Content » Vol 96, Issue 217

Investigative Report

Shadows of Beauty – Prevalence of Body Dysmorphic Concerns in Germany is Increasing: Data from Two Representative Samples from 2002 and 2013

Tanja Gieler1, Gabriele Schmutzer2, Elmar Braehler2,3, Christina Schut4, Eva Peters5 and Jörg Kupfer4

1Institute for Psychoanalysis and Psychotherapy, Giessen, 2Institute for Medical Psychology and Medical Sociology, University Clinic of Leipzig, Leipzig, 3Department of Psychosomatic Medicine and Psychotherapy, Universal Medical Center Mainz, Mainz, Rhineland-Palatinate, 4Institute of Medical Psychology, and 5Department of Psychosomatics and Psychotherapy, Justus-Liebig-University Giessen, Giessen, Germany

Body dysmorphic disorder (BDD) is a psychosomatic disease associated with reduced quality of life and suicidal ideations. Increasing attention to beauty and the development of beauty industries lead to the hypothesis that BDD is increasing. The aim of this study was to test this hypothesis in two representative samples of Germans, assessed in 2002 and 2013. In 2002, n = 2,066 and in 2013, n = 2,508 Germans were asked to fill in the Dysmorphic Concern Questionnaire (DCQ), which assesses dysmorphic concerns. Subclinical and clinical dysmorphic concerns increased from 2002 to 2013 (subclinical from 0.5% to 2.6%, OR = 5.16 (CI95% = 2.64; 10.06); clinical from 0.5% to 1.0%, OR = 2.20 (CI95% = 1.03; 4.73). Women reported more dysmorphic concerns than men, with rates of 0.7% subclinical and 0.8 clinical BDD in women and 0.3% subclinical and 0.1% clinical BDD in men in 2002. In 2013, 2.8% subclinical and 1.2% clinical BDD were found in women and 2.4% subclinical and 0.8% clinical BDD in men. Further studies should assess predictors for developing a BDD and evaluate factors determining the efficacy of disease-specific psycho­therapeutic and psychotropic drug treatments. Key words: cognititive behavior therapy; psychodynamic psychotherapy; body scheme; body image; dermatology.

Accepted Feb 16, 2016; Epub ahead of print Jun 9, 2016

Acta Derm Venereol 2016; Suppl 217: 83–90.

Tanja Gieler, Institute for Psychoanalysis and Psycho­therapy, Ludwigstrasse 73, DE 35392 Giessen. Germany E-mail:

The psychiatrist Morselli described body dysmorphic dis­order (BDD) and introduced the term Dysmorpho­phobia as early as 1886 (1). Subsequently, other psychiatrists also described young women who feared, because of their imagined ugliness, they would not find a lover (2). There are now increasingly frequent publications on this phenomenon (3–6). In 1987, the clinical picture of BDD was included in the DSM-IV as an official disorder diagnosis in the USA (7). Meanwhile, BDD is accepted as an independent syndrome in the DSM-IV-R and also in the ICD-10 (8). In the ICD-10, BDD is assigned to somatoform disorders (9). In the DSM-5, it is newly included in the compulsive disorders category (10). Delineation from compulsive disorders, hypochondriacal disorders as well as dysmorphic disorders in anorexia nervosa or bulimia must be differential-diagnostically determined (11).

BDD is a chronic emotional disorder, in which the afflicted cannot stop brooding over a minimal or imagined flaw (12–15). They experience their appearance as so disfigured that they are ashamed and prevent others from seeing them. These patients spend several hours a day checking themselves and their appearance in the mirror (mirror-checking), or they avoid mirrors and mirroring surfaces (12). Moreover, the patients use cosmetic products to cover up the imagined flaw, or they excessively manipulate their skin (12, 13, 15–17). However, they are rarely satisfied with the result or in harmony with their self-image. This emotional disorder, projected to the skin surface, affects especially the face, nose, ears and secondary sex characteristics (15). Objective observers usually cannot see the flaw (DSM 5 criterion A). People with BDD show a need to constantly assure themselves that everything looks “as it should”. Often, however, they avoid social contacts, public places, work and school. Many only leave the house at night (12, 17).

The BDD correlates with social withdrawal to an extent greatly exceeding normal shyness and may reach a clinical expression of social phobia (14, 18). The withdrawal can result in that the afflicted person no longer engage in or make new interpersonal contacts, are socially excluded, and become unable to work (19). Other comorbidities are eating disorders (20), anxiety and affective disorders (15, 21, 22). In this context, there is usually weight gain with subsequent diets. Suicidal reactions occur in about 15% of the cases in this vicious circle (23). The desire and implementation of cosmetic-dermatological and plastic-surgical interventions bring the corresponding risk of subsequent adverse events or lead to addiction to surgery (24, 25).

Various instruments are recommended for the diagnostic recording of BDD, some of which are used for clinical diagnostics or as screening questionnaires. There are two forms of interviews suitable to identify BDD. The structured Interview Diagnostic Module for BDD by Philipps et al. (17) (BDDDM) is recommended for clinical use. It is based on the DSM-4, and DSM-5 criteria, respectively and was also used in the representative studies by Rief et al. (26) and Buhlmann et al. (27). Moreover, there are semi-structured interviews, the so-called Yale-Brown Obsessive-Compulsive Scale (BDD-YBOCS) (28). The severity of the emotional symptoms and information for behaviour analysis can be obtained using these procedures. There are also questionnaires to record BDD: The DCQ was validated in Germany by Stangier et al. (29) and enables distinguishing between patients with a subclinical and clinical degree of BDD. It contains only 7 items and thus can be easily used as a screening instrument (see the Methods section for a precise description). In addition to the DCQ, two other questionnaires are used in the German-speaking region. The KDS-F (Körperdysmorpher Störungs-Fragebogen/Body Dysmorphic Disorder Questionnaire) with 43 items that can be categorized into 3 main scales and the KDS-K (short form of the KDS-F) (30). Buhlmann et al. (31) developed a questionnaire on BDD according to the criteria of the DSM-4 and validated it in 45 patients with BDD and control persons.

Epidemiology of body dysmorphic disorder

Some studies investigated the point-prevalence of BDD in the general population. In Germany, Rief et al. (26) found a frequency of 1.7%, whereas Stangier (32) reported a point-prevalence of 0.9%. Buhlmann et al. (27) found a point-prevalence of 1.8%. The differing data could be related to the different recording instruments that were used. Faravelli et al. (33) studied the prevalence exclusively in Florence, identifying 0.7% of the population, and Otto et al. (34) studied only women in the US in 7 US-American cities where data were recorded in a case-control study. Here, a prevalence of 0.7% was determined using structured interviews. In a North-American sample, Koran et al. (35) found a prevalence of 2.4%, using computer-assisted interviews meeting the criteria of the DSM-IV. Thus, BDD appears to be more frequent than, for example, hidradenitis suppurativa, which has a presumed prevalence of approximatively 1% of the population (36).

Considerably higher prevalences were found in specific settings. For example, it could be shown that in dermatological outpatient offices between 6.4 and 11.9% (29, 37–42) of the patients were affected, and also 5.7–7.0% of the plastic-surgery patients (43). In cosmetic-dermatological settings, BDD occurred in 6.3–15.2% of the patients (37, 38, 42, 44, 45). In psychiatric populations, between 0.5 and 10% of the patients are affected, (46–49), whereas a prevalence of about 4% has been reported in students (50, 51).

Table I presents an overview of studies to date on the prevalence of BDD in various settings.

Table I. Prevalences of body dysmorphic disorder (BDD) in various settings





Authors (ref)

General population

1.7% (Germany)

0.9% (Germany)


Dysmorphic Concern Questionnaire

2,552 national survey

Rief et al. 2006 (26)

Stangier 2007 (32)

0.7% (only Florence)

Personal interview by general practitioner

2,066 national survey

Faravelli et al. 1997 (33)

2.4% (USA- 1 City)

Computer-assisted structured interviews

673 interviews

Koran et al. 2008 (35)

1.8 % (Germany)

DSM-4 criteria

2,048 telephone interview

Buhlmann et al. 2010 (27)

2.1% (only women)

BDD Questionnaire (BDDQ)

2,891 Swedish women

Brohede et al. 2014 (59)

0.8% (Germany)

BDD criteria DSM-V

2,129 national survey

Schieber et al. 2015 (5)

Dermato­logical offices








Self-report questionnaire

Dysmorphic Concern Questionnaire

Dysmorphic Concern Questionnaire

Dysmorphic Concern Questionnaire

Dysmorphic Concern Questionnaire

BDD Questionnaire + DSM-IV Interview

Self-report BDD screening

268 dermatological patients

126 dermatological patients

156 patients




Phillips et al. 2000 (39)

Stangier et al. 2003 (41)

Stangier et al. 2003 (29)

Ritter et al. 2013 (40)

Wiedersich 2010 (42)

Conrado et al. 2010 (37)

Dogruk Kacar et al. 2014 (38)

Plastic surgery



2 body image measures

Dysmorphic Concern Questionnaire

100 women


Sarwer et al. 1998 (63)

Wiedersich 2010 (42)

Cosmetic dermato­logy








Brief self-report questionnaire

Dysmorphic Concern Questionnaire

BDD Questionnaire + DSM-IV Interview

Self-report BDD screening

BDD Structured Clinical Interview for DSM-IV (BDD SCID)







Altamura et al. 2001 (44)

Dufresne et al. 2001 (45)

Wiedersich 2010 (42)

Conrado et al. 2010 (37)

Dogruk Kacar et al. 2014 (38)

Dey et al. 2015 (64)

Patients with mental disorders


1.8% (Germany)



Psychiatric interview

Self report DSM-IV criteria

BDD module DSM-IV

BDD module DSM-IV

255 psychiatric patients

318 depressed and 658 non-depressed

350 psychiatric patients

155 German psychiatric patients

Brawman-Mintzer et al. 1995 (46)

Otto et al. 2001 (34)

Nierenberg et al. 2002 (48)

Kollei et al. 2011 (47)

Student population



DSM-IVmodule criteria

Cross-sectional study

133 German students

1,041 US students

Bohne et al. 2002 (50)

Boroughs et al. 2010 (65)

So far, there are no studies on the prevalence of BDD which have answered the question of the extent to which the disorder has increased in frequency over the past years. Attractiveness seems increasingly important for professional and social integration. This makes it plausible that rejection in everyday life is more frequently attributed to personal appearance and physical flaws and more intensively perceived or assumed. For this reason, the present study is intended to check whether dysmorphic concerns and the tendency to BDD have increased. The DCQ, as a validated instrument, was used to determine the prevalence of BDD in two large representative samples in Germany.


Representative sample

As part of a survey conducted by a professional institute (USUMA GmbH Berlin), persons in all parts of Germany were visited at home in the period of November to December 2002, and February to April 2013, respectively. The DCQ was used in this survey with a series of other psychosocial questionnaires. The data from the other questionnaires are being processed by the pertinent authors and are not part of the present study.

To obtain a representative sample of the population, a customary procedure in market research for sampling (random route) was used. First, the households to be questioned were selected. The target household in a certain region was selected by a randomization procedure using a multistep process (52). Within the target households, the person to be questioned was then determined using another randomized selection procedure (Schwedenschlüssel or Kish-Selection-Grid (53). In this procedure, each member of a household had the same chance of being selected for questioning. Target persons who were not reached on first contact had to be visited two more times at various times a day before they could be assigned to a drop-out reason. Differentiation was made between quality-neutral drop-outs, for example untenanted dwelling, and systematic drop-outs, when the person was not reached despite triple attempts. For the present study in 2013, 3,855 households were visited by trained interviewers (evaluable data from 2,508), while in 2002, 3,194 households were visited (evaluable data from 2,066). The selected sample corresponds to information from the Federal Bureau of Statistics (Statistisches Bundesamt (54, 55)). Table II compares the samples of the years 2002 and 2013, in which the DCQ data were evaluable.

Table II. Characteristics of the representative samples in 2002 and 2013*

n = 2,066
% (n)

n = 2,508
% (n)

Evaluable Dysmorphic Concern Questionnaire-Data

93.5 (1,934)

99.8 (2,504)


53.4 (1,032)

53.2 (1,331)

Highest educational degree (MD=10)

School education without university entrance diploma

86.7 (1,677)

81.8 (2,040)

University entrance diploma or higher

13.3 (257)

18.2 (454)


Without job

8.5 (165)

5.7 (142)


43.5 (842)

52.1 (1,304)

Not working

47.9 (927)

42.3 (1,058)


Living with partner

55.6 (1,076)

52.5 (1,314)

Without partner

44.4 (858)

47.5 (1,190)


< 24 years

12.0 (232)

10.2 (256)

25–34 years

13.1 (253)

14.3 (359)

35–44 years

17.6 (340)

15.2 (381)

45–54 years

16.3 (315)

17.8 (445)

55–64 years

17.8 (345)

18.1 (453)

65–74 years

14.9 (289)

15.2 (381)

> 75 years

8.3 (160)

9.1 (229)

*Self-reported by participants of the study.


Dysmorphic Concern Questionnaire (DCQ). The DCQ in the German validation (29) was used in order to screen for BDD. The DCQ was developed from the General Health Questionnaire according to Goldberg (56) by Oosthuizen et al. (57). The DCQ consists of 7 items, which have to be rated on a 4–point scale from 0–3 (not at all, like most people, more than other people, much more than other people) (Example item: “been told by others/doctor that you are normal in spite of your strongly believing that something is wrong with your appearance or bodily functioning”).

Stangier et al. (29) validated the DCQ in an unselected sample of 156 dermatological patients, additionally in 22 patients with clinically-proven BDD, 22 patients with disfiguring skin diseases and 21 patients with non-disfiguring skin diseases. A Cronbach’s α of 0.85 was calculated for the German version of the DCQ. The one extracted factor in the factor analysis explained 53.8% of the variance.

The convergent validity was determined by correlations with depression (r = 0.33) and compulsive disorders (r = 0.57–0.74). Moreover, a discriminative validity could be examined across the various samples. A cut-off value of ≥ 14 represented the best compromise between sensitivity and specificity. Seventy-two percent of the BDD patients could be correctly assigned to the diagnosis of BDD using this value. DCQ values between ≥ 11 points and < 14 points indicate a possible BDD and are termed a subclinical form. These two cut-off values were also used in this study to differentiate between a subclinical or clinical form of BDD.

Statistical data analysis

Statistical analyses were performed using IBM SPSS Statistic (SPSS Version 22 for Windows 2013 (58)). χ2-tests were performed to compare the frequency distributions. Afterwards, changes in the prevalence from 2002 compared to 2013 were determined by means of Odds ratios (OR; with confidence interval 95%). Moreover, the OR were determined for the comparison of degrees of the test variables (men/women; without university entrance diploma/ with university entrance diploma; with partner/without partner). Analyses of variance were used to compare differences between the two sample groups. Main differences were calculated at α = 0.05, with η2 as effect size.


A first evaluation was made using descriptive statistics regarding the point prevalence of BDD in the two representative samples. For this, the two cut-off values of the DCQ of ≥ 11–< 14 for subclinical disfiguration and ≥ 14 as clinically-relevant disfiguration in the sense of a BDD were used. Comparison of the data from 2002 and 2013 revealed an increase in the presence of dysmorphic concerns.

While in 2002 0.5% of the subjects reported subclinical symptoms, 2.6% of the subjects in 2013 did (OR = 5.16; CI95% = 2.64; 10.06). An increase from 0.5% to 1% of those questioned could also be observed with respect to the frequency of clinically-relevant symptoms (OR = 2.20; CI95% = 1.03; 4.73). The frequency distribution of no, subclinical and clinical BDD differs significantly between the years 2002 and 2013 (χ2 (2) = 32.71; p < 0.001).

The increase in prevalence of BDD is seen both in the subclinical and clinical form of BDD according to DCQ diagnostics in the entire sample. Both women and men more often reported subclinical symptoms in 2013 than in 2002 (women: OR = 4.21 CI95% = 1.87; 9.47; men: OR = 7.38; CI95% = 2.24; 24.35).

The subgroup without university entrance diploma also showed a higher prevalence of subclinical BDD in 2013 (OR = 9.49; CI95% = 3.79; 23.76), as did the subgroups with (OR = 5.38; CI95% = 2.09; 13.86) and without partner (OR = 4.89; CI95% = 1.90; 12.57).

Since the numbers regarding the prevalence in the individual age groups were small, no OR were determined in that case. Overall, however, it was observed that a more marked increase in prevalence is seen in the younger age groups (up to 54 years) than in the older groups.

With one exception, all comparisons between the degrees of the variables (men vs. women; without university entrance diploma/ with university entrance diploma; with partner/without partner) showed no noteworthy ORs. No statements can be made concerning an increase from 2002 to 2013 with respect to age because of the small sample size. In 2013, dysmorphic concerns appeared to be more important in the younger age group up to 54 years.

The two samples (2002 and 2013) are compared in Table III with respect to the frequency of subclinical and clinically-relevant body dysmorphic concerns.

Table III. Results of the study 2002 and 2013 of subclinical (≥ 11–< 14) and clinical (≥ 14) body dysmorphic disorder (BDD) with regard to gender, education, partnership and age



OR (95% CI)

Subclinical BDD

Clinical BDD

Subclinical BDD

Clinical BDD

Total sample, n (%)

10 (0.5)

9 (0.5)

65 (2.6)

25 (1.0)

χ2 (2)=32.71; p < 0.001

Subclinical: 5.16 (2.64; 10.06)
Clinical: 2.20 (1.03; 4.73)


7 (0.7)

8 (0.8)

37 (2.8)

16 (1.2)

χ2 (2)=15.21; p < 0.001

Subclinical: 4.21 (1.87; 9.47)
Clinical: 1.59 (0.68; 3.73)


3 (0.3)

1 (0.1)

28 (2.4)

9 (0.8)

χ2 (2)=19.35; p < 0.001

Subclinical: 7.38 (2.24; 24.35)
Clinical: 7.11 (0.90; 56.26)

OR (95% CI) women/men

2.06 (0.53; 7.99)

7.06 (0.88; 56.59)

1.18 (0.71; 1.93)

1.58 (0.70; 3.59)

University entrance diploma, n (%)


5 (0.3)

8 (0.5)

56 (2.7)

21 (1.0)

χ2 (2)=38.03; p < 0.001

Subclinical: 9.49 (3.79; 23.76)
Clinical: 2.23 (0.98; 5.04)


5 (1.9)

1 (0.4)

8 (1.8)

4 (0.9)

χ2 (2)= 0.60; ns

Subclinical: 0.91 (0.29; 2.81)
Clinical: 2.27 (0.25; 20.43)

OR (95% CI) with/without

6.63 (1.91; 23.06

0.83 (0.10; 6.65)

0.63 (0.30; 1.34)

0.85 (0.29; 2.48)

Partner, n (%)


5 (0.5)

4 (0.4)

32 (2.5)

13 (1.0)

χ2 (2)=18.42; p < 0.001

Subclinical: 5.38 (2.09; 13.86)
Clinical: 2.73 (0.89; 8.41)


5 (0.6)

5 (0.6)

33 (2.8)

12 (1.0)

χ2 (2)=14.33; p < 0.001

Subclinical: 4.89 (1.90; 12.57)
Clinical: 1.78 (0.62; 5.06)

OR (95% CI) without/with

1.26 (0.36; 4.36)

1.57 (0.42; 5.88)

1.14 (0.70; 1.87)

1.02 (0.47; 2.25)

Age, n (%)

< 24 years

0 (0.00)

2 (0.9)

11 (4.3)

2 (0.8)

25–34 years

4 (1.6)

0 (0.0)

19 (5.3)

3 (0.8)

35–44 years

3 (0.9)

0 (0.0)

11 (2.9)

3 (0.8)

45–54 years

3 (1.0)

0 (0.0)

14 (3.2)

5 (1.1)

55–64 years

3 (0.9)

1 (0.3)

7 (1.5)

1 (0.2)

65–74 years

1 (0.3)

0 (0.0)

9 (2.4)

1 (0.3)

> 75 years

2 (1.3)

0 (0.0)

3 (1.3)

1 (0.4)

Odds ratio (OR) were not calculated due to the small numbers of participants in the age-subgroups.

In order to present changes in the scale values in the DCQ, independent of an increased prevalence of BDD, the DCQ means of the study group excluding subjects in the subclinical and clinical group are presented in Table IV. The main effects for sex (higher value for women: F (1; 4,301) = 123.86; p < 0.001) and age (F (6; 4,301) = 5.80; p < 0.001) and the interaction effect sex × age (F (6; 4,301) = 2.33, p < 0.05) were significant. But the primary interest in this study is the change value. As in Table III, a more marked increase in value from 2002 to 2013 is seen (F (1; 4,301) = 285.06; p < 0.001) and a significant interaction effect for sex × examination time (F (1; 4,301) =10.97; p < 0.001) which in content shows a greater increase in DCQ values in women than in men. The other interaction effects (age × examination time and age × sex × examination time) were not significant.

Table IV. Dysmorphic Concern Questionnaire score in the total sample without subclinical and clinical cases, illustrated separately for men and women and age groups

2002 (n = 1,915)
Mean ± SD

2013 (n = 2,414)
Mean ± SD

Total sample

0.99 ± 1.94

2.24 ± 2.54


1.24 ± 2.16

2.74 ± 2.65


0.72 ± 1.63

1.68 ± 2.28


< 24 years

1.20 ± 2.21

2.52 ± 2.80

25–34 years

1.20 ± 2.10

2.56 ± 2.74

35–44 years

1.19 ± 2.10

2.10 ± 2.42

45–54 years

1.14 ± 2.17

2.36 ± 2.60

55–64 years

0.77 ± 1.56

2.18 ± 2.39

65–74 years

0.75 ± 1.68

2.05 ± 2.43

> 75 years

0.66 ± 1.49

1.90 ± 2.39

Age – Women

< 24 years

1.87 ± 2.69

3.07 ± 2.82

25–34 years

1.49 ± 2.28

3.11 ± 2.80

35–44 years

1.48 ± 2.29

2.82 ± 2.62

45–54 years

1.47 ± 2.41

2.95 ± 2.73

55–64 years

0.89 ± 1.75

2.62 ± 2.52

65–74 years

0.84 ± 1.77

2.38 ± 2.46

> 75 years

0.75 ± 1.62

2.19 ± 2.50

Age – Men

< 24 years

0.66 ± 1.54

2.02 ± 2.69

25–34 years

0.87 ± 1.81

1.82 ± 2.49

35–44 years

0.84 ± 1.81

1.32 ± 1.90

45–54 years

0.81 ± 1.83

1.69 ± 2.26

55–64 years

0.64 ± 1.34

1.72 ± 2.17

65–74 years

0.65 ± 1.57

1.69 ± 2.36

> 75 years

0.32 ± 0.81

1.48 ± 2.16


The assumption that the prevalence of dysmorphic concerns increased in the years from 2002 to 2013 could be verified by this questionnaire study in which the data of two representative samples were compared. The point prevalence for subclinical or clinically-relevant BDD show an increase in dysmorphic concerns in the German population. The number of those affected subclinically according to the DCQ (≥ 11–< 14) increased from 0.5% to 2.6 % in 2013. This means that the risk of developing at least a subclinical BDD was increased by about a factor 5 (OR = 5.16). Clinical BDD according to DCQ (≥ 14) increased from 0.5% in 2002 to 1.0%, corresponding to a doubling of the risk (OR = 2.2).

In addition to the subclinical and clinical prevalence, the means of the subjects not assigned to these groups were compared. The means of these subjects have also more than doubled within the last about 10 years. Overall, thus, there is a marked increase in BDD symptoms at all examined levels. This corresponds to the hypothesis.

The prevalence rates of clinical BDD found in similar representative studies range between 0.7–2.4% (33, 35). The method of diagnostics used differed considerably in the studies so that a direct comparison is hardly possible. Some studies only recorded a selected sample. Faravelli et al. (33), for example, recorded the prevalence by means of personal interviews done by general practitioners in the geographic area of Florence, which is probably not representative for all of Italy. Moreover, recordings by general practitioners does not necessarily represent specialist-specific knowledge of the diagnostics. Koran et al. (35) performed their prevalence study in a computer-assisted survey in only one city in the US, so that here, too, no representativeness for the USA is to be assumed. Brohede et al. (59) included only women in their study and found clinically-relevant BDD in 2.1% of the subjects, applying the Body Dysmorphic Disorder Questionnaire (BDDQ) in structured clinical interviews. When the symptoms of BDD according to DSM-4 (26) or DSM-5 (5) were examined, in a representative sample similar to the one in this study, the authors found prevalence of 1.7% (26), or 0.8%, respectively (5). Since the fluctuations in the prevalence figures did not show considerable difference and ranged from 0.7–2.4% (see Table I), the values obtained in our study appear to correspond to those of similar studies and the differences attributable simply to the various methodological approaches in the recording.

Apart from total values, there were differences between men and women. In women, subclinical BDD increased from 0.7% in 2002 to 2.8% in 2013, while the clinical form increased from 0.8% to 1.2% in women, the ORs for the subclinical form was 4.21, while it was 1.59 for the clinical form. The ORs in the group of men were 7.38 for subclinical and 7.11 for clinical BDD. The prevalence increased for the subclinical group from 0.3% to 2.4% and for the clinical form from 0.1% to 0.8%. Only the increase (ORs) for the subclinical form was significant for both sexes. Apparently, more women than men with BDD are identified by the DCQ. On the other hand, men appear to have a greater increase in prevalence than women. With regard to the literature there is an equal frequency of BDD in women and men (27, 45, 60). In contradiction to this, in our study we found higher prevalence in women than in men in the samples of 2013 (2.8 % in women vs. 0.8 % in men). The differences between women and men are, however, not significant. Since the difference between women and men slightly decreased from 2002 to 2013, it must be assumed that men are increasingly affected. Contrary to this, the means of the DCQ increased more for women than for men, see Table IV.

Contrary to the primary expectations, there was an increase in the representative sample of BDD prevalence in the group of persons without University Entrance diploma. Persons without University Entrance diploma showed an increase in subclinical BDD from 0.3% in 2002 to 2.7% in 2013 and regarding the clinical form from 0.5% in 2002 to 1.0% in 2013. This result corresponds to an OR of 9.49 in the subclinical group, which is significant. The extent to which social developments in ideal beauty among people without University Entrance diploma may be a possible explanation, can only be hypothetically discussed.

The variable “Partnership” was also important when looking at the prevalence rates of BDD. A clear increase of BDD symptoms occurred in the group “With partner”: Regarding the subclinical form there was an increase from 0.5% in 2002 to 2.5% in 2013 (OR 5.38) and regarding the clinical form we observed an increase from 0.4% in 2002 to 1.0% in 2013 (OR 2.73), but in the group “Without partner”, the values regarding the subclinical form also increased from 0.6% in 2002 to 2.8% in 2013 (OR 4.89), regarding the clinical form from 0.6% in 2002 to 1.0% in 2013 (OR 1.78). However, here again, only the increases regarding the subclinical form became significant.

Different changes in the individual age groups were not statistically calculated due to the low number of cases. Apparently, however, dysmorphic concerns are possible in all age groups.

The DCQ means excluding subclinical and clinical subjects increased from 0.99 in 2002 to 2.24 in 2013. That means that dysmorphic concerns have apparently increased in the general population (see Table IV).

One limitation of the representative survey might be the use of the screening questionnaire DCQ, since no personal interviews according to DSM-5 criteria could be performed. As already mentioned in the introduction, established questionnaires for recording BDD are the Dysmorphic Concern Questionnaire (DCQ; 57), the BDD Diagnostic Module (BDDDM) and the BDD Modification of the Yale-Brown Obsessive Compulsive Scale (BDD-YBOCS) (28, 30). The DCQ is easy to use with 7 questions and a cut-off value. The last two instruments are more detailed, semi-structured clinical interviews, which are not suitable for questionnaire studies. The FKS (31) is based on the criteria of the DSM-4 and must be re-validated according to the new classification in the DSM-5.

Since there were several missing data in the DCQ (2002 median 132; 2013 median 4), data analyses refer to sample sizes of n = 1,934 for 2002 and n = 2,504 for 2013. Due to the very different numbers of missing data in the two groups, a check was made whether the drop-outs were selective in 2002: essential sociodemographic data from subjects with and without missing DCQ values were compared. There were no differences between the groups with respect to sex (χ2 (1) = 2.03, ns) and age (t (2,064) = 0.004, ns). Regarding the variable “Highest education level completed” (χ2 (1) = 4.61, p < 0.05), there were more with lower education and less with university entrance diploma or higher educational level in the groups with missing DCQ values. Regarding the variable “Partnership” (χ2 (1) = 6.11, p < 0.05 there were more subjects living with a partner than living alone in the group with missing DCQ values. The participants of the study mentioned their variables self-reported, there was no possibility for proofing their statements.

The study was conducted as a point prevalence study. At both times (2002 and 2013), the BDD was recorded with identical standardized questionnaires. The aim was primarily to identify differences between the years 2002 and 2013. One advantage of this comparison is that the same questionnaire was used twice at an interval of 11 years and thus the changes are largely independent of the method. For reasons of practicability, it was not possible to perform a clinical interview according to the criteria of the DSM-5 in our study. To this extent it remains questionable whether BDD was actually present in those subjects who reported relevant dysmor­phic concerns, or whether some objectively disfigured individuals were among the subjects.

The increase in dysmorphic concerns in the German population apparently reflects a trend in the development of the frequency of BDD. This should lead to paying more attention to the clinical picture of BDD. The DCQ proved valuable as a screening instrument in this study, since comparable prevalence rates were found in other studies using other instruments. A clinical use appears sensible, since it can be assumed that prompt diagnostics and initiation of psychotherapy enables the doctor to secure greater effectiveness in relief of symptoms and of psychosocial consequences (24, 61, 62). The goal should therefore be to develop specific disorder-oriented therapeutic measures, which of course need to be examined in prospective therapy-comparative studies.


1. Morselli E. Sulla dismorfofobia e sulla tafefobia. Band VI. Bollettino Accademia delle Scienze, Mediche di Genova 1886, 110–119.

2. Gieler U. Psychodynamische Diagnostik und Therapie der körperdysmorphen Störung. In: Aglaja Stirn, Oliver Decker, Elmar Brähler (Hrsg.) Körperkunst und Körpermodifikation. Psychosozial 2003; 26: 55–64.

3. Fang A, Mantheny NL, Wilhelm S. Body Dysmorphic Disorder. Psychiatr Clin North Am 2014; 37: 287–300.

4. Husain Z, Janniger EJ, Krysicka JA, Micali G, Schwartz RA. Body dysmorphic disorder: beyond skin deep. G Ital Dermatol Venereol 2014; 149: 447–452.

5. Schieber K, Kollei I, de Zwaan M, Martin A. Classification of body dysmorphic disorder – what is the advantage of the new DSM-5 criteria? J Psychosom Res 2015; 78: 223–227.

6. Toro-Martinez E. DSM-5 OCD and related disorders. Vertex 2014; 25: 63–67.

7. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, ed. 4. Washington, DC: American Psychiatric Publishing, 1994.

8. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Washington (DC): American Psychiatric Association; 2000.

9. ICD10. Internationale Klassifikation psychischer Störungen, 7. Überarbeitete Auflage, 2010. Deutsches Institut für Medizinische Dokumentation und Information (DIMDI). Internationale Klassifikation der Krankheiten, 10. Revision.

10. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, ed. 5. Washington, DC: American Psychiatric Publishing, 2013.

11. Phillips KA, Kaye WH. The relationship of body dysmor­phic disorder and eating disorders to obsessive-compulsive disorder. CNS Spectr 2007; 12: 347–358.

12. Albertini RS, Phillips KA. Thirty-three cases of body dysmorphic disorder in children and adolescents. J Am Acad Child Adolesc Psychiatry 1999; 38: 453–459.

13. Horowitz K, Gorfinkle K, Lewis O, Phillips KA. Body dysmorphic disorder in an adolescent girl. J Am Acad Child Adolesc Psychiatry 2002; 41: 1503–1509.

14. Phillips KA. Body dysmorphic disorder: the distress of imagined ugliness. Am J Psychiatry 1991; 148: 1138–1149.

15. Phillips KA, Menard W, Fay C, Weisberg R. Demographic characteristics, phenomenology, comorbidity and family history in 200 individuals with body dysmorphic disorder. Psychosomatics 2005; 46: 317–326.

16. Grant JE, Menard W, Phillips KA. Pathologicall skin picking in individuals with body dysmorphic disorder. General Hospital Psychiatry 2006; 28, 487–493.

17. Phillips KA, McElroy SL, Keck PE, Pope HG, Hudson JI. Body Dysmorphic Disorder: 30 cases of imagined ugliness. Am J Psychiatry 1993; 150: 302–308.

18. Patterson WM, Bienvenu OJ, Chodynicki MP, Janniger CK, Schwartz RA. Body dysmorphic disorder. Int J Dermatol 2001; 40: 688–690.

19. Phillips KA, Menard W, Fay C, Pagano ME. Psychosocial functioning and quality of life in body dysmorphic disorder. Compr Psychiatry 2005; 46: 254–260.

20. Hartmann AS, Greenberg JL, Wilhelm S. The relationship between anorexia nervosa and body dysmorphic disorder. Clin Psychol Rev 2013; 33: 675–685.

21. Gunstad J, Phillips KA. Axis I comorbidity in body dysmorphic disorder. Comprehensive Psychiatry 2003; 44, 270–276.

22. Phillips KA, Nierenberg AA, Brendel G, Fava M. Prevalence and clinical features of body dysmorphic disorder in atypical major depression. J Nerv Ment Dis 1996; 184: 125–129.

23. Phillips KA, Menard W. Suicidality in body dysmorphic disorder: a prospective study. Am J Psychiatry 2006; 163: 1280–1282.

24. Phillips KA, Dufresne RG. Body dysmorphic disorder. A guide for dermatologists and cosmetic surgeons. Am J Clin Dermatol 2000; 1: 235–243.

25. Sarwer DB, Wadden TA, Pertschuk MJ, Whitaker LA. The psychology of cosmetic surgery: A review and reconceptualization. Clin Psychol Rev 1998; 18: 1–22.

26. Rief W, Buhlmann U, Wilhelm S, Borkenhagen A, Brähler E. The prevalence of body dysmorphic disorder: a population-based survey. Psychological Medicine 2006; 36: 877–885.

27. Buhlmann U, Glaesmer H, Mewes R, Fama JM, Wilhelm S, Brähler E, Rief W. Updates on the prevalence of body dysmorphic disorder: a population-based survey. Psychiatry Res 2010; 178: 171–175.

28. Phillips KA, Hollander E, Rasmussen SA, Aronowitz BR, DeCaria C, Goodman WK. A severity rating scale for body dysmorphic disorder: Development, reliability and validity of a modified version of the Yale-Brown Obsessive Compulsive Scale. Psychopharmacol Bull 1997; 33: 17–22.

29. Stangier U, Janich C, Adam-Schwebe S, Berger P, Wolter M. Screening for body dysmorphic disorder in dermatological outpatients. Dermatol Psychosom 2003; 4: 66–71.

30. Brunhoeber S. Kognitive Verhaltenstherapie bei körperdysmorpher Störung. Hogrefe Verlag Göttingen; 2009, p. 64.

31. Buhlmann U, Wilhelm S, Glaesmer H, Braehler E, Rief W. Fragebogen körperdysmorpher Symptome (FKS): Ein Screening-Instrument. Verhaltenstherapie 2009; 19: 237–242.

32. Stangier U. Prävalenz von körperdysmorphen Symptomen in der Allgemeinbevölkerung, DFG Abschlussbericht Nov 2007.

33. Faravelli C, Salvatori S, Galassi F, Aiazzi L, Drei C, Cabras P. Epidemiology of somatoform disorders: A community survey in Florence. Social Psychiatry and Psychiatric Epidemiology 1997; 32: 24–29.

34. Otto MW, Wilhelm S, Cohen LS, Harlow BL. Prevalence of body dysmorphic disorder in a community sample of women. Am J Psychiatry 2001; 158: 2016–2063.

35. Koran LM, Abujaoude E, Large MD, Serpe RT. The prevalence of body dysmorphic disorder in the United States adult population. CNS Spectr 2008; 13: 316–322.

36. Kromann CB, Ibler KS, Kristiansen VB, Jemec GBE. The influence of body weight on the prevalence and severity of hidradenitis suppurativa. Acta Derm Venereol 2014; 94: 553–557.

37. Conrado LA, Hounie AG, Diniz JB, Fossaluza V, Torres AR, Miguel EC, Rivitti EA. Body dysmorphic disorder among dermatologic patients: Prevalence and clinical features. J Am Acad Dermatol 2010; 63: 235–243.

38. Dogruk Kacar S, Ozuguz P, Bagcioglu E, Coskun KS, Uzel Tas H, Polat S, Karaca S. The frequency of body dysmor­phic disorder in dermatology and cosmetic dermatology clinics: a study from Turkey. Clin Exp Dermatol 2014; 39: 433–438.

39. Phillips KA, Dufresne RG, Wilkel CS, Vittorio CC. Rate of body dysmorphic disorder in dermatology patients. J Am Acad Dermatol 2000; 42: 436–441.

40. Ritter V, Stangier U. Kognitive Therapie bei körperdysmorpher Störung. Zeitschrift für klinische Psychologie und Psychotherapie 2013; 42: 192–200.

41. Stangier U, Köhnlein B, Gieler U. Somatoforme Störungen bei ambulanten dermatologischen Patienten. Psychotherapeut 2003; 48: 321–328.

42. Wiedersich A. Die Körperdsymorphe Störung – Das Bild der körperdysmorphen Störung in verschiedenen Behandlungssettings. Dissertation Universität Giessen 2010.

43. Stangier U, Hungerbühler R, Meyer A, Wolter, M. Diagnostische Erfassung der Körperdysmorphen Störung: Eine Pilotstudie. Nervenarzt 2000; 71: 876–884.

44. Altamura C, Paluello MM, Mundo E, Medda S, Mannu P. Clinical and subclinical body dysmorphic disorder. Eur Arch Psychiatry Clin Neurosci 2001; 251: 105–108.

45. Dufresne RG, Phillips KA, Vittorio CC, Wilkel CS. A screening questionnaire for body dysmorphic disorder in a cosmetic dermatologic surgery practice. Dermatol Surg 2001; 27: 457–462.

46. Brawman-Mintzer O, Lydiard RB, Phillips KA, Morton A, Czepowicz V, Emmanuel N, et al. Body dysmorphic disorder in patients with anxiety disorders and majordepression: A comorbidity study. Am J Psychiatry 1995; 11: 1665–1667.

47. Kollei I, Martin A, Rein K, Rotter A, Jacobi A, Mueller A. Prevalence of body dysmorphic disorder in a German psychiatric inpatient sample. Psychiatry Res 2011; 189: 153–155.

48. Nierenberg AA, Phillips KA, Petersen TJ, Kelly KE, Alpert JE, Worthington JJ, et al. Body dysmorphic disorder in outpatients with major depression. J Affect Disord 2002; 69: 141–148.

49. Wegner U, Meisenzahl EM, Möller HJ, Kapfhammer HP. Dysmorphophobie – Symptom oder Diagnose? Nervenarzt 1999; 70: 233–239.

50. Bohne A, Wilhelm S, Keuthen NJ, Florin I, Baer L, Jenike MA. Prevalence of body Dysmorphic disorder in a German college student sample. Psychiatry Res 2002; 31: 101–104.

51. Veale D, Boocock A, Gournay K, Dryden W, Shah F, Willson R, Walburn J. Body dysmorphic disorder. A survey of fifty cases. Br J Psychiatry 1996; 169: 196–201.

52. Hoffmeyer-Zlotnik, Jürgen HP. Stichprobenziehung in der Umfragepraxis–Die unterschiedlichen Ergebnisse von Zufallsstichproben in face-to-face-Umfragen. In: Faulbaum F & Wolf C, editors. Stichprobenqualität in Bevölkerungsumfragen. Sozialwissenschaftliche Tagungsberichte 12 Bonn 2006, p. 19–36.

53. Kish L. A procedure for objective respondent selection within the household. J Am Stat Assoc 1949; 44: 380–387.

54. Statistisches Bundesamt – Bundeszentrale für politische Bildung. Jahresbericht 2002. Statistisches Bundesamt Wiesbaden. 2002.pdf? blob=publicationFile.

55. Statistisches Bundesamt – Jahresbericht 2013. Statistisches Bundesamt Wiesbaden.

56. Goldberg, D. The detection of psychiatric illness by questionnaire: A technique for the identification and assessment of non-psychotic psychiatric illness. London, New York: Oxford University Press, 1972.

57. Oosthuizen P, Castle DJ, Lambert T. Dysmorphic concern: Prevalence and association with clinical variables. Aust N Z J Psychiatry 1998; 32: 129–132.

58. SPSS Statistics for Windows, Version 22.0. IBM Corp. Released. IBM Armonk, NY: IBM Corp., 2013.

59. Brohede S, Wingren G, Wijma B, Wijma K. Prevalence of body dysmorphic disorder among Swedish women: A population-based study. Compr Psychiatry 2014; 58: 108–115.

60. Phillips KA, Diaz SF. Gender differences in body dysmor­phic disorder. J Nerv Ment Dis 1997; 185: 570–577.

61. Phillips KA. The Broken Mirror: Understanding and Treating Body Dysmorphic New York (NY): Oxford University Press; 2005.

62. Veale D, Gournay K, Dryden W, Boocock A, Shah F, Willson R, Walburn J. Body dysmorphic disorder: A cognitive behavioural model and pilot randomised controlled trial. Behav Res Ther 1996; 34, 717–729.

63. Sarwer DB, Pertschuk MJ, Wadden TA, Whitaker LA. Psychological investigations in cosmetic surgery: A look back and a look ahead. Plast Reconstr Surg 1998; 101: 1136–1142.

64. Dey JK, Ishii M, Phillis M, Byrne PJ, Boahene KD, Ishii LE. Body dysmorphic disorder in a facial plastic and reconstructive surgery clinic: measuring prevalence, assessing comorbidities, and validating a feasible screening instrument. JAMA Facial Plast Surg 2015; 17: 137–143.

65. Boroughs MS, Krawczyk R, Thompson JK. Body Dysmorphic Disorder among diverse racial/ethnic and sexual orientation groups: Prevalence estimates and associated factors. Sex Roles 2010; 63: 725–737.