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  • The Body Dysmorphic Disorder Program at Rhode Island Hospital

  • Related Disorders

  • In addition to providing treatment services for Body Dysmorphic Disorder (BDD), we provide treatment for mental health disorders that have similarities to BDD, including obsessive-compulsive disorder (OCD), olfactory reference syndrome, and eating disorders.

    Obsessive Compulsive Disorder

    People with OCD suffer from unwanted and intrusive thoughts or images – called obsessions – that they find hard to get out of their mind. Some common obsessions are fears of contamination from germs or dirt, fear that something bad will happen because you forgot to lock the door or turn off an appliance, fear of accidentally causing harm, concerns about symmetry and order, moral or religious fears, and unwanted sexual thoughts. People with OCD usually try to ease the anxiety or distress from the obsessions by repeatedly doing certain behaviors – called compulsions – such as washing or cleaning again and again, checking things many times, or spending a lot of time arranging objects or making things perfect. The obsessions or compulsions are upsetting, interfere with day-to-day life, or take up a lot of time (about an hour or more a day).

    OCD and body dysmorphic disorder are similar in a number of ways. The appearance-related preoccupations that occur in BDD are similar to OCD obsessions. Like many people with OCD, most people with BDD perform repetitive and time-consuming behaviors (compulsions or rituals). These behaviors (such as mirror checking or comparing with others) are an attempt to reduce the anxiety or distress caused by the obsessive thoughts and to prevent an unwanted event (such as being rejected by other people) from occurring.

    Although BDD and OCD share many features, they are different disorders. Some of their differences are the following:

    • People with BDD are more likely than those with OCD to be depressed, experience suicidal thoughts and behaviors and abuse substances (alcohol or drugs).
    • People with BDD are more likely to strongly believe or be convinced that their beliefs are true – for example, that they really do look ugly or deformed. People with OCD are more likely to recognize that their obsessive beliefs are unrealistic or inaccurate. For example, people with OCD they are less likely to believe that they will really get cancer from touching an astray or that their house will burn down in a fire if they don’t check the stove multiple times.
    • People with BDD appear more likely to inaccurately believe that other people take special notice of them in a negative way (for example, mock them).
    • A majority of people with BDD seek and receive cosmetic treatment – such as surgery, dermatologic or dental treatment - in an attempt to diminish their preoccupation. This is not the case for OCD. These treatments appear to usually be ineffective for BDD.
    • There are some important differences in effective treatments for OCD and BDD, especially in cognitive-behavioral therapy for these disorders.

    Olfactory Reference Syndrome

    Olfactory Reference Syndrome (ORS) is an underrecognized disorder in which people are preoccupied with the belief that they emit an unpleasant or foul body odor, when in fact other people don’t perceive the odor. This most often consists of concerns about giving off a foul odor from the mouth, armpits, genitals, anus, feet, skin, groin, hands or head/scalp. People with ORS often describe the smell as “bad breath,” “sweat,” “a flatulence/fecal odor,” “urine,” or “vaginal” odor.

    People with ORS engage in time-consuming repetitive behaviors (compulsions or rituals) to try to decrease the anxiety and distress that their preoccupation causes. For example, they may frequently smell themselves to check for body odor, shower excessively, change their clothes many times a day, ask others if they smell okay, brush their teeth a lot or wash their clothes frequently. Many try to cover up the odor with perfume or cologne, chewing gum or mints, or a lot of deodorant or mouthwash. People with ORS may also request and obtain dental, dermatologic or surgical procedures to try to get rid of the body odor they perceive. Although more research studies are needed, such treatments do not appear to diminish the body odor concerns.

    The preoccupation with body odor causes significant distress and may cause depression, anxiety and suicidal thoughts and behavior. This disorder often causes problems with school, work, relationships and social functioning.

    ORS has some similarities to BDD, including emotionally painful obsessions that focus on the body, time-consuming repetitive behaviors in response to these obsessions, and seeking of nonpsychiatric medical treatment (for example, surgical, dermatologic or dental) to try to diminish their concerns. Much more scientific research is needed on ORS; however, ORS does appear to differ in some ways from BDD, such as the following:

    • The focus of the preoccupation is different. People with BDD worry about how they look, whereas people with ORS worry that they emit a foul body odor.
    • People with ORS may be more likely to strongly believe or be convinced that their beliefs are true.
    • People with ORS may be more likely to inaccurately believe that other people take special notice of them in a negative way.
    • There appear to be some important differences in effective treatments for OCD and BDD, both medication and cognitive-behavioral therapy.

    Depression

    Major depressive disorder, commonly called depression, is characterized by depressed mood and/or loss of interest in activities that occurs most of the day, every day or nearly every day, for at least two weeks in a row. Depression also involves other symptoms, including fatigue or loss of energy, feelings of worthlessness or guilt, difficulty concentrating, sleeping too much or difficulty sleeping, significant changes in appetite or weight, restlessness or slowness of movement, and thoughts of death or suicide. These symptoms are distressing to the depressed person and/or interfere with day-to-day life.

    BDD and depression commonly co-occur, suggesting that they may be related conditions. In fact, depression is the mental disorder that most often accompanies BDD. About 75% of people with BDD have had major depression at some point during their life. Additional evidence that BDD and depression are related disorders comes from our prospective, longitudinal study of BDD, in which BDD often immediately improved after depression improved, and vice versa.

    BDD and depression also have several features in common, such as:

    • Sadness and gloominess
    • Sensitivity to rejection
    • Poor self-esteem
    • Feelings of unworthiness and defectiveness
    • Feelings of guilt

    However, BDD is a separate disorder from depression; it is not simply a symptom of depression. Evidence for this includes (but is not limited to) the following:

    • People with BDD have prominent time-consuming preoccupations (obsessional thoughts) about their appearance and perform time-consuming repetitive, compulsive behaviors related to these concerns. People with depression are not obsessionally preoccupied with perceived appearance flaws and tend to focus less, not more, on their appearance when they are depressed. And depression does not involve repetitive, compulsive behaviors.
    • BDD and depression appear to have some neurobiological differences.
    • In our prospective longitudinal study, when depression went away about half of participants still had BDD. This would not be expected if BDD were simply a symptom of depression.
    • BDD typically begins earlier in life than depression and, when untreated, appears to often be more chronic.
    • BDD and accompanying depressive symptoms do not appear to respond as well to non-SRI (serotonin reuptake inhibitor) antidepressant medications as they do to SRIs. In contrast, depression responds well to both classes of medications. Also, BDD often takes longer to respond to an SRI and typically requires higher doses of an SRI than depression does.
    • BDD often improves with SRI medication regardless of whether depression improves.
    • Cognitive-behavioral therapy (a type of psychotherapy) for BDD involves not only cognitive restructuring but also exposure, response prevention, and perceptual retraining, unlike cognitive-behavioral therapy for depression.

    Social Anxiety Disorder

    People with social anxiety disorder (also known as social phobia) are markedly anxious or fearful of social situations in which they may be scrutinized by others. They are concerned that they will show anxiety or act in a way that will cause others to negatively evaluate them. Common situations that may cause distress include meeting new people, having conversations, being observed while eating or drinking, or performing in front of other people. People with social anxiety disorder avoid social situations that cause distress or endure these situations with intense fear or anxiety. This anxiety and avoidance of social situations causes significant emotional distress or interferes with daily life, such as dating, socializing, and functioning at work or school.

    Social anxiety and BDD often co-occur and share a number of features. Both disorders involve feelings of inadequacy and fears of being judged, rejected, or humiliated in social situations. Social avoidance is a hallmark of social anxiety disorder; it is also very common in BDD. Self-medication (e.g., drinking before a party) to try to decrease social anxiety is common both disorders.

    Although BDD and social anxiety disorder have some similarities, they are distinct disorders. Unlike social anxiety disorder, BDD preoccupations focus on perceived flaws in physical appearance. This is the cause of the social anxiety that so many people with BDD experience. In addition, individuals with BDD perform time-consuming repetitive behaviors (for example, mirror checking, comparing, skin picking, grooming) in response to their appearance concerns. Such compulsive behaviors are not a key feature of social anxiety disorder. Medication treatment for the two disorders differs in some ways. Similarly, cognitive-behavioral treatments for BDD and social anxiety overlap in some ways but also include distinct interventions.

    Anorexia Nervosa and Bulimia Nervosa

    People with anorexia nervosa refuse to maintain a minimally normal body weight, intensely fear gaining weight or becoming fat, and have a distorted view of their body shape or size. Individuals with this disorder lose weight primarily by restricting their food intake, but some people also purge (for example, by inducing vomiting or misusing laxatives or diuretics) or excessively exercising. The fear of becoming fat usually persists despite the weight loss. In fact, concern about weight gain may increase even as the person continues to lose weight.

    People with bulimia nervosa binge eat – that is, they eat an amount of food that is definitely larger than most people would eat under similar circumstances in a discrete period of time with a feeling of loss of control over their eating. People with this disorder use potentially harmful methods to prevent weight gain. Individuals with bulimia nervosa are typically ashamed of their eating problems and attempt to hide their symptoms.

    Anorexia nervosa and bulimia nervosa share features with BDD, including preoccupation with appearance, distorted body image and high levels of body dissatisfaction. Some people with BDD are preoccupied by body areas that are typically disliked in eating disorders, such as their weight or the size of their stomach, hips, or thighs. Furthermore, both BDD and eating disorders are often characterized by repetitive, compulsive behaviors related to appearance, including mirror checking, camouflaging the disliked body areas and body measuring.

    However, there are some important differences between BDD and eating disorders, which include the following:

    • People with BDD are usually preoccupied with non-weight concerns, such as the appearance of their skin, hair, nose, or other body areas (although BDD may also involve preoccupation with weight).
    • Most people with BDD do not have problematic eating behaviors.
    • BDD affects nearly as many men as women (unlike eating disorders, which affect mostly women).
    • A number of studies have found that people with BDD have poorer daily functioning and quality of life than people with eating disorders.
    • There are important differences in effective treatments for these disorders.