BDD patients present commonly as adolescents and young adults, and also frequently up to the individual’s mid-30s and 40s. The mean age of onset is 16–17 years, and the most common age at onset is 12–13 years [8, 20]. Although patients may present at a later age, the majority (approximately two thirds) will have the onset of symptoms before the age of 18 [8]. The disorder is usually not formally diagnosed until 10 to 15 years after the onset of BDD [21, 22]. Although some may experience an abrupt onset of BDD, the disorder usually evolves gradually [23]. The disease can be severe and is often chronic. Clinical features appear similar among all age groups; however, those with an earlier age of onset are more likely to have comorbidity and suicidal ideation [24].

BDD characteristics in children and adolescents are quite similar to those of adults. More youths than adults attempt suicide, however, 44 % compared to 24 %, respectively [23]. Youths also tended to have more delusional beliefs, lifetime violence, suggesting that they may be more impaired [23]. Those who develop BDD at an earlier age are more likely to be psychiatrically hospitalized, have a substance use disorder, and attempt suicide[23]. It is important to recognize BDD in younger persons, as long-term academic, relationship, and occupational problems can be incurred without proper treatment. Unfortunately, diagnosing BDD in children and adolescents is quite difficult because this is a time in development that many bodily changes occur and appearance concerns are quite common [9].

It has been reported that BDD patients are more likely to visit dermatology or plastic surgery providers than psychiatry providers, due to poor insight into the condition and preoccupation with a desire to physically intervene in an effort to improve their feelings about their appearance [25]. In the clinical dermatology setting, studies have estimated a prevalence of BDD of 9–14 %. Within the cosmetic surgery setting, the prevalence ranges from 3 to 53 % (see Table 9.1) [26–35]. With over 11 million cosmetic surgeries performed in the USA in 2013, 83.5 % of which were minimally invasive, it is important for clinicians to recognize those patients who may be suffering from BDD to avoid unnecessary procedures that may not ultimately improve cosmetic satisfaction [36].

BDD patients presenting for cosmetic treatment consultation can be difficult to treat, often demanding unnecessary medical or procedural treatments due to their distress and fixation with the perceived defect [1]. In a cohort of 289 individuals with BDD, Phillips et al. [37] reported 76.4 % sought nonpsychiatric treatment and 66.0 % actually received it. Within this cohort, 38.2 % requested treatment from more than one type of provider. Dermatologic treatment was the most commonly received treatment (45.2 % of the adults), followed by surgery (23.2 %). Cosmetic treatment unfortunately often does not provide relief, and the majority of BDD patients are dissatisfied with their dermatological or cosmetic treatments [1]. In one study, 61.4 % reported no change after a procedure. [5]. Associated litigious or other threats are not uncommon, and these individuals may be more likely to resort to aggression or even violence if their concerns are not heard or treatment is believed to be unsatisfactory. One survey of adolescent patients with BDD found that 38 % had a history of violent behavior, which may be an overestimate but provides an indication of the associated distress and comorbid psychiatric disease affecting the patient [5].

Studies have evaluated specific cosmetic treatments and found BDD in 23 % of the 13 patients desiring botulinum toxin (Botox®) for hyperhidrosis [38]. Botulinum toxin injections and collagen fillers were not approved for use in the USA until the early 2000’s. Some of the earlier studies of cosmetic clinic cohorts excluded, or did not capture, these treatments, and there is some speculation that the previously reported prevalence may underestimate the current prevalence rates [1].

In a 2009 cross-sectional Brazilian study [1], 150 general and cosmetic dermatology patients, and 50 controls were interviewed by clinical psychologists and surveyed for the presence of BDD. The study determined that the prevalence of BDD was higher in the dermatology groups (n = 31), as compared to the control group (n = 1). Cosmetic dermatology patients were further significantly more likely to have BDD than their general dermatology counterparts, with a BDD diagnosis in 14 % compared with 6.7 % of general dermatology patients. Cosmetic BDD patients were more likely to be single and have a lower BMI than the general dermatology and control groups. Additionally, those in the cosmetic dermatology group were more likely to have undergone either minimally invasive procedures or cosmetic plastic surgery and to currently be under treatment as compared to general dermatology patients. Importantly, 61.9 % of the cosmetic patients with BDD were dissatisfied with treatment results, as compared to 10 % of the general dermatology group [1].

Similarly, a cross-sectional Turkish study in 2013 [25] also evaluated the frequency of BDD in cosmetic and general dermatology settings. Subjects were screened for BDD using a self-report questionnaire. Of the 318 subjects, 151 of which were cosmetic and 167 general dermatology patients, a total of 20 (6.3 %) were diagnosed with BDD based on questionnaire results. The investigators again saw trends toward higher BDD prevalence in the cosmetic dermatology group as compared to general dermatology, with a BDD prevalence of 8.6 % as compared to 4.2 %, respectively [25]. Demographic analysis showed BDD patients were on average significantly younger than non-BDD subjects, with no differences in gender. None of the BDD patients were satisfied with their treatment results, echoing the findings in the Brazilian cohort.

Studies suggest that the most common complaints from BDD patients involve facial defects, such as skin blemishes or nasal shape. Patients may present with any one or more of a variety of distressing concerns, including hair loss or hypertrichosis, abnormalities in pigmentation, pore size, vessel pattern, pallor, reddening of the skin, concerns related to hyperhidrosis, genitalia size, muscularity, breast size or shape, and/or buttock shape [2, 5]. In the Turkish study described above, the BDD population was most concerned with body shape and weight (40 %), followed by acne (25 %).

Cosmetic rhinoplasty has been reported to be one of the most requested procedures in patients with BDD [39]. There is a high prevalence of BDD patients in rhinoplasty clinics compared to the general population. The prevalence of BDD has ranged from 20.7 to 24.5 % in those seeking rhinoplasty surgery (see Table 9.1) [1, 40, 41].

In a comparison of BDD patients in a psychiatry clinic requesting rhinoplasty and those without BDD who had undergone successful cosmetic rhinoplasty, the BDD patients were found to be significantly younger, more depressed, and anxious [41]. They also had a greater preoccupation with their nose and were impaired in professional and social spheres of life due to cosmetic nasal appearance concerns [2].

Picavet et al. [39] evaluated the prevalence of BDD and its clinical features in a Belgian cohort of patients seeking evaluation by otolaryngology (ENT) providers in consultation for rhinoplasty. Subjects were administered questionnaires to assess compulsivity and disruption of daily living secondary to appearance. Moderate or more severe BDD symptoms, as evaluated by the questionnaire, were observed in 33 % of rhinoplasty patients. After stratifying by the reason for rhinoplasty consultation, this increased to a 43 % prevalence rate in those seeking rhinoplasty for aesthetic concerns, compared with 12 % for those seeking rhinoplasty to correct a reported functional defect. In a control group of individuals presenting for other otolaryngology concerns, only 2 % were found to have at least moderate BDD symptoms, which correlates with estimates for the general population. The authors found a significant correlation between BDD severity score and history of previous rhinoplasty, psychiatric history, and reason for surgery (aesthetic versus functional). No correlation was found between the patient-completed BDD symptom questionnaire and objective nasal evaluation by a physician. However, an inverse correlation was observed between the BDD symptom questionnaire and patient-reported nasal evaluation. This supports the current disease model that it is the patient’s perception of a defect, rather than the severity of the actual defect, that drives the symptoms of BDD.

BDD shares significant overlap with other psychiatric disorders, particularly anxiety, depression, eating disorders, and obsessive–compulsive disorder (OCD). In patients receiving psychiatric treatment, 3.2 % of the outpatients and up to 12.1 % of the inpatients have been reported to have a BDD diagnosis [2, 3, 42]. The prevalence is approximately equivalent in males and females in outpatient psychiatric patients [2].