Understanding Body Dysmorphic Disorder

There are a number of factors that make people more likely to develop BDD. One is childhood experiences that can make someone feel ‘different’. Abuse, appearance-related teasing and bullying are common examples, as are visible problems like acne.  

Also, we have some evidence that individuals with BDD are more likely to have a good eye for detail and be less good at ‘global’ visual processing. It also seems that many individuals with BDD have higher levels of sensitivity to aesthetics in general; for example, they are more likely than other clinical groups to have had training in art or design.

The difference between BDD and vanity is huge. BDD involves shame, disgust and despair about one’s appearance. The motivation for looking in the mirror in BDD is related to things like wanting to camouflage or conceal perceived flaws or scrutinising to try and work out if there is anything that can be done to improve them. Vanity is more about being proud of one’s appearance – essentially the opposite. In fact, for many individuals with BDD, a fear of being seen as vain or superficial can be an obstacle to seeking help. BDD affects around two per cent of the population. Readers might find these papers of interest:

www.bdd-info.nl/Mirror-gazing-in-BDD.pdf

https://bpspsychub.onlinelibrary.wiley.com/doi/abs/10.1111/j.2044-8260.2012.02032.x

It’s usually very distressing and debilitating. A very large number of individuals with BDD consider suicide. People living with the condition feel ugly and ashamed of aspects of their appearance. They spend many hours affected by a distressing preoccupation with imagined or minor flaws. The most common areas of concern are facial features such as skin, hair, nose, eyes, chin, and teeth – but it can be any area of the body, including the genitals. 

The preoccupation causes clinically significant levels of distress such as shame, anxiety and disgust. In response, people with BDD camouflage their perceived flaw by covering it with clothing or using excessive amounts of make-up. They may also compare themselves to others, or against a more ideal version of their appearance in their mind. 

BDD often has an impact on important areas of life and many people with BDD find themselves single, unable to study or work, or even housebound. For a good insight into the lived experience of individuals with BDD, I recommend a book called Reflections on Body Dysmorphic Disorder compiled and edited by Nicole Schnackenberg and David Petro:

https://bddfoundation.org/information/helpful-resources/books-by-people-with-bdd/

When an individual has a clearly observable difference in their appearance such as excess skin following weight loss (bariatric) surgery, a certain amount of distress is, of course, understandable. What’s important to understand is just how extreme and rigid the levels of body shame can be in BDD. 

Rarely, someone with appearance-related adjustment (who does not have BDD) would spend anywhere near as many hours a day preoccupied or be as acutely distressed (or at least for that acute distress to last as long). Further, if the person with excess skin has that skin reduced surgically, it’s likely their body image would improve. If an individual with BDD seeks a surgical solution to their perceived flaw it’s highly unlikely that they will feel better about the way they look.

Muscle dysmorphia is a sub-diagnosis of BDD, sometimes called ‘bigorexia’ in the media. It relates to the individual being worried that their body build is too small or not muscular enough. Having plenty of lean, well-defined muscle is associated with the current ideals around the male masculine body. However, while it’s less common, women can indeed suffer from muscle dysmorphia.

Orthorexia, in which the individual is preoccupied with eating only healthy foods, can be indirectly linked to BDD. In these cases, the person with BDD may hope that avoiding certain foods will reduce their perceived flaw in some way (or prevent it from worsening). For example, individuals with BDD who are anxious about redness in their facial skin might avoid spicy foods.

The main psychological treatment is Cognitive Behavior Therapy, specific to BDD. This involves building a good formulation with the patient and helping them to reduce preoccupation, improve mood and regain functioning. The emphasis is on supporting the patient to drop safety-seeking behaviors (such as checking and camouflaging with clothing or make-up) and face feared/avoided situations. Like OCD, high doses of SSRI antidepressants have also been shown to be helpful. 

Here is a good review of current treatment approaches for BDD:

www.ncbi.nlm.nih.gov/pmc/articles/PMC7846290/

Using a case-series design we found that imagery rescripting as a brief, standalone treatment can be helpful for some patients. This helps patients to update or modify images from aversive memories that are connected to appearance distress.

The main tip to individuals who have BDD is to test out treating the problem ‘as if’ it’s a worry, shame and preoccupation problem, and stop treating their concern as an appearance problem. This might seem obvious, but it’s a substantial shift requiring significant courage. It means dropping safety-seeking behaviors like avoidance, mirror-checking, banning researching or seeking cosmetic and/or dermatological treatments and stopping concealing and camouflaging. 

Stopping mental activities like comparing, or vigilance for ridicule and rejection is also important. Alongside this, it’s essential to start reclaiming any neglected or avoided parts of life, like socialising, dating, work, exercise, family, hobbies and education. The aim is to treat yourself like a complex human being (looking after your hopes, dreams and values) and not like you’re an aesthetic object to be scrutinised. 

It can help to be well-informed on BDD and we recommend books like The Broken Mirror by Katherine Philips and Overcoming Body Image Problems including BDD by David Veale, Rob Willson and Alex Clarke.

https://bddfoundation.org/information/helpful-resources/self-help-books-for-bdd/

The website of the BDD Foundation (the only charity in the world exclusively devoted to people affected by BDD) is a rich resource for both members of the public and clinicians.

I’m not an expert in gender dysphoria (GD), but it’s clear that GD and BDD are very different. It’s true to say that both problems involve great dissatisfaction with appearance, but dissatisfaction in GD extends far beyond aesthetic concerns. It’s important to note that most individuals with BDD are not helped by surgical interventions and most regret having the operation. Conversely, the data on gender reassignment surgery suggest that the majority of individuals with GD are helped by the intervention and only a small number of people experience regret. People with BDD are highly likely to feel more satisfied with their appearance with the appropriate psychological help. 

Kohls and Roessner (2022) is an interesting starting point for further reading: https://acamh.onlinelibrary.wiley.com/doi/full/10.1111/jcpp.13717

While perfectionism can be a factor for some people with BDD, most mainly want to be normal and not stand out. BDD is seen as an OCD spectrum disorder and the two conditions do share several features (many hours a day worrying and checking, for example). However, BDD also shares several features with social anxiety disorder, such as high levels of self-consciousness and fear of ridicule.