What Is Body Dysmorphic Disorder (BDD)?

What Is Body Dysmorphic Disorder?

Where someone with distorted body image would tend to focus on overall physical shape or size, a person with body dysmorphic disorder will place extreme focus on a particular body part or feature of their body. Thoughts of their specific flaw surface frequently and can become overwhelming, often consuming their thoughts and presenting an obstacle to their general well-being and daily functioning.

BDD differs from common body image concerns in that the thoughts are persistent and intrusive, cause significant distress and impact behavior and functioning. Another important factor is that, with BDD, the person is often preoccupied with a flaw or trait that is barely noticeable, even nonexistent. Features that others might see as a slight imperfection or inconvenience (or not see at all) become consuming and unbearable, to the point of threatening their quality of life.

Symptoms

If you are dealing with BDD, you may often be consumed with intrusive and persistent thoughts related to a feature on your body, such as a mark, scar, shape, or symmetry of a particular body part. The thoughts can show up at any time without warning and, no matter how hard you try, you likely have difficulty in stopping or changing your thoughts about the perceived flaw.

Because of the persistence of these thoughts, it's possible you feel a significant disruption in your quality of life. If you think a loved one may be dealing with BDD, some of the behaviors they may be demonstrating include:

• Changing body positions frequently
• Clothing to hide certain body parts or features
• Excessive grooming
• Excessive use of makeup
• Overemphasizing other body parts or physical traits
• Repeatedly checking appearance in mirrors
• Seeking cosmetic surgery or other procedures
• Seeking excessive reassurance from others about that trait or body part
• Skin picking
• Wearing accessories such as hats, scarves, and gloves

People with BDD will often engage in repetitive behaviors in an attempt to address these physical concerns. Even though you can spend hours a day on these behaviors, any relief is short-lived.

Diagnosis

To avoid appearing vain or not being taken seriously by their healthcare provider, people with BDD may struggle for a period of time before coming forward and seeking help. Even then, they often disclose their concerns to a healthcare professional such as a dermatologist, reconstructive surgeon, or dentist, rather than a psychiatrist or other mental health provider.

People with BDD often fear judgment from others even though their level of distress is so high that it severely impacts their quality of life and relationships.

In order to be clinically diagnosed with BDD, the following criteria must be met:

1. Preoccupation with appearance. Not only must the person be preoccupied with one or more perceived defects, but it is also important to note that the focus of their attention is on a slight imperfection, something barely observable or noticed by others or nonexistent. In order to be considered "preoccupied" with the perceived flaw, the person would be engaging in the obsessive thoughts about their flaws for hours a day.
2. The person must engage in repetitive behavior in an effort to "fix" the perceived flaw. The repetitive behaviors are demonstrated in an attempt to conceal, fix, or respond to the focus of the obsessive thought. For example, someone may repeatedly look in the mirror, pick at their skin, change their clothes, reapply makeup, excessively ask others for reassurance, etc.
3. The preoccupation and repetitive behaviors must be clinically significant. In other words, the distress that the person experiences must be to the point that their quality of life is significantly impaired. The person's social life, occupation (school or work), and other important areas of their life must be impacted drastically as a result of these thoughts and behaviors.

Body dysmorphic disorder can be easily misdiagnosed as another mental health disorder, so it is important for a properly trained clinician to do a thorough diagnostic assessment to avoid potentially misdiagnosis. Some symptoms of BDD overlap with other conditions, such as:

• Agoraphobia
• Eating disorders
• Excoriation disorder (skin picking)
• Generalized anxiety disorder (GAD)
• Major depressive disorder (MDD)
• Obsessive-compulsive disorder (OCD)
• Psychotic disorders
• Social anxiety disorder (SAD)
• Trichotillomania (hair pulling)

Causes

No single cause of BDD has been identified. This disorder is considered to be influenced by a variety of factors, such as:

• A history of abuse
• A triggering event
• Brain abnormalities
• Bullying
• Genetic predisposition
• Social and interpersonal interactions

Related and Co-Occurring Disorders

Overlap has been shown to exist between BDD and other mental health disorders, particularly anxiety disorders such as OCD, social anxiety disorder (SAD), and substance related disorders. In the DSM-5, BDD is under the category of obsessive-compulsive and related disorders.

Research has shown that over 60% of people with BDD have a lifetime anxiety disorder and 38% had identified social phobia. The preoccupation with a perceived physical flaw can leave people feeling isolated and apprehensive of any social interaction, leading to feelings of hopelessness and depression.

Although unhealthy body image is often associated with eating disorders, it is important to point out that body dysmorphia is not necessarily related to weight or weight loss. For many with BDD, the focus is on a body part such as the nose, hair, or scars—things that disordered eating behaviors would not change or influence.

When the obsessive focus for someone is related specifically to the size of a body part, such as the thighs or midsection, eating disordered behavior may take place in an effort to address that perceived flaw. It is estimated that about 12% of those with BDD also meet the criteria for eating disorders such as anorexia and bulimia.

Prevalence

BDD is suggested to impact about 1 in 50 people within the general population, which would equate to roughly 5 to 7.5 million people in the United States alone. BDD seems to affect men and women equally, with an estimated 2.5% of women and 2.2% of men identified as having this disorder.

Although BDD can show up for people at any age, many start to show signs and behaviors of the disorder around the age of 12 or 13 years old.

Types

Although excessive focus and attention can be on a variety of body parts, traits, or characteristics, some of the more common include:

• Chest
• Hair
• Genitalia
• Muscularity or size of a body part
• Nose or other facial features
• Symmetry (hair, facial features, body parts)

Treatment

If you or a loved one are dealing with BDD, you may feel reluctant to start psychiatric treatment. It's very common for those with BDD to believe that psychiatric treatment is not an adequate solution to their concerns.

In fact, it is likely that you will have already sought out help in other ways, such as with makeup, hair and clothing consultants, plastic surgeons, aestheticians, dermatologists, and dentists (depending on the body feature in question). Those with BDD want their physical "problem" addressed. They want the perceived flaw to be fixed, transformed, or removed.

Psychotherapy

One approach that has shown to be effective in the treatment of BDD is cognitive behavioral therapy (CBT). In fact, CBT is a first-line treatment for BDD. It involves changing the maladaptive thoughts and beliefs present in the disorder. It can also involve exposure techniques that aim to decrease the repetitive behaviors and thoughts around the bodily preoccupations.

Medications

Additionally, the use of medications, specifically selective serotonin reuptake inhibitors (SSRIs), have been shown to be effective in decreasing some of the symptoms of BDD. These medications are often used most effectively in combination with cognitive behavioral therapy.

Coping

There are also things that you can do to help make the symptoms of the condition more manageable. These strategies may include:

• Avoiding comparison: Social comparison is a big challenge for many of us, and even more so if you're living with BDD. Because of insecurities around physical characteristics and a tendency to judge ourselves so harshly, being around others can be challenging and intimidating.
• Ensuring your safety: Physical safety is key in the treatment of BDD. By the time a person has started psychiatric treatment, it is likely that they have already shown some physically unhealthy coping behaviors such as excessive skin picking or pursuing a variety of unhelpful medical treatments. These behaviors can leave you and your loved ones feeling no hope that the situation can change. It is important that this behavior is seen as not only harmful to one's well-being but also ineffective in accomplishing the goal of "fixing" a perceived flaw.
• Focusing on self-acceptance: After spending so much time focused on personal flaws, the idea of self-acceptance can feel foreign and sometimes even impossible but, with the help of treatment, it can be possible to challenge debilitating thoughts and unhealthy behaviors, improve your self-talk, and come to a place of greater acceptance and self-compassion.