 188: 170, 2000. 106. Sarwer, D. B., Cash, T. F., Magee, L., et al. Female college
86. Phillips, K. A., and Rasmussen, S. A. Change in psychosocial students and cosmetic surgery: An investigation of experi-
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