Body Dysmorphic Disorder (BDD)

What is body dysmorphic disorder?

Body dysmorphic disorder (BDD), also known as body dysmorphia and dysmorphophobia, is a mental health condition characterized by a distorted perception of appearance. BDD often begins in adolescence and is believed to equally affect males and females. ^[1]

People with BDD have an obsessive preoccupation with one or more minimal or imagined flaws or defects in their appearance, that is so severe it has a negative impact on their quality of life ^[2].

People with BDD often believe they are ugly or deformed in some way and this belief consumes hours of their time, by thinking about, examining, or attempting to fix this imagined defect ^[3]. 

Often, their preoccupation with the flaw or flaws begins to impact social and professional functioning and can cause increasingly worsening mental health issues, such as depression and anxiety ^[3].

For some people with BDD, this belief can become delusional in nature. Individuals may become convinced that they have a serious deformity and/or that others are commenting on or laughing at the imagined defect ^[4].

Symptoms of body dysmorphic disorder

Symptoms of body dysmorphic disorder may vary from person to person, but whether mild or severe, the symptoms will likely cause ongoing distress and have a negative impact on quality of life and mental health.

Symptoms of BDD include ^[5][6]:

• Preoccupation with a flaw: this flaw may be barely noticeable to others or be entirely imagined but causes excessive worries, thoughts, and behaviors.
• Low self-esteem: people with BDD often feel very self-conscious or embarrassed by their appearance and have little self-confidence.
• Compulsive behaviors: such as regular or prolonged attempts to fix or hide the flaw or picking at skin or hair.
• Avoiding or regularly looking in the mirror: spending long periods of time looking in the mirror at the perceived flaw or attempting to avoid looking in mirrors.
• Camouflage: attempting to hide the flaw with make-up, hair styles, or clothing.
• Needing reassurance: regularly asking others for reassurance about their appearance.
• Loss of control: inability to control, reduce, or stop behaviors related to the perceived defect.
• Social impairment: often avoiding interactions with others because of low self-esteem and shame, contributing to a lack of friends and romantic relationships.
• Impaired functioning: poor productivity or concentration at school or work because of behaviors associated with the condition or feeling self-conscious.
• Co-existing conditions: many people with BDD also have other mental health conditions, particularly depression which may be caused by BDD, or anxiety disorders.
• Suicidal ideation: research suggests that there are high rates of suicidal thoughts and attempts amongst those with BDD ^[2].

The above symptoms are also present in those with delusional BDD but tend to be of a greater severity. Also, people with delusional BDD tend to have less insight into their condition, and higher rates of attempted suicide, impairment in social functioning, and drug and alcohol abuse ^[4].

Causes of body dysmorphic disorder

It is not known exactly what causes body dysmorphic disorder, but research suggests that there are several contributing factors to the development of the condition.

Genetics

Studies have found that people diagnosed with BDD are significantly more likely to have a direct relative with BDD than the general population ^[7]. Many also have a relative with obsessive compulsive disorder (OCD) or depression, suggesting that these conditions may also impact the likelihood of developing the disorder ^[5].

Childhood trauma

Research suggests that a large proportion of people diagnosed with BDD have experienced some sort of childhood trauma or abuse, including sexual, physical, and emotional abuse, childhood neglect, or bullying, indicating that these experiences may increase the chance of going on to develop the condition ^[7][8].

Brain functioning

There are implications that levels of chemicals in the brain can impact the likelihood of developing BDD. Several studies have found a relationship between serotonin levels and BDD, although the exact relationship is not currently clear ^[2][7].

Personality traits

People with BDD have been found to be more likely to have personality traits such as perfectionism and neuroticism, suggesting that these traits may play a role in the development of the condition ^[2][7].

Body changes

As BDD often begins in adolescence, there are suggestions that the hormonal and bodily changes experienced at this time may be a contributory factor in the development of BDD, although further research is needed to clarify this relationship ^[7].

Diagnosing body dysmorphic disorder

Body dysmorphic disorder is believed to be severely underdiagnosed, partly because people may be deterred from seeking professional help due to a fear of being trivialized, seen as narcissistic, or because of feelings of shame, or because the symptoms may be misdiagnosed as conditions such as depression, anxiety, or OCD, or in the case of delusional BDD, as symptoms of psychosis ^[2][3].

Because of the potential for misdiagnosis, it is important to provide your doctor with information about all your symptoms and experiences, to enable them to make an informed and correct diagnosis. They may ask about symptoms of other conditions, to attempt to rule out diagnoses that are not applicable, and to fully understand your mental state.

When making a diagnosis of BDD, your doctor or therapist will ask questions relating to the diagnostic criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) ^[9]. This may include:

1. Do you worry or feel unhappy about the way you look, and if so, what specifically concerns you?
2. How much time do you spend thinking about these concerns?
3. Does this impact your quality of life, such as affecting your social or professional functioning or causing extreme distress?

Your doctor will use your answers to these questions, along with any other information you provide about your symptoms, to ascertain whether you have a preoccupation with a perceived defect and if this impacts your life to the point that a diagnosis of BDD would be appropriate. 

Treatment for body dysmorphic disorder

Current understanding of BDD suggests that a treatment of either cognitive behavioral therapy (CBT) or a selective serotonin reuptake inhibitor (SSRI), or a combination of the two, is a leading treatment for the condition ^[3].

CBT can help to restructure cognition, helping to provide alternative behavioral responses to emotions associated with the disorder and reduce emotional distress related to perceived flaws in appearance. CBT can teach positive coping strategies and assist in changing beliefs and harmful behaviors, such as social withdrawal and regular mirror checking ^[2].

SSRIs, a type of antidepressant medication, can help to reduce negative emotions that may contribute to the symptoms of the condition and help to improve functioning ^[2][3]. SSRIs have also been found to be effective in treating delusional BDD, more so than antipsychotic medications alone, although a combination of an antipsychotic and an SSRI may be prescribed ^[4]. Medication could be considered as an additional treatment recommendation from your therapist.

Psychoeducation about the condition may also be prescribed as part of a treatment plan, to help in improving insight and understanding of the condition, particularly for those with delusional BDD ^[3].

Self-care for body dysmorphic disorder

If you believe you may have body dysmorphic disorder, there are several ways in which you can manage the condition, such as ^[5][10]:

• Ask for help: seeking professional advice is crucial in managing any mental health condition, in order to receive proper treatment and prevent worsening symptoms.
• Speak with loved ones: similarly, it is important to communicate about your concerns with your friends or family, to receive support in managing your condition.
• Attend a support group: you may find it useful to attend a support group with others who also have BDD, to share and discuss experiences, learn new ways to manage the condition, and reduce negative emotions such as shame and aloneness.
• Don’t attempt self-surgery: some people with BDD perform surgeries on themselves to remove or change their perceived flaw, which can result in infection, scarring, or a worsening of the initial concern, so should not be attempted.
• Learn your triggers: understanding and recognizing potential triggers can help in forming a management plan and avoiding worsening symptoms and behaviors.
• Set goals: having a goal or a limit for your behaviors can help in improving your condition, such as gradually increasing social interactions or gradually reducing time spent looking in the mirror at the ‘defect’.
• List positive attributes: consider writing a list of your positive traits and ask others for their input, as this can help to boost self-esteem and reduce negative feelings.
• Relaxation exercises: engaging in activities such as breathing or relaxation exercises, mindfulness, meditation, and yoga, can help to reduce anxiety and improve mood, which can contribute to an improvement in symptoms of BDD.
• Improve general well-being: ensuring you get enough sleep, eat well, drink plenty of water, and engage in regular exercise can all contribute to improvements in mental and physical health, thereby reducing the impact of your condition.

Helping someone with body dysmorphic disorder

If you know someone with BDD, you can help them by ^[10]:

• Listening: talking to them about their condition, listening to their concerns, and acknowledging their feelings can help to reduce feelings of shame and validate their experiences.
• Asking how you can help: for example, they may want someone to attend a therapy session or doctor’s appointment with them or want help with tasks or activities that increase their anxieties.
• Giving praise: acknowledge and celebrate achievements unrelated to their condition, as well as any progress in their recovery, to help raise self-esteem and motivation.
• Learning: learn more about the condition and about your loved one’s personal triggers, so that you can help them avoid or manage challenging situations.

FAQs about BDD

What is the outlook for people with body dysmorphia?

Studies suggest that, with appropriate treatment, people with a diagnosis of BDD can experience significant reductions in symptoms within a year, which can be maintained over time with ongoing support ^[3][11]. Everyone is different; that after an assessment with a therapist and a few sessions, you may have more clarity on your timeline for treatment and recovery.

How common is body dysmorphia?

According to various studies and research, BDD affects between 0.7% and 2.5% of the population, although it is believed to be underdiagnosed, so the actual figures may be higher ^[1][3].