Individuals with body dysmorphic disorder (BDD) are preoccupied with an aspect of their appearance that they perceive to be defective in some way. These perceived defects in appearance are not observable or are only slightly noticeable to others. Research indicates that about 1% of adults in the US have body dysmorphic disorder.8
What Is Body Dysmorphia?
When a person does not have an accurate view of themselves, they are said to have a distorted body image. There are varying degrees of distortion based upon the discrepancy between reality and perception. The most severe of these cases is a condition called body dysmorphic disorder.
Signs of Body Dysmorphia
Signs that you or a loved one is dealing with body dysmorphic disorder may seem to appear overnight or occur gradually over time. Individuals typically begin to complain that they are “ugly, disgusting, or grotesque” due to a flaw that they see in their appearance that others may not even notice at all. These flaws are usually confined to the face, skin, hair, or complexion. Other body parts can be focused on as well such as height, legs, thighs, scars, etc. In masculine individuals, there is a condition called muscle dysmorphia in which the patient perceives that they are not lean or muscular enough.
Body Dysmorphic Disorder is quite time-consuming both mentally and physically. A person may spend a great deal of mental energy obsessing over their perceived flaws, ways to correct the flaws, and ways to avoid having others notice them. The individual may also spend hours staring into a mirror checking their bodies, evaluating, and scrutinizing themselves. They may go to dermatologists, dentists, and even surgeons to correct the imperfections that they are unable to tolerate.
Body Dysmorphic Disorder is usually first seen in early adolescence. It is thought to be related to the onset of puberty and the dramatic physical changes associated with this period of development. The prevalence among men and women is nearly equal with numbers in women being only slightly higher.7 As people age, the incidence rates do decrease. Different areas of focus are present such as wrinkled skin, balding in males, and even age spots or other facial blemishes. In the younger population, a focus may be on the shape of one’s nose or face, their hair, or the shape of their legs, hips, or buttocks.
Symptoms of Body Dysmorphia
Due to the significant level of distress that one experiences due to body dysmorphic disorder, they may go to great lengths to either change or improve their appearance. Some individuals have some insight into their problematic behaviors while others do not have much at all. There are many symptoms that are characteristic of this disorder.
The symptoms of body dysmorphia may include:
- Seeking reassurance about appearance
- Body Checking
- Avoiding mirrors
- Skin Picking
- Obsessive thoughts about body image/appearance
- Hygiene/grooming routines that take a great deal of time
- Avoiding social events or having one’s photo taken
- Hiding areas of one’s body with clothing, make-up, or objects (pillows, blankets)
- Relationship/occupational/educational issues due to body image concerns
- Financial issues related to expenditures associated with appearance (plastic surgery, dental procedures, doctor’s appointments, etc.)
- Excessive shopping
- Subjecting self to needless medical procedures to correct an absent flaw
- Comparing one’s appearance to other people
- Excessive diet or exercise (especially in the case of muscle dysmorphia)
Causes & Triggers of Body Dysmorphia
As with most conditions, there is rarely one cause or reason that an individual is suffering from body dysmorphic disorder. There are neurobiological, psychological, and sociocultural theories as to the origin of body dysmorphic disorder. It is likely that all these factors play a role in the development of this condition. Some things that are thought to contribute to the development of body dysmorphic disorder are related to both biology and environment.
Some of those causes or triggers are:
- A family history of appearance-related disorders, depression, anxiety, or OCD
- Teasing or bullying related to appearance
- Perfectionistic traits
- Anxiety or depression
- Societal pressures to meet unrealistic standards of beauty/emphasis placed on beauty
Common Co-Occurring Disorders
Comorbidity, meaning at least two medical conditions are existing together, is common in body dysmorphic disorder. Eating disorders, social anxiety disorder (social phobia), and obsessive-compulsive disorder are common co-occurring conditions. Rates of comorbid personality disorders in body dysmorphic disorder are high, with avoidant personality disorder being the most common. Associated traits include low self-esteem and high levels of neuroticism, introversion, unassertiveness, social anxiety and inhibition, rejection sensitivity, and perfectionism.9
Body Dysmorphia & Eating Disorders
Several eating disorders are characterized by a disturbance in body image. Anorexia and bulimia are two eating disorders that are closely related to body dysmorphic disorder due to the patient’s focus on appearance. Those with eating disorders are concerned with weight and body shape while those with body dysmorphic disorder are preoccupied with one or more specific body parts that they perceive to be flawed, but not necessarily overweight.
In the case of an eating disorder, the individual perceives themselves to be overweight or fears gaining weight despite either being of average size or even considerably underweight. These patients do suffer from a distorted body image as with those who have body dysmorphic disorder. Individuals with body dysmorphic disorder are often focused on features such as their nose, their complexion, or their hair.
There can be overlap between these two diagnoses in that with each there can be concern over body parts such as thighs, legs, and hips. Also, behaviors such as regularly checking in mirrors to evaluate one’s appearance and comparing to others are common in both eating disorders and body dysmorphic disorder.
Body Dysmorphia & Anxiety or Depression
A person who believes that they have defects in their appearance are generally quite self-conscious and may develop social anxiety. This can lead to isolation and loneliness. In the most severe cases this condition may lead to depression or even suicide. Studies report that greater than 70% of those with body dysmorphic disorder also struggle with social anxiety and/or depression.5 According to a study examining the connection between body dysmorphic disorder and suicide, 45-70% of patients with body dysmorphic disorder have reported suffering from suicidal ideation and 22-24% have attempted suicide.6
Social anxiety is a condition characterized by extreme fear of social situations or being judged by others. Quite often individuals suffering with social anxiety avoid social situations in which they believe they might be evaluated negatively or encounter large groups of people. This leads to isolation and a lack of personal relationships. Loneliness, poor self-esteem, and isolation can lead to or exacerbate depression in these patients.
Body Dysmorphic Disorder & Obsessive-Compulsive Disorder (OCD)
Body Dysmorphic Disorder (BDD) and Obsessive-Compulsive Disorder (OCD) have areas of overlap. They both are characterized by obsessions and compulsions (ritualistic behaviors performed repetitively to reduce anxiety). In the case of OCD, these obsessions and compulsions can be related to appearance, but they are more often related to other things such as contamination or illness.
Obsessions may be related to one’s appearance or a flaw in appearance while compulsions may be body checking or seeking out reassurance regarding how they look. In the case of the individual with OCD, they may engage in body checking or checking to ensure doors are locked, the stove has been turned off, or that they did not forget some other important task. With body dysmorphic disorder, the focus is entirely on some aspect of their appearance.
Body Dysmorphic Disorder & Personality disorders
A personality disorder is an enduring pattern of maladaptive behaviors, cognitions, and experiences which markedly deviate from the expectations of the individual’s culture. These patterns are pervasive and inflexible usually beginning in adolescence or early adulthood and are stable over time. Personality disorders are usually associated with significant distress and impairment.
The most common personality disorder observed in the body dysmorphic disorder population is avoidant personality disorder.8 Avoidant personality disorder is characterized by social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation. These traits are understandably present in those who believe that they have a physical flaw so severe that they need to avoid social interaction as in body dysmorphic disorder.
Diagnosis of Body Dysmorphia
Despite having many similarities to anorexia and bulimia as it relates to body dissatisfaction, body dysmorphic disorder (BDD) is not classified as an eating disorder, but rather it is listed under Obsessive-Compulsive and Related Disorders.” body dysmorphic disorder is outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-V).1
The primary criteria for diagnosing body dysmorphic disorder are:
- A preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or seem slight to others
- At some point during the course of the disorder, the individual has performed repetitive behaviors (e.g. mirror checking, comparing his or her appearance with that of others) in response to the appearance concerns
Clinicians will also specify whether muscle dysmorphia is present as defined by the individual being preoccupied with the idea that his or her body build is too small or insufficiently muscular. This condition is a subtype of body dysmorphic disorder and predominantly seen in males.
Most often patients with body dysmorphic disorder will first consult with plastic surgeons or dermatologists rather than counselors or psychiatrists. These individuals frequently seek out the services of these medical professionals due to their perception that their bodies or skin is flawed to the point that they need medical treatment or even plastic surgery to improve the defects. Often a low level of insight regarding their condition is present as well. Collaboration between professionals is imperative to ensure that the condition is appropriately addressed.
Treatment of Body Dysmorphia
Body Dysmorphic Disorder can be successfully treated with intervention. Treatment for body dysmorphic disorder consists of medication, therapy, or a combination of both. An effective therapeutic option is a form of psychotherapy known as cognitive behavioral therapy (CBT). This along with antidepressant medication (SSI’s) is another common approach to dealing with body dysmorphic disorder.5 CBT is especially helpful as it is also effective for the treatment of eating disorders. These conditions have a great deal of overlap and are often treated simultaneously.
Therapy
Those with body dysmorphic disorder will likely benefit from cognitive behavioral therapy. Several studies have found that CBT has successfully reduced the symptoms of body dysmorphic disorder and related conditions such as depression. It is important to seek out a professional with experience treating this condition as well as any co-occurring condition the patient has. It is likely that a Certified Eating Disorders Specialist (CEDS) will be adept at managing this condition as eating disorders are often seen with co-occurring disorders such as OCD, anxiety, depression, personality disorders, and body dysmorphic disorder.
Common types of therapies used to treat body dysmorphic disorder include:
Cognitive Behavioral Therapy (CBT)
CBT is helpful in the treatment of body dysmorphic disorder because it focuses on changing the distorted or negative thinking that the patient has related to their perceived flaws in appearance. While addressing distorted thinking, a therapist also helps the patient to modify their ineffective behaviors related to their thoughts and emotions.
Exposure & Response Prevention (ERP)
ERP is a type of CBT that is designed to assist a patient to gradually face that which they are fearful to encounter. In the case of body dysmorphic disorder, it could be social situations in general or wearing clothing that reveals parts of their body they believe to be flawed such as short pants or shirts, bathing suits, or even certain types of footwear.
Intended Treatment Outcome & Timeline
The following is a list of the timeline how treatment of body dysmorphic disorder will typically go:
- Distinguish body dysmorphic disorder from typical body image concerns and/or those associated with an eating disorder.
- Clinician will make a differential diagnosis (determine whether there are other disorders to address and/or if body dysmorphic disorder is the concern rather than another condition)
- Begin psychotherapy (CBT/ERP)
- Add medications if treatment resistant
- Client will work to change body-image related thoughts and beliefs
- Client will gradually expose self to more and more previously avoided situations to change body-image related habits
- Client will work on relapse prevention plan
- Client will be better able to manage distress concerning their perceived flaws
- Client will experience a reduction in co-occurring symptoms such as anxiety or depression
Lifestyle Changes
In addition to therapy and medication, there are lifestyle changes that can assist a patient in managing symptoms of body dysmorphic disorder and improving their overall condition.
These include:
- Self-Care: (Adequate sleep, well-balanced meals, and regular exercise)
- Reduction or elimination of caffeine
- Reduction or elimination of alcohol or other mood-altering substances
- Engage in activities that promote stress-reduction or relaxation: (massage, meditation, yoga)
Medication
Antidepressants such as selective serotonin reuptake inhibitors (SSRIs) may have a positive impact on the obsessive thoughts and rituals associated with body dysmorphic disorder. They are effective for treating body dysmorphic disorder, depression, and most anxiety disorders including OCD. These medications help to reduce obsessional thoughts and compulsive behaviors characteristic of body dysmorphic disorder.4
Studies have shown that about two-thirds to three-quarters of patients will experience at least a 30% reduction in the symptoms of body dysmorphic disorder from taking SSRI antidepressants such as Prozac (fluoxetine), Zoloft (sertraline), Luvox (fluvoxamine), Lexapro (escitalopram). Anafranil (clomipramine) is also sometimes used. It is a tricyclic antidepressant which acts much like an SSRI and is often used to treat OCD. Medication treatment can allow a person to experience reduced distress and improved daily functioning.4
A patient most often works together with their psychiatrist or psychiatric nurse practitioner who prescribes their medication along with their therapist who conducts the CBT and/or ERP sessions to achieve the best treatment outcomes. These professionals may work in the same office or simply coordinate care for their patients from their respective practices.
How to Get Help for Body Dysmorphia
It is a big step to ask for help, and at times it can seem overwhelming. You will need to first seek out a therapist who is skilled in treating body dysmorphic disorder. A good starting place is a Certified Eating Disorders Specialist (CEDS). These therapists will either be Licensed Professional Counselors (LPC), Licensed Marriage and Family Therapists (LMFT), or Psychologists (PhD, PsyD).
Another specialty to search for is an OCD specialist who may also have experience in other co-occurring issues such as personality disorders, eating disorders, and social anxiety. There are online directories that make it easy to search for professionals with specific areas of expertise. You can also consult your insurance carrier, online search engines, or your primary care physician.
You may want to ask a family member or friend to assist you with this process. There are many ways that loved ones can offer you support. They can assist you with researching local providers, they can accompany you to your appointments, they can remind you of appointments, and they can help you to compile a list of questions to ask your new providers about treatment and what to expect.
How to Get Help for a Loved One
It can be difficult to watch a loved one struggle with a condition such as body dysmorphic disorder. It can also be quite frustrating to manage the condition and related symptoms. It is helpful to attempt to understand their perspective even when you do not relate to or agree with their opinion about their appearance. Your loved one needs to know that they have your emotional support as they attempt to seek out treatment for their condition.
A loved one may ask you to assist them in seeking out a professional to work with to address their condition. A first step to take in the process of finding a qualified therapist to treat body dysmorphic disorder, is to search online directories, contact your insurance carrier, or conduct an internet search using any major search engine. A therapist needs to have experience treating body dysmorphic disorder, OCD, and/or eating disorders as this condition requires specialized training to be effective.
A psychiatrist is another professional that you may want to seek out if your loved one is open to medication. If this isn’t something that they are ready to consider right away, their treatment team may be able to address this possibility at a later date if the need seems evident. Some individuals feel more comfortable speaking to their primary care physicians at first regarding medications due to their already established relationship with them. If this is the case, encourage your loved one to schedule a consultation with their physician to address their concerns.
How to Get Help for a Child
If you suspect that your child is struggling with body dysmorphic disorder, it is important that they are evaluated by a professional. There are online resources available to assist you in seeking out a qualified professional to evaluate your child. If you are unable to locate a qualified therapist through an online search, your insurance carrier should be able to provide you with a list of professionals in your area. You can also search for a child psychiatrist or consult your child’s pediatrician regarding the symptoms that you are seeing in your child.
The therapist you seek out will need to have experience in treating children and families in addition to body dysmorphic disorder, OCD, and/or eating disorders. When treating children, family involvement is an important element in the recovery and relapse prevention process.
It is important to encourage your child to participate in treatment and let them know that there is hope for them to get better with assistance. You can let them know that you are there to assist them along the way, and you will be participating in family therapy with them.
Body Dysmorphia Statistics
Body Dysmorphia is a condition that impacts women, men, and children.
The following are some relevant statistics available regarding the condition:
- Over 60% of patients with body dysmorphic disorder had a lifetime anxiety disorder in a recent study5
- 38% of patients with body dysmorphic disorder had social phobia in a recent study5
- As many as 12% of those with body dysmorphic disorder also have anorexia or bulimia5
- Age of onset is adolescence in most cases7
- Incidence rates are nearly equal in men and women7
- 45-70% of patients with body dysmorphic disorder have reported suffering from suicidal ideation6
- 22-24% of patients with body dysmorphic disorder have attempted suicide5
4 Ways to Manage Living With Body Dysmorphia
Living with body dysmorphic disorder can seem like a daunting task, but there are ways to decrease your sense of stress when considering managing this condition. The very best thing to do is to seek out professional assistance, be gentle with yourself, and take it one step at a time.
Additionally, there are four steps that you can put into practice to assist with your recovery:
1. Set Realistic Expectations
Body dysmorphic disorder is a serious condition which impacts most areas of a person’s life. Setting realistic expectations about what treatment will achieve and how long that may take will help to manage feelings of self-doubt and frustration with the process. At the onset of therapy, it is helpful to have a discussion with your counselor and psychiatrist about what to expect and the length of treatment predicted so that you are prepared.
2. Reduce Stress
Anytime a person is tackling a major life change, stress is bound to be a part of it. Even positive changes bring about stress. Adhering to a routine that is designed to reduce and manage stress is crucial. Identify activities that lead to relaxation and a sense of fulfillment while undergoing treatment for body dysmorphic disorder or any other mental health concern. A few examples are journaling, yoga, moderate exercise, meditation, and practicing mindfulness.
3. Find Healthy Alternatives
Establishing healthy alternative behaviors to the rituals associated with body dysmorphic disorder is an important step. Replacing positive self-statements for the negative ones, engaging in relaxation and meditation when feeling anxious, and practicing self-care when tempted to treat your body in a harmful way are all examples of healthy alternatives.
4. Control Stimuli
Stimulus control involves managing potential triggers while learning coping skills to deal with them. Suggestions are things such as removing mirrors from your home, ditching scales, and avoiding harmful social media sites that lead to comparison to others.
