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What is Body Dysmorphic Disorder & How Do You Know If You Have (BDD)?

What is Body Dysmorphic Disorder & How Do You Know If You Have (BDD)?

Body Dysmorphic Disorder is a mental disorder where individuals are preoccupied or obsessed with one or more perceived flaws in their appearance.

Body Dysmorphic Disorder

What does it mean to have body dysmorphic disorder (BDD)? Photo (Shutterstock)

Have you ever looked in a mirror and became obsessed that one of your eyes is slightly larger than the other? Or been fixated that your tooth may be a little crooked? Now, imagine that this imperfection is all that you saw every single time that you looked in a mirror.

And, that this flaw is the only thing others think about when they look at you. When you become consumed by these thoughts and feelings, and they begin to cause problems in your daily life, you may be experiencing body dysmorphic disorder.

Body dysmorphic disorder (BDD) is considered to be a mental disorder. People who have body dysmorphic disorder become obsessed and/or preoccupied with an imagined defect or some tiny aspect that they see as a flaw in their appearance[1].

These obsessive and controlling thoughts can lead the individual to spend excessive amounts of time trying to cover or conceal the flaw, to seek verbal approval of his/her looks (even though the person is not likely to believe what people say), and to withdraw from social situations.

Because these thoughts are so intrusive, suicidal ideations tend to frequently accompany body dysmorphic disorder as well as higher rates of suicide.

What is Body Dysmorphic Disorder (BDD)?

In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), body dysmorphic disorder is characterized under the chapter of “Obsessive-Compulsive and Related Disorders[2].” BDD is a mental disorder where individuals are preoccupied or obsessed with one or more perceived flaws in their appearance.

This preoccupation typically focuses on one or more body areas or features, such as their skin, nose (size or shape), teeth, or hair. The skin is frequently the main focus for people with body dysmorphic disorder—with a preoccupation on wrinkles, scars, acne, or paleness.

Fixation on body hair is also common and may include anxiety over hair loss, characteristics of hair, and/or unwanted facial hair. Some people with BDD may show concern about a perceived asymmetry of a body part. Yet, anybody area or part can be the subject of a person’s obsession.

A systematic review of body dysmorphic disorder reveals that BDD affects approximately 1.9 percent of the population and has a higher prevalence among females rather than males[3]. Body dysmorphic disorder typically starts in adolescence (but can begin at any age). This disorder causes people distress and functional impairment. It may also lead to the inappropriate use of plastic surgery and cosmetic treatments[3].

BDD is characterized by two types of obsessive behaviors (these are behaviors that a person may be spending hours each day engaging in):

1. Persistent thinking about a perceived flaw (that is usually imagined, or if present, barely noticeable).

2. Compulsive checking of the perceived flaw (such as spending a lot of time in front of the mirror) and obsessively trying to minimize the appearance of the perceived flaw (like trying to cover it up with makeup or clothing).

Individuals with body dysmorphic disorder may often try to hide symptoms due to being embarrassed and ashamed and/or fear being negatively judged.

In fact, many people with body dysmorphic disorder report intense feelings of shame and low self-esteem[4]. They may feel self-hatred due to beliefs that they are unacceptable and unlovable.

People affected by BDD are convinced that others make fun of their appearance, which can cause them to isolate themselves from social interactions. Because of this, approximately 80 percent of people with body dysmorphic disorder report having experienced suicidal thoughts—with one in four individuals actually attempting suicide. The rate of suicidal thoughts for people affected by BDD is 10 to 25 times higher than that of the general population[5].

Subtypes of Body Dysmorphic Disorder

There are two subtypes of body dysmorphic disorder: Muscle dysmorphia and BDD by proxy[6]:

1. Muscle Dysmorphia: A preoccupation with the idea that your body build is too small or that you are not muscular enough. The person may over-value his/her appearance and believe that others negatively evaluate his/her appearance. Muscle dysmorphia is different from an eating disorder or healthy fitness/bodybuilding because the person has an inaccurate perception and obsession with body image. His/her self-esteem is rested almost entirely on building muscle whereas other factors (like intelligence, sense of humor, relationships, etc.) are not important.

2. BDD By Proxy: A preoccupation with the perceived imperfections with another person’s appearance. This person is often a spouse/partner but could be a parent, child, sibling, or stranger. The individual will often engage in repetitive, compulsive behaviors to reduce anxiety (or guilt about having this preoccupation) and to improve the person’s appearance.

Causes of Body Dysmorphic Disorder

It is not well understood as to what causes body dysmorphic disorder. There appear to be both biological and environmental causes. Some research suggests that brain chemicals, called neurotransmitters (specifically serotonin) could play a role in causing BDD—since this helps to regulate mood.

Body image fixation is also more common in people whose biological family members also have this disorder, so this suggests that there could be a genetic cause as well.

Neuroanatomic (the study of the structure and organization of the nervous system) findings also seem to show some evidence that body dysmorphic disorder may have biological causes.

For example, there has been a research that found that the orbitofrontal cortex and anterior cingulate cortex volumes of people with BDD are significantly smaller than those without BDD—this means that the brains of individuals with body dysmorphic disorder contain more white substance as compared to people who do not have this disorder[7].

Fixation on one’s negative body image could also be driven by the image-obsessed culture that we live in. The constant onslaught of unrealistic, idealized physical perfection and expectations of beauty that are glamorized in our culture is thought to be an aggravating factor of BDD.

Additionally, it appears that certain factors seem to increase one’s risk of developing or triggering body dysmorphic disorder. These include childhood teasing, physical or sexual abuse, low self-esteem, emotional conflict during childhood, and/or parents and others who were critical of the person’s appearance.

Signs and Symptoms of Body Dysmorphic Disorder (BDD)

Many people may be unhappy with some part of the way they look. Yet, if the amount of time and energy you spend thinking about your inferior body part interferes with your day-to-day functioning or causes you substantial emotional distress, you may be experiencing body dysmorphic disorder.

Common signs and symptoms of BDD to look for include[1]:

  • Preoccupation with physical appearance
  • Belief that one has an abnormality or defect in appearance that makes his/her ugly
  • Constantly asking for reassurance that the defect is not visible or too obvious
  • Engaging in repetitive and time-consuming behaviors, such as looking in a mirror, picking at the skin, excessive grooming, and trying to hide or cover up the perceived defect (such as with the use of makeup or clothing)
  • Feeling extremely self-conscious—does not want to go out in public, refuses to appear in pictures, avoiding mirrors altogether, and/or feeling anxious when around other people
  • Believes that others take special notice of his/her appearance in a negative way and constantly compares appearance to that of others.
  • Repeatedly measuring or touching the perceived flaw
  • Repetitively consults with medical specialists, such as plastic surgeons or dermatologists, to find ways to improve his/her appearance and/or has frequent cosmetic procedures with little satisfaction

Common areas of concern for people with body dysmorphic disorder may include:

  • Hair – Head or body hair, an absence of hair (baldness), unwanted hair.
  • Facial features – Most often involving the nose, but may also include the shape and size of any feature (including eyes, teeth, ears, smile, and lips).
  • Skin imperfections – Such as wrinkles, scars, moles or freckles, acne, paleness, and blemishes.
  • Body features – Obsessing about weight or muscle size/tone, thighs, buttocks, penis size, breast size, and/or the presence of certain body odors.
  • Asymmetry of a body part

Diagnosis Criteria for Body Dysmorphic Disorder

Diagnosing body dysmorphic disorder can be very hard because of the shame associated with this disorder. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) has specific criteria associated with this disorder. Thus, in order to be diagnosed with BDD, the following DSM-5 criteria must be met[2]:

  • Appearance Preoccupations: The individual must be preoccupied with one or more nonexistent or slight defects or flaws in their physical appearance. Preoccupation is usually demonstrated as thinking about the perceived defects for at least an hour a day. Individuals who are distressing or preoccupied with obvious appearance flaws (such as those that are easily noticeable/clearly visible at a conversational distance) should not be diagnosed with BDD.
  • Repetitive Behaviors: The person must perform repetitive, compulsive behaviors in response to the concerns with his/her appearance. These compulsions can be behavioral (and thus observed by others)—such as checking in a mirror, excessive grooming, skin picking, reassurance-seeking, or clothes changing. Other BDD compulsions are mental acts. This can include comparing one’s appearance with that of other people.
  • Clinical Significance: The preoccupation must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. This criterion helps to distinguish body dysmorphic disorder, which requires treatment, from more normal appearance concerns.
  • Differentiation from an Eating Disorder: If the individual’s preoccupation focuses on being too fat or weighing too much, the clinician must determine if these concerns are not better explained by an eating disorder. So, if the person’s only appearance concern focuses on excessive fat or weight, and the person’s symptoms meet the diagnostic criteria for an eating disorder, then he or she should be diagnosed with an eating disorder.

A person may be diagnosed with body dysmorphic disorder if criteria for an eating disorder are not met, and the person is of normal size but is obsessed with being fat or over-weight. A person can be diagnosed with both an eating disorder and BDD (if the preoccupation in appearance focuses on concerns other than weight or body fat).

Treatment for Body Dysmorphic Disorder

Body dysmorphic disorder treatments typically include medication, therapy, or a combination of both. The goal of treatment is to improve the person’s quality of life and overall day-to-day functioning.

Treatment for body dysmorphic disorder is also aimed at reducing the distress associated with one’s perceived flaw and decreasing the compulsive behaviors that are associated with BDD.

  • Therapeutic Treatment for Body Dysmorphic Disorder: includes the use of cognitive-behavioral therapy (CBT). CBT is the only type of therapy that research consistently shows as being effective for the treatment of BDD. Cognitive-behavioral therapy focuses on changing the thinking and behavior of an individual with body dysmorphic disorder. The goal is to correct the person’s false belief about his/her perceived flaw and to minimize compulsive behavior. The therapist tries to help the person identify unhealthy appearance-related thoughts and to replace them with more realistic beliefs. Through exposure and response prevention, the person is also taught strategies to decrease compulsive behaviors when faced with certain emotional or environmental triggers[8].
  • Medical Treatments for BDD: currently, there are no medications that have been FDA-approved for treating body dysmorphic disorder. However, clinical experience and research suggest that certain antidepressant medications, known as selective serotonin reuptake inhibitors (SSRIs), are and effective and safe treatment for many who are affected by BDD[9]. Selective serotonin reuptake inhibitors (SSRIs) are commonly used for the treatment for body dysmorphic disorder. Even though these medications are classified as antidepressants, they appear to help lessen the obsessive thoughts and compulsive behaviors associated with BDD. Certain antipsychotic medicines (like olanzapine, aripiprazole, and pimozide)—used alone or in conjunction with an SSRI also show promise in effectively treating body dysmorphic disorder.
  • Neurostimulation Techniques: transcranial magnetic stimulation, electroconvulsive therapy, and targeted neurosurgery may offer an innovative direction for the treatment of body dysmorphic disorder—especially in individuals who are not experiencing improvement from medication and therapy. Repetitive transcranial magnetic stimulation involves the use of focused electromagnetic fields to stimulate specific regions within the brain and may prove to be helpful in the treatment of BDD. This modality may be successful because corticostriatal circuits are known to play a role in body dysmorphic disorder, but additional research on this treatment approach is still needed[10].
  • Family Therapy: having the support of one’s family is also a crucial aspect of BDD treatment success. It is important that family members understand body dysmorphic disorder and learn to recognize its signs and symptoms. Building a strong social/familial support team can be a source of invaluable help for a person affected by BDD.

It should be pointed out that many people with body dysmorphic disorder pursue surgical treatment options, such as plastic surgery, cosmetic procedures, and hair implants in hopes of “fixing” their perceived flaws.

There is no evidence that these actions are helpful in the treatment BDD. It seems that this type of solution rarely improves body dysmorphic disorder symptoms and may actually make symptoms worse.

In fact, following a cosmetic treatment, it is not uncommon for a person with BDD to develop a new area of concern (for example, changing from a concern about freckles to now being concerned about nose size) and/or report an increase in his/her preoccupation of appearance.

This occurs because ongoing a cosmetic procedure may correct the actual appearance of the flaw but does not address the person’s obsessive/compulsive thoughts and actions.

Body Dysmorphic Disorder Outlook

Body dysmorphic disorder is a real mental disorder. It is important to distinguish that the appearance preoccupations felt by people affected by BDD are much more serious than having a mere vanity problem.

People who have body dysmorphic disorder typically feel extreme shame and embarrassment and are at greater risk of attempting suicide. Try to learn to recognize the signs of BDD because early identification and treatment of this disorder often yields the best results.

Also, the good news is that if you receive and follow a treatment regimen, the outlook is promising for people with body dysmorphic disorder. If you have been prescribed medication, it is important to note that you may need to try different medications or dosages before you find the right fit for you. Always follow your doctor’s recommendations and don’t hesitate to ask any questions you may have about them.

People who have a strong support network also tend to do better over time. And if you are affected by body dysmorphic disorder, educate yourself. Pay special attention to the certain triggers that increase your symptoms, and make sure you talk about these with your therapist and/or doctor.

Feedback:

References

[1] Hardardottir H,Hauksdottir A, Bjornsson AS. Body dysmorphic disorder: Symptoms, prevalence, assessment and treatment. Laeknabladid 2019 March; 105(3):125-131. https://www.ncbi.nlm.nih.gov/pubmed/30806630
[2] American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (5th Ed.). Washington, DC: American Psychiatric Publishing. https://books.google.com/books?id=-JivBAAAQBAJ&lpg=PA1&dq=dsm-5&pg=PT432#v=onepage&q=dsm-5&f=false
[3] Veale D, Gledhill LJ, Christodoulou P, Hodsoll J. Body dysmorphic disorder in different settings: A systematic review and estimated weighted prevalence. Body Image, 2016 September; 18:168-186. https://doi.org/10.1016/j.bodyim.2016.07.003
[4] Weingarden H, Shaw AM, Phillips KA, Wilhelm S. Shame and defectiveness beliefs in treatment seeking tatients with body bysmorphic disorder. The Journal of Nervous and Mental Disease, 2018 June; 206(6), 417-422. https://www.ncbi.nlm.nih.gov/pubmed/29557815
[5] Phillips KA. Suicidality in body dysmorphic disorder. Primary Psychiatry, 2007 Dec; 14(12): 58–66. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2361388/
[6] Cuzzolaro M. (2018) Body Dysmorphic Disorder and Muscle Dysmorphia. In: Cuzzolaro M., Fassino S. (eds) Body Image, Eating, and Weight. Springer, Cham. https://doi.org/10.1007/978-3-319-90817-5_5
[7] Soler PT, Ferreira CM, da Silva Novaes J, Fernandes HM. Body dysmorphic disorder: Characteristics, psychopathology, clinical associations, and influencing factors. Pathophysiology-Altered Physiological States, 2018 Nov. https://www.intechopen.com/books/pathophysiology-altered-physiological-states/body-dysmorphic-disorder-characteristics-psychopathology-clinical-associations-and-influencing-facto
[8] Wilhelm S, Phillips KA, Greenberg JL, O'Keefe SM, Hoeppner SS, Keshaviah A, Sarvode-Mothi S, Schoenfeld DA. Efficacy and posttreatment effects of therapist-delivered cognitive behavioral therapy vs supportive psychotherapy for adults with body dysmorphic disorder: A randomized clinical trial. JAMA Psychiatry, 2019 Apr 1;76(4):363-73. https://www.ncbi.nlm.nih.gov/pubmed/30785624
[9] Dong N, Nezgovorova V, Hong K, Hollander E. Pharmacotherapy in body dysmorphic disorder: Relapse prevention and novel treatments. Expert Opinion on Pharmacotherapy, 2019 July ;20(10):1211-9. https://www.tandfonline.com/doi/abs/10.1080/14656566.2019.1610385
[10] Hong K, Nezgovorova V, Hollander E. New perspectives in the treatment of body dysmorphic disorder. F1000Research, 2018;7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5871801/
[11] Body dysmorphic disorder. In: Diagnostic and Statistical Manual of Mental Disorders DSM-5. 5th ed. Arlington, Va.: American Psychiatric Association; 2013. http://www.psychiatryonline.org. Accessed March 24, 2016.
[12] Phillips KA. Body dysmorphic disorder. In: Gabbard's Treatment of Psychiatric Disorders. 5th ed. Arlington, Va.: American Psychiatric Association; 2014. http://psychiatryonline.org/doi/full/10.1176/appi.books.9781585625048.gg22. Accessed March 24, 2016.
[13] Body dysmorphic disorder. Merck Manual Professional Version. http://www.merckmanuals.com/professional/psychiatric-disorders/obsessive-compulsive-and-related-disorders/body-dysmorphic-disorder Accessed March 24, 2016.
[14] Veale D, et al. Body dysmorphic disorder. BMJ. 2015;350:h2278.
[15] Fang A, et al. Body dysmorphic disorder. Psychiatric Clinics of North America. 2014;37:287.
[16] Greenberg JL, et al. Cognitive-behavioral therapy for adolescent body dysmorphic disorder: A pilot study. Behavior Therapy. 2016;47:213.
[17] Body dysmorphic disorder. Anxiety and Depression Association of America. http://www.adaa.org/understanding-anxiety/related-illnesses/other-related-conditions/body-dysmorphic-disorder-bdd. Accessed March 24, 2016.
[18] Sawchuk CN (expert opinion). Mayo Clinic, Rochester, Minn. April 12, 2016.
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Dawn Stacey, PhD, LMHC

She is a licensed mental health counselor and completed her Ph.D. in psychology from Capella University....

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