Associated Features and Disorders
Frequent checking of the defect, either directly or in a reflecting surface (e.g., mirrors, store windows, car bumpers, watch faces) can consume many hours a day. Some individuals use special lighting or magnifying glasses to scrutinize their “defect.” There may be excessive grooming behavior (e.g., excessive hair combing, hair removal, ritualized makeup application, or skin picking). Although the usual intent of checking and grooming is to diminish anxiety, be reassured about one’s appearance, or temporarily improve one’s appearance, these behaviors often intensify the preoccupation and associated anxiety.
Consequently, some individuals avoid mirrors, sometimes covering them or removing them from their environment. Others alternate between periods of excessive mirror checking and avoidance. Other behaviors aimed at improving the “defect” include excessive exercise (e.g., weight lifting), dieting, and frequent changing of clothes. There may be frequent requests for reassurance about the “defect,” but such reassurance leads to only temporary, if any, relief. Individuals with the disorder may also frequently compare their “ugly” body part with that of others. They may try to camouflage the “defect” (e.g., growing a beard to cover imagined facial scars, wearing a hat to hide imagined hair loss, stuffing their shorts to enhance a “small” penis). Some individuals may be excessively preoccupied with fears that the “ugly” body part will malfunction or is extremely fragile and in constant danger of being damaged. Insight about the perceived defect is often poor, and some individuals are delusional; that is, they are completely convinced that their view of the defect is accurate and undistorted, and they cannot be convinced otherwise. Ideas and delusions of reference related to the imagined defect are also common; that is, individuals with this disorder often think that others may be (or are) taking special notice of their supposed flaw, perhaps talking about it or mocking it.
Avoidance of usual activities may lead to extreme social isolation. In some cases, individuals may leave their homes only at night, when they cannot be seen, or become housebound, sometimes for years. Individuals with this disorder may drop out of school, avoid job interviews, work at jobs below their capacity, or not work at all. They may have few friends, avoid dating and other social interactions, have marital difficulties, or get divorced because of their symptoms. The distress and dysfunction associated with this disorder, although variable, can lead to repeated hospitalization and to suicidal ideation, suicide attempts, and completed suicide. Individuals with Body Dysmorphic Disorder often pursue and receive general medical (often dermatological), dental, or surgical treatments to rectify their imagined or slight defects. Occasionally, individuals may resort to extreme measures (e.g., self-surgery) to correct their perceived flaws.
Such treatment may cause the disorder to worsen, leading to intensified or new preoccupations, which may in turn lead to further unsuccessful procedures, so that individuals may eventually possess “synthetic” noses, ears, breasts, hips, or other body parts, which they are still dissatisfied with. Body Dysmorphic Disorder may be associated with Major Depressive Disorder, Delusional Disorder, Social Phobia, and Obsessive-Compulsive Disorder.