**2. Definitions and characteristics**

BDD is defined by a recurring and persistent concern about a specific trait or a group of characteristics, noticed in the self-image. The etiology is associated to a perfectionist pre-morbid personality, teasing in school, or a traumatic event. Recent research suggests that more than three-quarters of individuals with BDD reported a perception of childhood maltreatment [2]. The patient relates that these traits are ugly, unattractive, abnormal, or even crippled. The selfnoticed flaws are not necessarily bad or abnormal to other individuals. These appearence concerns range from seem unattractive or inappropriate, to horrible, repulsive or often described as monstrous. Patients can focus in specific details or several parts. It is very frequent that the skin is the focus of the disorder, for example, acne, scars, wrinkles, pale skin, or body hair, characteristics of hair, hair loss, and unwanted facial hair, nose (size and shape). However, any part can be the focus of this disorder. Some even present concern about the perception of asymmetry of body parts. The perceptions are intrusive, unwanted, and take time (about 3–8 h a day); it is usually hard to avoid or control [9–11].

The BDD can be classified according to the level of insight. In the good or reasonable insight, the individual can recognize that the beliefs of BDD may not be true. In the case of poor insight, the individual believes that it is most likely true. In the absence of an insight or a delusional state, the individual is completely convinced that his/her beliefs are true. The degree of compromise affects the treatment of the patient [9, 12].

BDD can also be divided into delusional and not delusional. The delusional type is more severe because the individual presents visual hallucinations, in which he/she perceives his/ her defect as monstrous, whereas in the non-delusional mode, the subject only overevaluates a little imperfection, which was already there. It is believed that 36–60% of the cases of BDD are delusional [13]. However, both BDD delusional and non-delusional usually have good treatment response to the same type of therapeutic. Nevertheless, it is important to establish the differential diagnostics in order to determine the severity of the disease, the comorbidities, and the risk factors [13, 14].

Some variations were found in brain structure and function. Research suggests that BDD patients may have some alteration in the white substance of the brain, leading to a functional impairment due to disorganization in the tract which connects the vision with emotional issues and memory [13, 15].

BDD, which was primarily called dysmorphophobia, is a severe psychiatric disorder usual and disabling. It is marked by deep psychological sorrow, directly proportional to the imaginary or delusional physical defect. This "defect" is always focused in a given area of the body, such as, nose, hair, freckles, or breasts. Any part of the body can be "chosen"; it can include the presence of unwanted body hair or the body weight or the body shape [4–6].

Even though BDD being still an underrecognized and underdiagnosed pathology in our society, it causes too much pain, social, and professional impairment to the patients. It affects another important area of their lives too: most of them have deep emotional issues and cannot keep a marriage or a long-term relationship because of BDD. Recently, some repetitive behaviors and mental acts related to appearance concerns were added to the list of symptoms too [8, 9].

Most of these patients look for appearance-enhancing treatments, trying to get rid of their sorrow and frustration, but it usually exacerbates the psychological symptoms and leads to more dissatisfaction [7, 8]. Therefore, it is paramount that not only psychologists and psychiatrists know more about BDD, but also, professionals of esthetics area, cosmetology and gyms, which include alternative specialty doctors, physiotherapists and personal trainers. They could identify potential patients and referral to specialized treatment.
