244 Obsessive-Compulsive and Related Disorders
androgenic steroids and other substances to try to make their body bigger and more mus-
cular. Body dysmorphic disorder by proxy is a form of body dy smorphic disorder in
which individuals are preoccupied with defects they perceive in another person’s appear-
ance.
Insight regarding body dysmorphic disorder  beliefs can range from good to absent/
delusional (i.e., delusional beliefs consisting of complete conviction that the individual’s
view of their appearance is accurate and un distorted). On average, insight is poor; one-
third or more of individuals currently have delusional body dysmorphic disorder beliefs.
Individuals with delusional body dysmorphic di sorder tend to have greater morbidity in
some areas (e.g., suicidality), but this appears accounted fo r by their tendency to have
more severe body dysmorphic disorder symptoms. 
Associated Features Supporting Diagnosis 
Many individuals with body dysmorphic disord er have ideas or delusions of reference,
believing that other people take special notice  of them or mock them because of how they
look. Body dysmorphic disorder is associated with high levels of anxiety, social anxiety,
social avoidance, depressed mood, neuroticism, and perfectionism as well as low extro-
version and low self-esteem. Many individuals are ashamed of their appearance and their
excessive focus on how they look, and are relu ctant to reveal their concerns to others. A
majority of individuals receiv e cosmetic treatment to try to  improve their perceived de-
fects. Dermatological treatment and surgery ar e most common, but any type (e.g., dental,
electrolysis) may be received . Occasionally, individuals may perform surgery on them-
selves. Body dysmorphic disorder appears to respond poorly to  such treatments and