Body dysmorphic disorder: common, severe and in need of treatment research.

The appearance preoccupations trigger feelings of depression, anxiety, distress, shame, or other painful emotions. These emotions, in turn, trigger repetitive compulsive behaviors that are intended to alleviate the emotional distress [5] . As required by DSM-5 criterion B (which is new to DSM-5), all individuals with BDD perform excessive repetitive behaviors in response to the preoccupations with appearance at some time during the course of the disorder [1] . These repetitive behaviors have many similarities to OCD compulsions, and thus they are commonly referred to as compulsions or rituals. Common excessive behaviors include checking mirrors, excessive grooming, seeking reassurance about the perceived defects, skin picking (to try to minimize perceived blemishes), and tanning (e.g. to darken ‘pale’ skin) [3] . Some BDD compulsions consist of mental acts, such as comparing one’s own appearance with that of other people, rather than observable behaviors [3] . The repetitive behaviors are difficult to control and occur, on average, for 3–8 h a day [4, 5] . Nearly all patients camouflage the perceived defects (e.g. with a hat, makeup, hair, clothes, body position). Although camouflaging is a safety behavior, it can also be done repeatedly (e.g. reapplying makeup 20 times a day), in which case it may be considered a repetitive behavior [3] . Body dysmorphic disorder (BDD) is common yet very under-recognized. It has a point prevalence of about 2%, making it more common than obsessive-compulsive disorder (OCD), anorexia nervosa or schizophrenia [1] . BDD typically causes tremendous suffering and substantial impairment in psychosocial functioning. The rates of suicidal ideation, suicide attempt and completed suicide appear markedly high. Yet treatment research on BDD lags very far behind that of other common and severe disorders. Thus, the study by Veale et al. [2] is a major contribution to the literature and to patient care. Individuals with BDD (previously known as ‘dysmorphophobia’) are preoccupied with one or more perceived defects or flaws in their appearance; these defects, however, are not observable or appear only slight to others (DSM-5 criterion A) [1] . Preoccupations most often focus on skin (e.g. perceived acne, scarring, wrinkles, color), nose (e.g. size or asymmetry) and hair (e.g. too little hair) but may focus on any body area [3] . Patients typically describe the disliked body parts as ‘ugly’, ‘unattractive’, ‘hideous’, or even ‘monstrous’. The preoccupations occur, on average, for 3–8 h a day (usually for at least an hour a day). They are intrusive, unwanted, and usually difficult to resist and control [4, 5] . Received July 15, 2014 Accepted after revision: July 19, 2014 Published online: October 16, 2014