Body Dysmorphic Disorder

Body Dysmorphic Disorder Image by: Alan Cleaver

Are you concerned about some aspect of your appearance, so much so that it negatively affects your lifestyle? For instance, do you spend many hours a day checking your 'defect' in the mirror or do you, perhaps, spend hours attempting to hide what you regard as a flaw. Maybe you actually remain at home, avoiding dating and other social interactions. If this is you or someone you know, you might perhaps have Body Dysmorphic Disorder – a little-known mental disorder.

What is Body Dysmorphic Disorder?

Body Dysmorphic Disorder (BDD) is a mental health condition related to body image in which an individual has a preoccupation with a defect in his or her appearance. The defect is either imagined or if a slight physical anomaly is present, the person’s concern is markedly excessive.

Body Dysmorphic Disorder is diagnosed only if the preoccupation causes significant distress or impairment in social, occupational or other areas of functioning and the preoccupation is not better accounted for by another mental disorder such as Anorexia Nervosa, where the dissatisfaction with body size and shape predominates.

What are the Most Common Areas of the Body Involved?

Complaints usually involve imagined or slight flaws of the face or head such as acne, wrinkles, scars, vascular markings, paleness or redness of the complexion, swelling, facial asymmetry or disproportion, excessive facial hair and hair thinning.

Other common preoccupations include the shape, size or some other aspect of the nose, eyes, eyelids, eyebrows, ears, mouth, lips, teeth, jaw, chin, cheeks or head. However, any body part may be the focus of concern. For example: the breasts, buttocks, genitals, abdomen, shoulders, arms, hands, hips, legs, feet, spine, larger body regions or overall body size.

The preoccupation may simultaneously focus on several body parts. Although the complaint is often specific, for example a 'crooked' lip or a 'bumpy' nose, it is often vague, for example, a 'falling' face or 'inadequately firm' eyes.

Because of embarrassment over their concerns, some individuals with Body Dysmorphic Disorder avoid describing their 'defects' in detail and may instead refer only to their general ugliness.

When Does a Concern With Appearance Become BDD?

Many people have some degree of concern about some aspect of their appearance. Unlike normal concerns about appearance, the preoccupation with appearance in Body Dysmorphic Disorder is excessively time consuming and associated with significant distress or impairment in social, occupational or other areas of functioning.

An individual with Body Dysmorphic Disorder can also be distinguished from someone who merely has a negative attitude toward their body by the associated features of Body Dysmorphic Disorder. For example,

An individual with Body Dysmorphic Disorder will spend many hours a day checking their 'defect' in the mirror, or in any available reflecting surface such as store windows or their watch faces. Some individuals use special lighting or magnifying glasses to scrutinise their 'defect'.

There may be excessive grooming behaviour, such as excessive hair combing, hair removal, ritualised make-up application or skin picking. Although the checking and grooming are intended by some individuals to lessen anxiety about the 'defect', it often increases the preoccupation and associated anxiety. As a result, some individuals avoid mirrors – sometimes covering them or removing them from their environment altogether. Others may alternate between periods of excessive mirror checking and mirror avoidance.

An individual with Body Dysmorphic Disorder may frequently ask for reassurance about the 'defect', but such reassurance leads only to temporary relief or no relief at all.

Individuals with Body Dysmorphic Disorder may frequently compare their 'ugly' body part with that of others. Ideas of reference related to the imagined defect are also common. That is, individuals with this disorder often think that others may be (or are) taking special notice of their supposed flaw, perhaps talking about it or mocking it. They may try to camouflage their 'defect' by for example, growing a beard to hide imagined facial scars; wearing a hat to hide imagined hair loss; or stuffing their underwear to enhance a 'small' penis.

Who is Affected?

Body Dysmorphic Disorder is diagnosed with approximately equal frequency in men and women.

It is recognised as a ‘hidden’ disorder, as many people are too ashamed to reveal their problem. As a result, it is not known how many people have experience of BDD. In addition, Body Dysmorphic Disorder is often missed by doctors: people with Body Dysmorphic Disorder often have other mental health problems and the Body Dysmorphic Disorder may be misdiagnosed or not recognised.

A recent review estimated that between 1% and 4-5% of the population is affected by Body Dysmorphic Disorder at any one time. People with a diagnosis of BDD are often seen in dermatology (skin) and cosmetic surgery settings. One study showed that up to 12% of patients seen by dermatologists and up to 15 % of patients seeking cosmetic surgery had a diagnosis of BDD. (It is worth noting that Body Dysmorphic Disorder is usually not recognised in settings in which cosmetic procedures are performed).

Body Dysmorphic Disorder can affect all age groups, but usually begins in adolescence when people are most sensitive about their appearance. It may not be diagnosed for many years, however, for two reasons: 1. Most parents (about 76% of parents) think their child is either over-conceited or simply lying about his/her condition;
2. Individuals with the disorder are often reluctant to reveal their symptoms. When they do seek help from mental health professionals, they often do so with other symptoms such as depression, social anxiety or obsessive-compulsive disorder, but do not reveal their real concerns about their appearance.

Are People With Body Dysmorphic Disorder Vain?

People living with Body Dysmorphic Disorder are not vain, but believe themselves to be ugly or defective. They tend to be very secretive and reluctant to seek help because they are afraid that others will think them vain or self-obsessed.

How Severe a Condition is Body Dysmorphic Disorder?

As is the case for other mental health conditions, the type and severity of Body Dysmorphic Disorder symptoms varies from person to person.

Most individuals with this disorder experience significant distress over their supposed deformity. They often describe their preoccupations as “intensely painful”, “tormenting” or “devastating”. Most find their preoccupations difficult to control and they may make little or no attempt to resist them. As a result, they often spend hours a day thinking about the “defect”, to the point where these thoughts may dominate their lives. Significant impairment in many areas of functioning generally occurs. Feelings of self-consciousness about their 'defect' may lead to avoidance of work or public situations.

Avoidance of usual activities may lead to extreme social isolation. In some cases, individuals may leave their homes only at night, when they cannot be seen or become housebound, sometimes for years. Individuals with this disorder may drop out of school; avoid job interviews; work at jobs below their capacity; or not work at all. They may have few friends, avoid dating and other social interactions, have marital difficulties or get divorced because of their symptoms.

Individuals with Body Dysmorphic Disorder often pursue and receive general medical, dental or surgical treatments to rectify their imagined defects. Such treatment may cause the disorder to worsen, leading to intensified or new preoccupations, which may in turn lead to further unsuccessful procedures, so that individuals may eventually possess 'synthetic' noses, ears and breasts et cetera with which they are still dissatisfied. As mentioned above, Body Dysmorphic Disorder is usually not recognised in settings in which cosmetic procedures are performed.

Body Dysmorphic Disorder may be associated with Major Depressive Disorder, Delusional Disorder, Social Phobia, Obsessive –Compulsive Disorder and Generalised Anxiety Disorder. It may also exist alongside an eating disorder such as anorexia or bulimia.

Substance misuse can be common - in one study 49% of patients sampled had a lifetime substance misuse problem and 68% said that their BDD symptoms contributed to their substance misuse.

The distress and dysfunction associated with this disorder can lead to repeated hospitalisation and to suicidal ideation (thoughts of suicide), suicide attempts and completed suicide. About 80% of people with BDD have suicidal ideation. The completed-suicide rate in patients with BDD is 45 times higher than that of the general United States population.

Studies have also shown that people with a diagnosis of BDD have a worse quality of life than those with depression.

How is the Condition Likely to Progress?

Many individuals with experience of Body Dysmorphic Disorder have repeatedly sought treatment from dermatologists or cosmetic surgeons with little satisfaction, before finally accepting psychiatric or psychological help. Treatment can improve the outcome of the condition for most people.

Some people living with Body Dysmorphic Disorder may function reasonably well for a time and then relapse. Others may remain chronically unwell. Research on outcome without therapy is not known, but it is thought that the symptoms persist for many years.

What Causes Body Dysmorphic Disorder?

There has been very little research into BDD and the cause of BDD is not clear. What is clear, however, is that there is no single cause of Body Dysmorphic Disorder. Research shows that a number of factors may be involved and that they can occur in combination.

As with other mental disorders, the cause of BDD can best be understood in terms of the Diathesis Stress Model. Read more about the Diathesis Stress Model in my article entitled Understanding Mental Disorders.

The Diathesis-Stress Model says that predisposing factors and precipitating factors influence each other and result in the disorder, which is then maintained by various other factors.

An example of the possible causes of a Body Dysmorphic Disorder mental disorder is shown below:

1. Long-Term, Predisposing Factors.

A. Heredity – BDD may be caused by the individual’s genetic make-up.

B.Childhood Circumstances:

1. Parenting style – parents who either place excessive emphasis on aesthetic appearance or disregard it completely;

2. Teasing, bullying or abuse, particularly during adolescence (Around 60% of people with BDD report frequent or chronic childhood teasing);

3. Low self-esteem;

4. Neglect, physical and/or sexual trauma, insecurity and rejection.

C. Cumulative stress over time.

2. Biological Factors

A. Chemical imbalance of serotonin or other chemicals in the brain.

B. Medical conditions that can cause disorders - Eczema, baldness, dermatosis papulosa nigra, freckles, scarring, skin tone and other physical traits such as body size and weight can also factor into the onset of BDD via low self-esteem and negative thinking.

3. Short-Term, Precipitating (Triggering) Factors

A. Stressors that precipitate the disorder. For example: Media pressure (glamour models and the implied necessity of aesthetic beauty) may act as a trigger in those already genetically predisposed or could worsen existing BDD symptoms;

B. Conditioning;

C. Other mental disorders – Obsessive –Compulsive Disorder, Social Phobia, Eating Disorders.

4. Maintaining Causes

  1. Negative self-talk;
  2. Making comparisons with other people;
  3. Mistaken beliefs;
  4. Withheld feelings;
  5. Excessive self-focused attention and behavior;
  6. Demanding perfection, or an impossible ideal, in their appearance;
  7. Judging self almost exclusively on appearance;
  8. Avoiding social situations;
  9. Seeking reassurance;
  10. Checking the perceived defect;
  11. Fear of being alone and isolated all their life;
  12. Believe that they are worthless if they cannot correct the aspect of their appearance that causes distress (the perceived defect).

Do I Have Body Dysmorphic Disorder?

If you suspect that you may have BDD take the self – test. Answer the following questions:

  • Do you find yourself excessively concerned or distressed by appearance flaws that friends, family members or doctors tell you are minor or non-existent?
  • Do your appearance concerns interfere with your ability to work, take care of things at home, or socialise?
  • Have you undergone multiple cosmetic procedures (but still feel unsatisfied with your appearance)?
  • Do you believe that receiving plastic surgery will transform your life or fix all of your problems?

If you answered "YES " to any of the above questions it is recommended that you seek professional help and obtain treatment. Contact a psychologist or psychiatrist.

What can I do to Help Myself if I Think I Have BDD?

If you feel you may be suffering from Body Dysmorphic Disorder, see your GP, a psychiatrist or a psychologist.

They will consider how distressing the condition is for you and how much your life is affected, to work out whether you have:

  • mild BDD, where symptoms are distressing but manageable and you are able to carry on with everyday life; or
  • more severe BDD, where symptoms are very distressing and seriously restrict your everyday life.

This will also help your healthcare provider to identify the most suitable treatment.

Questions Your Healthcare Provider may ask

  • Do you currently think a lot about your appearance? What feature(s) are you unhappy with? Do you feel your features are ugly or unattractive?
  • How noticeable do you think your feature is to other people?
  • On an average day, how many hours do you spend thinking about your feature?
  • Does your feature currently cause you a lot of distress?
  • How many times a day do you currently check your feature?
  • How often do you feel anxious about your feature in social situations? Does it lead you to avoid social situations?
  • Has your feature had an effect on dating or on an existing relationship?
  • Has your feature interfered with your ability to work or study?

How is Body Dysmorphic Disorder Treated?

There has been little research on the treatment of Body Dysmorphic Disorder; guidelines based on the evidence available have been drawn up to help healthcare professionals treat BDD.

They are generally regarded to be as follows:

Step 1: Cognitive Behaviour Therapy (CBT)

Adults and adolescents experiencing BDD should initially be offered Cognitive Behaviour Therapy (CBT; described below) and be given self-help materials.

CBT is a psychotherapeutic approach or “talking therapy” that can help you manage your problems by changing the way you think and behave. During therapy, people learn alternative ways of thinking, including ways of directing their attention away from themselves. They learn to give up comparing their appearance with others' and dwelling on their perceived defect. They confront their fears without their camouflage and learn to stop rituals such as checking and excessive grooming. A possible adverse effect of treatment is that anxiety may occur in the short term. However, facing up to the fear is likely to get easier over time and the anxiety gradually subsides.

The most commonly practiced CBT technique used for treating BDD is termed 'exposure and response prevention' (ERP). This behaviour therapy works by repeatedly exposing an individual to their perceived defect, obsession or phobia over time so that they become 'habituated', reducing the symptoms.

Some people may find it helpful to join a self-help group to get moral support from other sufferers and practical tips on how to cope with BDD in daily life.

Step 2: CBT & Antidepressants

If the first step is not effective, the person suffering from BDD should be offered the choice of more intensive CBT, a course of a serotonin-specific reuptake inhibitor (SSRI) antidepressant or a combination of the two.

Depression is thought to be associated with lower levels of certain chemicals in the brain, including serotonin. SSRIs (serotonin-specific reuptake inhibitors) block the reuptake of serotonin back into the nerve cells that originally released them, thereby prolonging its action.

SSRIs are prescribed for mental health conditions other than depression and have had some success in treating people with BDD. Evidence for the benefit of SSRIs in treating BDD is limited and less certain than for other mental health problems.

It is recommended that the SSRI s be taken daily for at least 12 weeks before it has an effect. If it is effective, treatment should continue for at least 12 months, to allow for further improvements and to prevent a relapse. When the treatment is complete and your symptoms are under control, the SSRI dose should be reduced gradually to minimise the possibility of withdrawal symptoms.

Adults younger than 30 will need to be carefully monitored when taking SSRIs because of the potential increased risk of suicidal thoughts and self-harm associated with the early stages of treatment.

Step 3: Prescription Change

If a first course of SSRIs and CBT with exposure and response prevention (ERP) is not effective, the next step is to try a different SSRI or another antidepressant called clomipramine.

If the symptoms of BDD are severe, other treatment options have not worked, psychotic symptoms are present or there is a risk of self-harm or suicide, a healthcare professional may recommend treatment at a residential or inpatient unit. However, most people with BDD do not have to stay in hospital for treatment.

A Note Regarding Treatment

These treatments may not be appropriate for everyone. As is the case for all mental health problems, the person may be able to manage and recover from the condition with the help of other therapies, including talking therapies other than CBT or by using the information available to develop their own solutions.

Celebrities who may Have Suffered From Body Dysmorphic Disorder

Although diagnoses have not been confirmed, some speculate that stars like Michael Jackson and Marilyn Monroe suffered from BDD.

Experts have proposed that Jackson suffered from BDD because he had over 30 plastic surgeries and seldom showed his face without makeup.

Marilyn Monroe’s stylist believed that her obsessions with the mirror were a form of Body Dysmorphic Disorder as Monroe sought to constantly examine and change her face.

Heidi Montag may also suffer from BDD. She underwent ten cosmetic surgeries within one day.

In 2010, singer Lily Allen told Q magazine that she, too, was preoccupied with her body shape and suffered from the disorder.

In 2001, Actress Uma Thurman publicly stated that she developed BDD after the birth of her daughter.

Most recently, Sarah Michelle Gellar stated that she suffered from BDD: “I totally have Body Dysmorphic Disorder”.

A note of warning: Although one can neither doubt nor confirm these celebrity cases, one must ensure that celebrity misstatements or cinematic mischaracterisations do not taint or undermine the debilitating reality of disorders like BDD.

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