Although the level of functioning varies widely, BDD usually impairs functioning and causes other complications. (3,!°,12) Some people, with effort, function well despite their distress, although often below their capacity. Those with severe BDD may be profoundly impaired by their symptoms—for example, they may housebound for years and chronically suicidal. 'IP

Some degree of social impairment is nearly universal. Individuals with BDD may have few or no friends, avoid dating and other social interactions, or get divorced because of their symptoms. They often avoid specific locations, such as restaurants, beaches, or shopping centres, in which they feel particularly self-conscious about how they look. Impairment in academic or occupational functioning is also common and is typically due to poor concentration due to BDD obsessions, time-consuming BDD-related behaviours, or self-consciousness about being seen. Patients not uncommonly drop out of school or stop working. In one series, more than a quarter of patients had been completely housebound for at least 1 week, more than half had been treated as an inpatient in a psychiatric unit, and nearly 30 per cent had attempted suicide/11 A recent study of dermatology patients who committed suicide reported that most had acne or BDD.

BDD behaviours are usually problematic. They can be time-consuming, distracting, and distressing, and can increase rather than decrease anxiety. Skin picking can cause considerable skin damage, to the point of necessitating emergency surgery.

Patients with BDD experience unusually high levels of perceived stress (13) and markedly poor quality of life. In one study, BDD patients' mental health-related quality of life was markedly worse than that of the general population, and of patients with depression, diabetes, or a recent myocardial infarction.

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