Body Dysmorphia: Signs, Symptoms, & Treatments

What Is Body Dysmorphia?

Body dysmorphia involves a distorted body image, where someone doesn’t have an accurate view of their own body. There are varying degrees of distortion based on the discrepancy between reality and perception. The most severe of these cases is a condition called body dysmorphic disorder.

Who Experiences Body Dysmorphia?

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 of body dysmorphia among men and women is nearly equal with numbers in women being only slightly higher.²

As people age, body dysmorphia becomes less likely, but 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.

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. If someone is constantly calling themselves or certain parts of their body “ugly” or “gross,” or if they’re continuously body-checking and going to appointments related to changing aesthetic elements of their body, these could be signs of body dysmorphia.

Calling Themselves Ugly

People with body dysmorphia 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. More common in males, there is a condition called muscle dysmorphia, in which the person perceives that they are not lean or muscular enough.

Spending Lots of Time on Their “Flaws”

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. They 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.

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 people have some insight into their problematic behaviors while others do not have much at all.

The symptoms of body dysmorphia may include:

• Body checking
• Hygiene/grooming routines that take a great deal of time
• Avoiding mirrors
• Skin picking
• Obsessive thoughts about body image/appearance
• Seeking reassurance about appearance
• Obsessive thoughts about the fear of smelling bad (olfactory reference syndrome)
• 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, or educational issues due to body image concerns
• Financial issues related to spending so much on 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)

What Causes Body Dysmorphia?

As with most conditions, there is rarely one cause or reason that someone develops body dysmorphia. There are neurobiological, psychological, and sociocultural theories as to the origin of body dysmorphic disorder. It’s 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.

Causes or triggers of body dysmorphia include:

• A family history of appearance-related disorders, depression, anxiety disorders, or obsessive-compulsive disorder (OCD)
• Teasing or bullying related to appearance
• Perfectionistic traits
• Societal pressures to meet unrealistic standards of beauty/emphasis placed on beauty

Common Comorbidities With Body Dysmorphia

Eating disorders, social anxiety disorder (social phobia), and OCD are common co-occurring conditions with body dysmorphic disorder. Rates of comorbid personality disorders in body dysmorphic disorder are high, with avoidant personality disorder being the most common.

Associated traits with body dysmorphia include:³

• Low self-esteem 
• High levels of neuroticism
• Introversion
• Unassertiveness
• Social anxiety and inhibition
• Rejection sensitivity
• Perfectionism

Body Dysmorphia & Eating Disorders

Several eating disorders are characterized by a disturbance in body image. Anorexia nervosa and bulimia nervosa are closely related to body dysmorphic disorder due to the person’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 they perceive to be flawed, but not necessarily overweight.

In the case of an eating disorder, the person perceives themselves to be overweight or fears gaining weight despite either being of average size or even considerably underweight. These patients suffer from a distorted body image as with those who have body dysmorphic disorder, but people with body dysmorphic disorder are often focused on specific features such as their nose, their complexion, or their hair.

Body Dysmorphia & Anxiety or Depression

A person who believes they have defects in their appearance are generally quite self-conscious and may develop social anxiety disorder. This can lead to isolation and loneliness, and in the most severe cases, this condition may lead to depression or even suicide.

Studies report that more than 70% of those with body dysmorphic disorder also struggle with social anxiety and/or depression.⁴ 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.⁵

Body Dysmorphic Disorder & Obsessive-Compulsive Disorder (OCD)

Body dysmorphic disorder and 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.

Someone with OCD may engage in body checking or checking to ensure doors are locked, the stove has been turned off, or that they didn’t forget some other important task. With body dysmorphic disorder, the focus is entirely on some aspect of their appearance.

Body Dysmorphic Disorder & Personality Disorders

The most common personality disorder observed in the body dysmorphic disorder population is avoidant personality disorder.¹ 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 they need to avoid social interaction.

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. Rather, it’s listed under Obsessive-Compulsive and Related Disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM-V).⁶

The primary criteria for diagnosing body dysmorphic disorder are:

1. A preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or seem slight to others
2. 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 person 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, people 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.

Body Dysmorphia Treatment

Body dysmorphic disorder can be successfully treated with intervention. Treatment consists of medication, therapy, or a combination of both. One effective therapeutic option is known as cognitive behavioral therapy (CBT). Antidepressant medication (SSRI’s) is another common approach to dealing with body dysmorphic disorder.⁴

Therapy for Body Dysmorphia

Several studies have found that CBT has successfully reduced the symptoms of body dysmorphic disorder and related conditions like depression. It’s 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 dysmorphia include:

• Cognitive behavioral therapy for eating disorders (CBT-E): CBT-E 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 and response prevention (ERP): ERP is a type of CBT designed to assist a patient to gradually face that which they’re 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.

Medication for Body Dysmorphic Disorder

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 reduce obsessive thoughts and compulsive behaviors characteristic of BDD.⁷

Studies have shown that about two-thirds to three-quarters of people 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).⁷

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.⁷

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

You will need to know how to choose 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 therapist 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 primary care physician.

How to Get Help for a Child With Body Dysmorphia

If you suspect your child is struggling with body dysmorphic disorder, it’s important to have them evaluated by a professional. Online resources are available to assist you in seeking out a qualified professional. If you’re unable to locate a qualified therapist through an online directory, your insurance carrier should be able to provide 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 experience 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’s important to encourage your child to participate in treatment and let them know that there is hope for them to get better with assistance. Let them know that you’re there to assist them along the way, and you’ll be participating in family therapy with them.

4 Ways to Manage Living With Body Dysmorphia

Living with body dysmorphia can seem like a daunting task, but there are ways to decrease your sense of stress when considering managing this condition. The very best things to do are to seek out professional assistance, be gentle with yourself, and take it one step at a time.

Here are four steps to assist with your body dysmorphia recovery:

1. Set Realistic Expectations for Yourself Throughout Recovery

Body dysmorphic disorder 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’s helpful to have a discussion with your counselor and psychiatrist about what to expect and the length of treatment predicted so you’re prepared.

2. Reduce Your Stress Levels

Anytime a person tackles a major life change, stress is bound to be a part of it. Even positive changes bring about stress. Adhering to a routine that’s 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. Examples are journaling, yoga, moderate exercise, meditation, and mindfulness.

3. Find Healthy Alternatives to Your Checking Behaviors

Establishing healthy alternative behaviors to the rituals associated with body dysmorphic disorder is an important step. Replacing negative self-talk with positive statements, 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 & Triggers

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. Social media and eating disorders have a particularly volatile relationship.