BDD occurs in all age groups.^{(3, 4 and 5)} It appears about equally common in females and males or may be somewhat more common in females.⁽³⁾ Most individuals with BDD have never been married, and a high proportion is unemployed, often because of their psychopathology.^{(3, 4, 5, 6 and 7)}

People with BDD are preoccupied with the idea that some aspect of their appearance is ugly, unattractive, deformed, flawed, or defective in some way.^{(1, 2, 3, 4, 5 and 6,8, 9 and 10)} Concerns usually focus on the face or head but can involve any body area.^{(3, 4, 5 and 6, 8, 9 and 10)} Skin (e.g. acne, scars, lines, or pale skin), hair (e.g. thinning or excessive body or facial hair), and nose (e.g. size or shape) concerns are most common. Most patients are preoccupied with several body areas. The preoccupation usually focuses on specific areas but may involve overall appearance.

BDD preoccupations are distressing, time consuming (occurring for an average of 3-8 h a day), and usually difficult to resist or control.⁽³⁾ They are often associated with low self-esteem, shame, rejection sensitivity, and high levels of neuroticism, introversion,
depressed mood, anxiety, anger-hostility, and perceived stress.⁽³⁾ Patients often believe that they are unacceptable—e.g. worthless, inadequate, unlovable, and an object of ridicule and rejection.^(3,9)

Insight is usually poor or absent; 27-39 per cent of patients are currently delusional (completely convinced that their belief is accurate and undistorted).^(3,11,12) Most do not recognize that their belief is due to a mental illness or has a psychological/psychiatric cause.^(3,12) In addition, a majority have ideas or delusions of reference, believing that others take special notice of the supposed appearance defects—for example, stare at them or mock the person because of how they look.^(3,12) Referential thinking can fuel feelings of anger and rejection as well as social isolation.

Nearly all patients perform BDD-related compulsive or safety behaviours (Table 5.2.8.1), which are time consuming (occurring for hours a day) and difficult to resist or control.^{(3, 4, 5 and 6,10)} The behaviours usually aim to examine, improve, hide, or obtain reassurance about the perceived defects. These behaviours typically do not alleviate distress and may even worsen it.

Compulsive skin picking, which 27-45 per cent of BDD patients do to try and improve their appearance, can cause considerable skin damage.^(3,5) Emergency surgery is sometimes required—for example when sharp implements used for picking rupture major blood vessels. Compulsive tanning to darken ‘pale’ skin or minimize perceived acne, scarring, or ‘marks’ can cause skin damage and may increase cancer risk.⁽³⁾

Functioning and quality of life are usually very poor.^(3,4,7) Some people, with effort, function adequately despite their distress, although usually below their potential. Those with severe BDD may be profoundly impaired by their symptoms—for example, housebound for years, unemployed and socially isolated, and chronically suicidal.

Social impairment is nearly universal.^(3,7) People with BDD feel embarrassed and ashamed of their ‘ugliness’, are anxious around others as a result, and fear being rejected because of how they look. Thus, they may have few or no friends; avoid dating, physical intimacy, and other social interactions; or get divorced. Impairment in academic or occupational functioning is common, due to the time consuming and distracting nature of BDD symptoms and a desire to avoid interactions with others.^(3,7) In a broadly ascertained BDD sample (n = 200), 36 per cent of individuals were not currently working and 32 per cent were not able to be in school or do school work because of psychopathology (BDD was the primary diagnosis for most).⁽⁷⁾ In two BDD series, more than a quarter of individuals had been completely housebound for at least 1 week because of BDD symptoms, and more than 40 per cent had been psychiatrically hospitalized.^(5,13) Mental health related quality of life is markedly poorer than for the general population and even poorer than for patients with diabetes, a recent myocardial infarction, or clinical depression.⁽⁷⁾

Suicidal ideation and attempts appear very common. Reported lifetime rates of suicidal ideation and suicide attempts are 78-81 and 24-28 per cent, respectively.^(9,13,14) Among adolescent inpatients, those with BDD have significantly greater suicidality than those without BDD. The rate of completed suicide, while preliminary, appears markedly high. In a prospective study, the annual suicide rate was 0.35 per cent, which is approximately 45 times higher than for the US population (adjusted for age, gender, and geographic region) and higher than for most other mental disorders.⁽¹⁵⁾ A study of dermatology patients who committed suicide found that most had acne or BDD.⁽¹⁶⁾ Indeed, individuals with BDD have many suicide risk factors.^(3,14)

In several BDD studies, 36-38 per cent of patients reported lifetime aggression/violence due specifically to BDD symptoms.^(3,10) Such behaviour may be fuelled by anger about looking ‘deformed’, an inability to fix the perceived defect, and misperceptions of being rejected, ridiculed, or mocked because of the appearance ‘defects’. Individuals with BDD tend to misinterpret self-referent facial expressions as contemptuous and angry,⁽¹⁷⁾ misinterpret ambiguous social (and other) situations as threatening,⁽¹⁸⁾ and have high levels of anger/hostility.⁽³⁾ Surgeons and dermatologists may be victims of violence—even murder—fuelled by dissatisfaction with the outcome of cosmetic procedures.⁽³⁾ In a survey of 265 plastic surgeons, 12 per cent reported that a BDD patient had physically threatened them.⁽¹⁹⁾

Major depressive disorder is the most frequently comorbid disorder, occurring in about 75 per cent of individuals with BDD.^(5,13) Social phobia, OCD, and substance use disorders are also common.^(5,8,13) Of note, one study found that 49 per cent of 200 BDD subjects had a lifetime substance use disorder, 70 per cent of whom reported that BDD contributed to their substance use.⁽⁵⁾ Muscle dysmorphia,
a preoccupation with the idea that one’s body is insufficiently lean or muscular, may lead to anabolic steroid abuse.⁽³⁾