Body dysmorphia in males – what to look out for

Body dysmorphic disorder (BDD) is characterised by self-perceived flaws in one’s appearance that might be imagined or imperceptible to others¹. BDD affects around one in 50 Australians² and is equally prevalent in males and females³. Insight into the disorder is poor — 27-60% of people with BDD have delusional beliefs that their view of their appearance is accurate⁴, and covering up the perceived defect is common¹. 

These characteristics make the diagnosis of BDD difficult when it is not accompanied by common comorbid conditions like anxiety, low mood and hostility or unless specific questions are asked about BDD symptoms. The Body Dysmorphic Disorder Questionnaire is a brief four-question form that can be completed by individuals to screen for BDD.

Distinguishing BDD from someone’s normal concerns about their appearance is difficult. Only one in five men is unconcerned by his appearance, and two in five are dissatisfied by how they look⁵.

Behaviours that are common in people with BDD include:

• Grooming
• Picking at skin
• Checking appearance in the mirror
• Mirror avoidance
• Seeking reassurance
• Camouflaging (covering the perceived defect with makeup, hair and/or clothing)
• Touching perceived defect
• Excessive exercise
• Comparing appearance with others
• Seeking correction of the perceived defect (e.g. cosmetic surgery)
   

Often, people with BDD seek correction of the perceived flaw in their appearance. Around one in four to one in three men who seek cosmetic surgery have BDD, and most people with BDD have sought or received cosmetic treatments⁵. It’s important to recognise BDD in people seeking these treatments because such interventions are unlikely to satisfy their concerns⁶.

Awareness of the behavioural signs of BDD is important for recognition and, ultimately, diagnosis but a distinguishing characteristic is the impact of the appearance concerns. Preoccupation with appearance that causes significant distress or interferes with day-to-day function is fundamental to BDD. These impacts of BDD may be hidden or denied⁵ and may, therefore, not be obvious.
 

Sometimes, BDD is mistaken or misdiagnosed as another disorder⁵. Common misdiagnoses, and reasons for them, include⁵:

• Major depression

- Depressive symptoms that coexist might be diagnosed but BDD missed

- Symptoms of BDD are mistaken as symptoms of depression

• Social anxiety

- BDD can cause social anxiety, which might be noticeable, but BDD hidden

• Agoraphobia

- Anxiety about appearance can lead some people with BDD to be reluctant to leave their homes

• Obsessive-compulsive disorder

- Obsessive and repetitive behaviours may not be recognised as focusing on appearance

• Panic disorder

- BDD may not be recognised as the cause of panic attacks

• Trichotillomania (hair pulling)

- Hair pulling that is aimed at improving a perceived defect might be attributed to stress or anxiety

• Schizophrenia

- Delusional beliefs and referential thinking may relate only to appearance
 

Concern that someone may have BDD should result in referral to a mental health specialist with expertise in diagnosing and treating the disorder. Successfully encouraging appropriate treatment is best achieved by focusing on the ability to reduce distress and improve day-to-day function, which is possible with cognitive behavioural therapy and antidepressant medicines⁵.