Becky is a 29-year-old unmarried woman with asthma and seasonal allergies who is referred to see a psychiatrist, Dr. Clark, by her primary care provider for the evaluation of a possible eating disorder because of expressed preoccupation with what she is eating and a 7 lb weight loss since her last visit six months before. Becky tells Dr. Clark that “this isn’t in my head,” describing “a rash” on her face which she believes may be related to food allergies. Despite negative allergen testing, she endorses being convinced that she is sensitive to wheat and dairy and that she develops flushing on her face when she eats them. She explains that she has been aware of her flushed skin for the past eight years. Feeling “embarrassed” by this aspect of her appearance, she had tried to manage the symptom on her own for several years, trying numerous topical treatments and home remedies, such as drinking apple cider vinegar. About a year ago, becoming increasingly frustrated by her symptom, she saw a dermatologist who—she reports—told her there was “nothing to see” and seemed “patronizing”. Becky saw two more dermatologists after that, whom she describes as equally unresponsive. About two months ago, she began reading about food allergies and is sure that wheat, dairy, and “nightshade vegetables” are causing her symptoms, so she began progressively limiting her diet. She says the flushing has persisted, but attributes this to her sense that “trace amounts” of these food allergens are present in other foods despite her efforts to buy “pure products”. She has been spending an estimated 3 h a day reading about food allergies and checking ingredient lists of foods. She also spends about 2 h in the morning applying makeup to conceal her flushed skin and more time throughout the day when she “checks” on her flushing in her handheld mirror. She avoids looking at herself in bathroom mirrors during the day, afraid of how her flushing might look in “new” mirrors.

Dr. Clark does not appreciate any abnormal discoloration of Becky’s skin from her chair across the office room; when she asks where on her face the flushing is, Becky becomes angry, saying that everyone tells her she looks “normal”, and the fact that they do not seem to “notice” upsets her even more.

Upon further history, Becky describes a history of worries about her body going back to childhood, with concerns about going blind or dying as a young girl, and worries about the width of her thighs as a teenager. She admits that in high school she would measure her thighs three times a day and do various exercises that she thought might make them smaller. She had a period of food restriction in order to lose weight from her thighs at age 16, reporting that she lost approximately 5 lb over two months but then resumed a more normal diet. She had seen a therapist as an 8-year-olds for her “worries” about sickness and dying; she subsequently saw the school counselor during her senior year because of concerns by her parents and teachers that she was anxious, but she did not find this helpful. She has never been on psychiatric medications.

Preferred diagnosis: Body Dysmorphic Disorder

With further exploration of her symptoms, Dr. Clark diagnoses Becky with body dysmorphic disorder (BDD). BDD is not considered an eating disorder but has many overlapping features with the feeding and eating disorders and should be considered in the evaluation of an individual presenting with concerns about physical appearance (see Differential Diagnosis for further discussion).

The diagnosis of BDD requires preoccupations with perceived flaws or defects in one’s physical appearance, repetitive behaviors in response to these thoughts about appearance, impairment in functioning due to the preoccupations and behaviors, and the exclusion of an eating disorder that could better explain the patient’s symptoms. The individual’s physical flaw may not be evident to others; in cases where an objective physical defect is present, the individual’s response to the defect surpasses what would be expected, including the intensity of the concerns or the degree of behaviors associated with the defect. Specifiers for BDD include the muscle dysmorphia variant, which applies to individuals focused on not being muscular enough, and the insight specifier (categorized as “with good or fair insight,” “with poor insight,” and “with absent insight/delusional beliefs”). Previously located in the somatoform disorders section, BDD is currently classified as one of the obsessive–compulsive and related disorders in DSM-5 , with modifications based on advances in the understanding of the condition [see Text box: “Spotlight on DSM-5: Body Dysmorphic Disorder”].

BDD has a point prevalence of approximately 1.5–2.5, though these estimates are thought to be lower than the actual prevalence, as this diagnosis is often missed—due to various factors, including lack of widespread awareness of, and screening for, the condition, and the shame that individuals with BDD often experience, making them less likely to disclose their thoughts and behaviors about their appearance. In clinical samples, both psychiatric outpatient and inpatient settings, the prevalence is higher; notably, up to one-quarter of all patients seeking non-psychiatric treatment, such as dermatologic and surgical interventions, may have BDD, based on some estimates [2]. BDD is slightly more common in women than men, though this difference is not marked. Gender and cultural standards may influence the focus of the patient’s attention; for example, while the most common physical areas of concern include skin, hair, and nose, women with BDD appear to be more preoccupied with weight, breasts, buttock, and legs, while men may be more concerned about their genitals, musculature, and hair/balding.