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Symmetry obsessions are a common symptom of obsessive–compulsive disorder (OCD) and have several demographic and clinical correlates. Appearance-related symmetry concerns appear common in body dysmorphic disorder (BDD); however, no published studies have examined this topic. This study examined the clinical features, prevalence, and correlates of symmetry concerns involving physical appearance in two BDD samples (N=160 and N=115). More than 25% of participants in each sample reported symmetry concerns for a body part with which they were preoccupied (total of 18 body parts in sample 1 and 18 in sample 2). In sample 1, BDD participants with appearance-related symmetry concerns were older than those without appearance-related symmetry concerns. In sample 2, those with appearance-related symmetry concerns reported poorer mental health-related quality of life, were more likely to have experienced lifetime suicidal ideation, had better BDD-related insight, and were less likely to have a lifetime eating disorder. In both samples, participants with appearance-related symmetry concerns were more likely to have lifetime OCD but not OCD-related symmetry obsessions. Thus, symmetry is a common appearance concern in BDD that is associated with comorbid OCD but not with OCD symmetry concerns specifically, suggesting that symmetry concerns may have a different mechanism/pathophysiology in BDD versus OCD.

Body dysmorphic disorder (BDD) is defined in DSM-IV as a distressing or impairing preoccupation with nonexistent or slight defects in physical appearance ( American Psychiatric Association, 1994). In recent years, substantial efforts have been made to better understand the phenomenology of BDD and to identify its clinical features, including body areas of excessive concern, repetitive behaviors such as compulsive grooming and skin picking, and level of insight (e.g., Fontenelle et al., 2006, Grant et al., 2006 and Phillips et al., 2005). One feature of BDD that has not received empirical attention is appearance-related symmetry concerns. Our clinical observations suggest that appearance-focused symmetry concerns are common in BDD; for example, patients may report distressing and/or impairing preoccupation with supposedly “uneven” or “asymmetrical” eyebrows, eyes, hair, or other body areas, which appear normal to others. To our knowledge, no published reports have examined preoccupation with appearance-related symmetry as a symptom of BDD.

Appearance-related symmetry concerns are a common symptom of BDD. Clinicians should assess patients with BDD for preoccupation with symmetry and should not assume that such concerns are a symptom of OCD. Clinicians should also be aware that appearance-related symmetry concerns in BDD may be associated with suicidal ideation and poorer mental health-related quality of life, although replication of these findings is needed. Research is needed to further examine the relationship between symmetry concerns as a symptom of BDD versus OCD and to explore distinct versus shared risk factors for the development of symmetry concerns in these disorders. In addition, studies should explore the relationship of appearance-related symmetry concerns to treatment outcome in BDD, as this topic has not been examined.