- Body Dysmorphic Disorder (BDD)
- Do you spend a lot of time focusing on your physical flaws? Have these thoughts interfered with your overall wellbeing? You may have body dysmorphic disorder.
- Signs and symptoms of body dysmorphic disorder
- Muscle dysmorphia: a common subtype of BDD
- Causes of body dysmorphic disorder
- Getting help for body dysmorphic disorder
- If your child has body dysmorphic disorder
- Self-help for body dysmorphic disorder
- Overview of CBT for BDD and its empirical support
- Assessment, motivational assessment, and psychoeducation
- Cognitive strategies
- Exposure and ritual prevention (E/RP)
- Perceptual retraining
- Brief overview over additional modules
- Relapse Prevention
- Body Dysmorphic Disorder Statistics and Facts
- Co-Occurring Disorders
- Risk Factors
- Knowing the First Steps to Take
- Supporting and Encouraging Your Child
- What to Do When Things Escalate
- When Individual Therapy isn’t Enough
- Taking Care of Yourself
- Managing Day-to-Day Life With Body Dysmorphic Disorder
- Body Dysmorphia
- Observing Signs and Symptoms
- Causes and Risks
- Treatment Options
- Healing Is Possible
- Body Dysmorphic Disorder
- What Is Body Dysmorphic Disorder?
- What Are the Signs & Symptoms of Body Dysmorphic Disorder?
- How Is Body Dysmorphic Disorder Diagnosed?
- How Is Body Dysmorphic Disorder Treated?
- What Causes Body Dysmorphic Disorder?
- What’s It Like for Someone With Body Dysmorphic Disorder?
- What if I Have Body Dysmorphic Disorder?
- Living with Body Dysmorphic Disorder (BDD)
- The Damage Goes Beyond Just Feeling Bad About Your Body
- The Red Flags for Body Dysmorphic Disorder
- There Are Many Signs That Someone May Have BDD
- Why These Signs Should be Taken Seriously
- Assistance Is Available for BDD
Body Dysmorphic Disorder (BDD)
Do you spend a lot of time focusing on your physical flaws? Have these thoughts interfered with your overall wellbeing? You may have body dysmorphic disorder.
We all have days when we feel insecure about a certain aspect of our appearance or think we don’t look our best. But if you find yourself spending a lot of time obsessing over, hiding, or trying to correct what you see as flaws, you may have body dysmorphic disorder (BDD). This condition affects both men and women of any age, although most cases begin in adolescence.
If you have body dysmorphic disorder, you may feel like there’s an uncrossable divide between your perception of your body and what your family and friends tell you. Even though you view certain aspects of your appearance as abnormal or ugly, the reality is, others don’t see you the same way. While you know, objectively, that your loved ones are correct, you can’t escape the stress and anxiety your body image causes you. If this sounds like you, know that you’re not crazy, self-obsessed, or vain. BDD is a real psychological disorder that can improve with treatment. The first step is recognizing the signs.
Common features people with BDD focus on
With body dysmorphic disorder, any aspect of the face or body is fair game, but the most common things people focus on are:
- facial features, such as the nose
- skin (moles, freckles, scars, acne)
- muscle size or tone
- size and shape of genitalia or breasts
- hair (including facial and body hair)
You may feel like there’s nothing you can do to feel better about the way you look—at least short of plastic surgery or a magic wand. But with the right coping techniques, you can develop the ability to “step outside yourself” and view your appearance in a more holistic and positive way.
Body dysmorphic disorder vs. normal insecurities
It’s normal to fixate on a large pimple or the size or your thighs from time to time. But if your preoccupation with your appearance causes you significant distress or interferes with your day-to-day life, those are signs that you’re dealing with a bigger problem. When you look in the mirror, is there a particular feature that jumps out at you that you’d like to change? Do you feel the need to seek constant reassurance from your family or friends, even though you don’t believe them when they tell you it looks fine? If the drive to improve your body or erase a particular “flaw” dominates your thoughts and actions, you may have BDD.
Signs and symptoms of body dysmorphic disorder
If you suffer from body dysmorphic disorder, you may:
Repeatedly check your reflection in the mirror or stay away from mirrors altogether. Do you check your reflection compulsively, even when you’re alone? On the other end of the spectrum, do you avoid mirrors because seeing your reflection causes you distress?
Isolate yourself so others will not see the offending body part. This includes avoiding work, school, social events or public places out of stress over others seeing you. Or leaving the house only at night or at times where you’re less likely to see other people.
Spend a lot of energy camouflaging or covering up the perceived flaw. You may wear strategic clothing, makeup, or accessories to disguise the area you’re worried about. You may also position your body in a way to minimize the “flaw.” Or cover it with hats, scarves, baggy pants, etc. or wear clothing inappropriate for the weather.
Go to lengths to avoid having your picture taken. Do you avoid social gatherings, such as birthday parties, where photos will be taken? Do you police the photos others take and post to social media, making sure your “flaw” isn’t visible?
Undergo plastic surgery, sometimes more than once, to correct the perceived imperfection. Do you believe that plastic surgery will solve all of your problems? Have you already undergone a procedure but are still not happy with the results?
Pick your skin compulsively, leading to injury. Skin picking is also a symptom of Obsessive-Compulsive Disorder (OCD). However, if it is done with the intention of improving appearance, it more likely points to BDD.
Obsess over the “flawed” body part and what others think about it. Do you spend a lot of time and energy thinking about your flaws? Do these flaws make you feel depressed, anxious, ashamed, or profoundly ugly? Do you worry about what others are seeing and thinking when you’re socializing?
Seeking reassurance. Do you repeatedly ask your close friends or family members if you look okay, or about the appearance of the feature you dislike? Do you still feel bad and unattractive, despite their reassurance?
Compare yourself negatively to others. This includes celebrities and photos of yourself at a younger age. The focus is on how bad your “flaw” looks in comparison to others.
Feel depressed, anxious, or have suicidal thoughts. This may co-occur with dissatisfaction over a recent cosmetic procedure.
Put a lot of effort into changing the feature, with excessive exercise, weight lifting, or tanning. If you suffer from BDD, you might also feel unhappy with your hair. Do you feel you need frequent haircuts? Do you avoid going out after you’ve had one? You may also use your hair to cover up “imperfections.”
Spend a significant amount on personal grooming. Do you find that a significant amount of your paycheck or allowance goes toward products and services designed to enhance your looks? But then, do you quickly grow disillusioned with them and think you can find a better treatment? If so, your compulsion may point to a larger issue than simply wanting to look your best.
Muscle dysmorphia: a common subtype of BDD
Muscle dysmorphia is a subtype of body dysmorphic disorder centered on the belief that your muscles are not large enough. Although this can affect both genders, it is more common in men. Like body dysmorphic disorder in general, it can be difficult to recognize. You might start out feeling accomplished, since often sufferers are applauded for their discipline and commitment to their health. But if you identify with the following symptoms, it may be time to re-evaluate:
- Excessive exercise and weight lifting, often for many hours a day.
- A fixation on counting calories
- Avoiding restaurants due to an imagined lack of control over food options.
- Arranging meals to achieve a “perfect” combination of carbohydrates, fats, proteins, and vitamins.
- Adhering to a rigid meal schedule.
- Either excessively checking or avoiding mirrors and reflective surfaces.
- Wearing multiple layers of clothing to appear bigger
- Using of steroids or other performance enhancing drugs.
- Your self-worth is based exclusively on the size of your muscles
Muscle dysmorphia vs. eating disorders
While sometimes referred to as “bigorexia” or “reverse anorexia,” muscle dysmorphia is not exactly an eating disorder, despite sharing some similarities with one. Although your self-image may drive you to follow a precise, time-consuming diet, the goal is to increase the size of your muscles, rather than lower your body fat. Also, not all sufferers of muscle dysmorphia have disordered eating.
Causes of body dysmorphic disorder
The specific causes of body dysmorphic disorder are unknown. Like most other mental disorders, it is the result of a variety of factors. These include irregularities in brain structure, genetics, and life experiences. Past traumas such as childhood neglect, abuse, or criticisms about your body may all play a role. In a culture that emphasizes youth and a narrow standard of attractiveness, it can be easy to feel inadequate. Certain personality traits, such as anxiety or perfectionism, can also put you at risk for developing BDD.
Getting help for body dysmorphic disorder
If you recognize yourself from the list of symptoms and have decided to seek help, give yourself credit. That itself is a significant step and shouldn’t be taken lightly. Research shows that many people with BDD have seen a dermatologist for ten years before they seek out a mental health professional. You may feel ashamed of your compulsion, fearing that others will label you as “vain” or “self-absorbed” if you ask for help. But like other disorders rooted in anxiety, support is available.
What to expect when seeing a professional
If you’re nervous about starting the treatment process, here’s what you should prepare to discuss with your therapist or psychiatrist:
Psychosocial history: In order to get to the bottom of your condition, a therapist may ask you to discuss any past experiences of bullying, teasing, or abuse. You may want to consider your family’s values, and any perceptions you might have internalized from friends or the media about the “right” way to look.
How your viewpoint has affected your life: Think about any changes that have occurred since you started spending more time correcting the “flaw.” Consider both positive and negative outcomes. Have you lost friends or relationships? Have your grades dropped, or has your performance at work worsened because you don’t have time to focus on other pursuits? On the flip side, have you found that you’re receiving more compliments on your muscle gains or new makeup routine? If so, how does this balance out the compromises you may have made in other parts of your life?
Life and treatment goals: Before your appointment, think about your life goals and how your body fixation has impacted them. With the help of your therapist, you can break the treatment process down into manageable steps. Be prepared to talk about the pros and cons of your journey to recovery. What do you think are your biggest obstacles to accepting yourself, “flaws” and all?
Family support: If your family has expressed concern, you may want to think about including them in your treatment. They can provide your therapist with insight into your life history and current situation. By discussing treatment plans with family members in the home, they can help you recognize and dismantle negative patterns.
Treatment options for body dysmorphic disorder
Treatment for body dysmorphic disorder includes both individual and group therapy as well as medication. If your symptoms are milder, they may improve from either treatment alone, but therapy and medication work together for faster results. This is especially true if you or your loved one is having suicidal thoughts.
Cognitive behavioral therapy (CBT). This is the only psychological treatment for BDD supported by research. It focuses on changing the thought and behavior patterns set off by the condition. Your therapist will help you identify situations that cause anxiety and develop healthier coping mechanisms. Through CBT, you can learn to step outside yourself and view your body through a more objective, and forgiving, lens.
As you progress through treatment, your therapist will guide you through more challenging situations. This process, called habituation, helps rewire the way your brain responds to triggers. You will also learn to identify any avoidance behaviors (like crossing the street to get away from reflective surfaces) and compulsive responses. These could include skin picking or a constant need for reassurance.
Medication for body dysmorphic disorder. Although, in the United States, the Food and Drug Administration hasn’t yet approved any medications that treat BDD specifically, research has shown that serotonin reuptake inhibitors (SSRIs) can be very effective. A form of antidepressant, SSRIs may help ease the obsessive thoughts and behaviors that are hallmarks of BDD. They may also reduce the symptoms of anxiety and depression that often co-occur with BDD. With your mind more at ease, you may also find it easier to engage with CBT.
If your child has body dysmorphic disorder
Body dysmorphic disorder most often begins around age 12 or 13. As a parent, you may at first have trouble differentiating between adolescent insecurities and something more serious. Research shows that BDD is often under-recognized and under-diagnosed. It also shares symptoms with other mental health conditions such as depression, obsessive-compulsive disorder, and social anxiety. The good news is, the treatment plan is often similar and can help with these co-occurring disorders. Here are some ways to support your child or loved one:
Educate yourself about BDD. This disorder is often confusing to those on the outside. In reality, the physical flaws that sufferers are so focused on are actually unnoticeable or very slight. However, it is important not to minimize their pain but rather approach the problem from a place of empathy and understanding.
Nurture a supportive environment to encourage treatment. Spend quality time with your loved one and assure them that you care. Even if they reject your reassurances about their appearance, they will feel your support. Try not to force treatment or make them feel guilty.
Hone your listening skills. Sometimes just letting someone know that you’re willing to lend an ear goes a long way. If they do confide in you, try to withhold judgment and keep your reactions in check. As you encourage them to seek treatment, focus on how they could benefit from the support of a professional who understands the condition, rather than how their behavior worries you.
Take care of yourself. Recognize that your loved one will go through ups and downs as they grapple with their condition. Keep the difficult times in perspective and don’t neglect your own self-care. It may help to see a therapist yourself or join a support group.
Self-help for body dysmorphic disorder
If you have body dysmorphic disorder, you’re often fixated on a particular body part and then find it difficult to control how much you think about it. To practice diverting your attention, try living every day in the present moment. Easier said than done? There are two strategies that may help: mundane task focusing and a more formal meditation practice. These coping mechanisms complement each other. If you incorporate both into your routine, they will start to feel natural.
Mundane task focusing
Many of us go through household tasks on autopilot. When washing the dishes or brushing your teeth, are you really thinking about what you’re doing? Or is your mind wandering, planning ahead for the day or possibly worrying about your appearance? Write down a list of tasks you routinely engage in when your thoughts are most likely to stray.
The next time you vacuum the floor, for example, try practicing mindfulness. Engage your senses and take note of how the vacuum feels against the carpet. What noises do you associate with this job? Do the smells in your home change as move the vacuum through the room?
If you feel your attention slipping, don’t beat yourself up. Just gently bring your mind back to the present moment. Practicing awareness helps bring your focus away from your body and any negative self-talk.
While it may not seem natural at first, meditation gets easier with practice. First, find a comfortable sitting position and check in with your body. Ask yourself, what am I thinking and feeling? What are my body sensations? Spend 30 seconds gathering these impressions without acting on them or trying to push any thoughts away.
Next, close your eyes and direct your focus to your breath. Take note of the way it moves in and out of your body. At this time, try to clear your head. It might help to picture any thoughts as clouds, passing through your mind as they would through the sky. Spend about 1 to 2 minutes doing this.
Next, expand your awareness to the rest of your body. Allow yourself to think and feel without judgment. If you find yourself starting to dwell on certain emotions, gently tell yourself to ‘relax’ or ‘let go.’ Continue this for another 1 to 2 minutes. As you start to grow more comfortable with meditation, you can increase the amount of time you practice. The goal is to center yourself and take your focus off repetitive thoughts about your appearance.
Reducing negative predictions
Once you become more skilled at managing your thoughts, you can use these coping strategies to talk yourself down before you face a triggering situation. This could be anything from a birthday party to a work conference with a room full of strangers.
If you have BDD, you may find yourself defaulting to negative predictions about how a particular event will go. You may start to imagine the worst: that everyone will point and laugh, for example, or that you’ll find yourself sitting alone because nobody wants to associate with you because of your flaw. In truth, though, reality is much less distressing.
The next time you catch yourself spiraling into anxiety, try writing your worst fears down in a thought diary. Once you acknowledge them, try coming up with a more realistic outcome. Instead of thinking, “Nobody will talk to me.” Try, “maybe I will meet someone new and we’ll have an interesting conversation.” It is important though, not to go to the other extreme. Otherwise, you will set yourself up for disappointment. For example, rather than imagining, “everyone will tell me I’m beautiful,” or “I will meet the love of my life,” consider smaller, yet still positive, expectations.
by Andrea Hartmann, PhD, Jennifer Greenberg, PsyD, & Sabine Wilhelm, PhD
Overview of CBT for BDD and its empirical support
CBT models of BDD (e.g., Veale, 2004; Wilhelm et al., 2013) incorporate biological, psychological, and sociocultural factors in the development and maintenance of BDD. The model proposes that individuals with BDD selectively attend to minor aspects of appearance as opposed to seeing the big picture. This theory is informed by clinical observations and neuropsychological (Deckersbach et al., 2000) and neuroimaging findings (Feusner et al., 2007; Feusner et al., 2010). Individuals with BDD also overestimate the meaning and importance of perceived physical imperfections. For example, when walking into a restaurant, a patient with BDD who has concerns about his nose might think, “Everyone in the restaurant is staring at my big, bulbous nose.” Patients are also more likely misinterpret minor flaws (e.g., perceived asymmetry) as major personal flaws (e.g., “If my nose is crooked, I am unlovable”) (Buhlmann et al., 2009; Veale, 2004). Self-defeating interpretations foster negative feelings (e.g., anxiety, shame, sadness) that patients try to neutralize with rituals (e.g., excessive mirror checking, surgery seeking) and avoidance (e.g., social situations). Because rituals and avoidance may temporarily reduce painful feelings they are negatively reinforced and thus maintain maladaptive beliefs and coping strategies.
CBT for BDD typically begins with assessment and psychoeducation, during which the therapist explains and individualizes the CBT model of BDD. In addition, CBT usually includes techniques such as cognitive restructuring, exposure and ritual prevention, and relapse prevention. Some CBT for BDD includes perceptual (mirror) retraining. A modular CBT manual (CBT-BDD; Wilhelm et al., 2013) has been developed to target core symptoms of BDD and to flexibly address symptoms that affect some, but not all, patients. Additional modules might address depression, skin picking/hair plucking, weight and shape concerns, and cosmetic surgery seeking (e.g. Wilhelm et al., 2013). CBT-BDD has been shown to be effective in open (Wilhelm et al., 2011) and randomized control trials (Wilhelm et al., 2014).
Assessment, motivational assessment, and psychoeducation
CBT begins with an assessment of BDD and associated symptoms. Clinicians should inquire about BDD-related areas of concern, thoughts, behaviors, and impairment. It is important to ask specifically about BDD symptoms as it often goes undetected in clinical settings (e.g., Grant et al., 2002) due to embarrassment and shame. Clinicians should be aware of clues in clinical presentation such as appearance (e.g., scarring due to skin picking) and behaviors (e.g, wearing camouflage), ideas or delusions of reference (e.g., feelings that people talk about them, stare at them), panic attacks (e.g., when looking into the mirror), depression, social anxiety, substance abuse and suicidal ideation as well as being housebound. Additionally, differential diagnosis should be clarified in a structured clinical interview including eating disorders, obsessive compulsive disorder, depression, and social phobia. Given the high rates of depression and suicidality in BDD, it is critical to evaluate depression and suicidality at the onset and regularly throughout treatment.
For patients reluctant to try CBT or who hold highly delusional appearance beliefs, the therapist should incorporate techniques from motivational interviewing (MI; Miller & Rollnick, 2003) that have been adapted for the use in BDD (Wilhelm et al., 2013). In a first step, the therapist should empathize with the patient’s body image-related distress instead of directly questioning the validity of the beliefs (“I see that you really suffer because you are so worried because of the way you look. Let’s try to reduce this distress.”). Also, non-judgmental Socratic questioning can be employed (“What might be the advantages of trying CBT for BDD?“). The therapist can also discuss the discrepancy between BDD symptoms and the patient’s goals (“What should your life look like 10 years from now?“). In particular, for patients with poor insight it might be more helpful to address the usefulness of beliefs instead of the validity (e.g., “Are your beliefs preventing you from participating in activities you enjoy?“). MI strategies often need to be used throughout treatment.
Next, the therapist should provide psychoeducation about BDD, such as its prevalence, common symptoms, and differences between body image and appearance. Then, the therapist and patient develop an individualized model of BDD based on the patient’s specific symptoms. Such models include theories of how body image problems develop (including biological, sociocultural and psychological factors) (Wilhelm et al., 2013). It is important to explore factors in the patient’s current life that are serving to maintain body image concerns, including triggers for negative thoughts about appearance, interpretations of these thoughts, emotional reactions, and (maladaptive) coping strategies. This will help to inform the treatment and which specific modules are needed.
Cognitive strategies include identifying maladaptive thoughts, evaluating them, and generating alternative thoughts. Therapists introduce patients to common cognitive errors in BDD, such as “all-or-nothing thinking” (e.g., “This scar makes me completely disgusting”) or “mindreading” (e.g., “I know my girlfriend wishes I had better skin”). Patients are then encouraged to monitor their appearance-based thoughts in and outside of the session and identify cognitive errors (e.g., “Why am I so nervous about riding the subway?” “I know others are staring at my nose and thinking how ugly it looks”. Cognitive distortion: “personalization”). After the patient has gained some skill in identifying maladaptive thoughts and cognitive errors, the therapist can start to evaluate thoughts with the patient (e.g., Rosen et al., 1995; Veale et al., 1996; Wilhelm et al., 2013). While it is often helpful to evaluate the validity of a maladaptive thought (e.g., “What is the evidence others are noticing or judging my nose?”), it can also be beneficial to examine its usefulness (e.g. “Is it really helpful for me to think that I can only be happy if my nose were straight?”; Wilhelm et al., 2013), particularly for patients with poor insight. Once the patient has become adept at identifying and restructuring automatic appearance-related beliefs, deeper level (core) beliefs should be addressed. Common core beliefs in BDD include I’m unlovable” or “I’m inadequate” (Veale et al., 1996). These deeply held beliefs filter a patient’s experiences, and if not addressed, can thwart progress and long-term maintenance of gains. Core beliefs often emerge during the course of therapy. They can also be identified using the downward arrow technique, which involves the therapist asking repeatedly about the worst consequences of a patient’s beliefs (e.g., for the thought “People will think that my nose is huge and crooked,” the therapist would ask the patient, “What would it mean if people noticed your nose was big/crooked?”) until the core belief is reached (e.g., “If people noticed that my nose was big/crooked, they wouldn’t like me and this would mean that I am unlovable.”; Wilhelm et al., 2013). Negative core beliefs can be addressed through cognitive restructuring, behavioral experiments, and strategies such as the self-esteem pie, which helps patients learn to broaden the basis of their self-worth to include non-appearance factors (e.g., skills, achievements, moral values).
Exposure and ritual prevention (E/RP)
Prior to beginning E/RP, the therapist and patient should review the patient’s BDD model to help identify the patient’s rituals (e.g., excessive mirror checking) and avoidance behaviors (e.g., avoiding riding the subway) and discuss the role of rituals and avoidance in maintaining his symptoms. The therapist and patient jointly develop a hierarchy of anxiety provoking and avoided situations. Patients often avoid daily activities, or activities that could reveal one’s perceived flaw, including shopping (e.g., changing in a dressing room), going to the beach, intimate sexual encounters, going to work or class, or accepting social invitations. The hierarchy should include situations that would broaden a patient’s overall social experiences. For example, a patient might be encouraged to go out with friends twice per week instead of avoiding friends on days when he thought his nose looked really “huge.” The first exposure should be mildly to moderately challenging with a high likelihood for success. Exposure can be very challenging for patients, therefore, it is important for the therapist to provide a strong rationale for exposure, validate the patient’s anxiety while guiding him towards change, be challenging and encouraging, be patient and a cheerleader, and quickly incorporate ritual prevention. To reduce rituals, patients are encouraged to monitor the frequency and contexts in which rituals arise. The therapist then teaches patients strategies to eliminate rituals by first learning how to resist rituals (e.g., waiting before checking the mirror) or reduce rituals (e.g., wearing less makeup when out in public). The patient should be encouraged to use ritual prevention strategies during exposure exercises. It is often helpful to set up exposure exercises as a “behavioral experiment” during which they evaluate the validity of negative predictions (e.g., if I don’t wear my hat, someone will laugh at my thinning hair”). The goal of E/RP is to help patients practice tolerating distress and acquire new information to evaluate their negative beliefs (Wilhelm et al., 2013).
Individuals with BDD often have a complex relationship with mirrors and reflective surfaces. A patient may vacillate between getting stuck for hours in the mirror scrutinizing, grooming, or skin picking, and active avoidance of seeing his reflection. Usually patients focus only on the body parts of concern and get very close to the mirror, which magnifies perceived imperfections and maintains maladaptive BDD beliefs and behaviors. Furthermore, patients tend to engage in judgmental and emotionally charged self-talk (“Your nose looks so disgusting”). Perceptual retraining helps to address distorted body image perception and helps patients learn to engage in healthier mirror-related behaviors (i.e., not getting too close to the mirror, not avoiding the mirror entirely). The therapist helps to guide the patient in describing his whole body (head to toe) while standing at a conversational distance from the mirror (e.g., two to three feet). Instead of judgmental language (e.g., “My nose is huge and crooked.”), during perceptual (mirror) retraining, patients learn to describe themselves more objectively (“There is a small bump on the bridge of my nose”). The therapist encourages the patient to refrain from rituals, such as zoning in on disliked areas or touching certain body parts. Perceptual retraining strategies can also be used to broaden patients attention in other situations in which the patient selectively attends to aspects of their and others’ appearance (e.g., while at work or out with friends). Patients are encouraged to practice attending to other things in the environment (e.g., the content of the conversation, what his meal tastes like) as opposed to his own or others’ appearance (Wilhelm et al., 2013).
Brief overview over additional modules
Specific treatment strategies may be necessary to address symptoms affecting some but not all patients including: skin picking/hair pulling, muscularity and shape/weight, cosmetic treatment, and mood management (Wilhelm et al., 2013). Habit reversal training can be used to address BDD-related skin picking or hair pulling. Patients with significant shape/weight concern, including those suffering from muscle dysmorphia often benefit from psychoeducation and cognitive-behavioral strategies tailored to shape/weight concerns. Therapists can use cognitive and motivational strategies to address maladaptive beliefs about the perceived benefits of surgery while at the same time helping the patient to nonjudgmentally explore the pros and cons of pursuing cosmetic surgery (Wilhelm et al., 2013). Depression is common in patients with BDD and may become treatment interfering (Gunstad & Phillips, 2003). Patients with significant depression can benefit from activity scheduling, as well as cognitive restructuring techniques for more severely depressed patients (Wilhelm et al., 2013).
Treatment ends with relapse prevention focused on consolidation of skills and helping patients plan for the future. Therapists help patients expect and respond effectively to upcoming challenges (e.g., starting college, job interview, dating). Therapists may recommend self-therapy sessions in which patients set time aside weekly to review skills and set upcoming BDD goals. Booster sessions can be offered after treatment ends as a way to periodically assess progress and review CBT skills as needed (Wilhelm et al., 2013).
Gunstad, J., & Phillips, K.A. (2003). Axis I comorbidity in body dysmorphic disorder. Comprehensive Psychiatry, 44, 270-276.
Miller, W.R. & Rollnick, S. (2002). Motivational interviewing: Preparing people for change (2nd edition). New York: Guilford Press.
Sarwer, D. B., & Crerand, C. E. (2008). Body dysmorphic disorder and appearance enhancing medical treatments. Body Image, 5, 50-58.
Veale, D. (2004). Advances in a cognitive behavioural model of body dysmorphic disorder. Body Image, 1, 113-125.
The most common treatment plan for body dysmorphic disorder is a combination of psychotherapy and medication. Cognitive behavioral therapy (CBT) has been found to be the most effective at treating BDD and antidepressant medications have also been shown to help individuals coping with this disorder.
CBT provides coping techniques and tools for managing irrational thoughts and negative thinking patterns. Your therapist can help you turn negative thoughts and behaviors into positive. A particular form of CBT, known as Exposure and Response Prevention (ERP), is often used to treat people with BDD and OCD. Exposure involves taking steps to confront situations that cause your irrational concerns, such as going out in public with the perceived flaw uncovered. Response prevention teaches you to resist the urge to cover up that perceived flaw with makeup or clothing, how to stop seeking reassurance from others about your appearance, and how to decrease the amount of time you spend repeatedly checking your appearance.
Antidepressants, specifically selective serotonin reuptake inhibitors, are often prescribed to help relieve the obsessive thoughts and compulsive behaviors associated with the disorder. These are effective, in part, because it is believed that a partial cause of body dysmorphia is due to problems related to the brain chemical serotonin. Your doctor may prescribe a gradually increasing dose of antidepressants to see how well you tolerate the medication and any potential side effects. Other medications may be prescribed, depending on your specific symptoms. If your symptoms are unmanageable and interfere with your daily life, in-patient treatment at a hospital, clinic or specialized treatment center may be required.
To get the most out of your treatment:
- Don’t skip any therapy sessions, even if you don’t feel like talking
- Take any medication prescribed as directed and don’t stop without consulting your doctor. You may experience withdrawal symptoms if you discontinue your medication too abruptly, and without it, your symptoms may return.
- Learn as much as you can about your condition and how it affects you.
- Pay attention to warning signs and learn what triggers your symptoms so you can discuss them with your therapist or physician.
- Stay physically active to help keep your mood elevated.
- Avoid alcohol and drugs that can interact with your medication and worsen your symptoms.
Article Sources Last Updated: Oct 24, 2019
Practically every teen (and adult) dislikes something about their appearance, such as an imperfect nose, acne scars, or skinny calves. That’s normal. Some teens, however, obsess about a slight or imagined physical flaw. They’ll spend hours each day fretting about it, scrutinizing it in the mirror, or figuring out ways to hide it with things like makeup or clothing. They may even refuse to leave the house or socialize with friends, fearing judgment or ridicule due to the “hideous’ feature – even though they look completely normal to everyone else. This irrational behavior is known as body dysmorphic disorder, or BDD for short.
Body dysmorphic disorder can negatively impact every area of your teen’s life. If left untreated, symptoms continue into adulthood. Individuals with BDD often resort to countless – not to mention very expensive and potentially risky – cosmetic surgeries in a desperate, but ultimately futile, attempt to “fix” the perceived imperfection.
It can be difficult to determine if your teen’s concern about his or her appearance and seeming obsession with the mirror is normal or not. This brief guide is designed to help you know the signs to watch for and the steps to take if you suspect your teen has body dysmorphic disorder.
Body Dysmorphic Disorder Statistics and Facts
Following are several statistics and facts pertaining to body dysmorphic disorder:
- Body dysmorphic disorder affects approximately 1% of individuals in the U.S.
- The onset of BDD typically occurs during early adolescence, although it can occur at any age
- BDD appears to affect males and females equally
- A study reported in the Journal of Clinical Psychiatry found high rates of suicidal thoughts (78%) in individuals with BDD; over 1/4th of those individuals had attempted suicide
- 97% of individuals suffering from BDD avoided work and / or other social activities, according to study published in the American Journal of Psychiatry. Nearly 1/3rd couldn’t leave their home due to the disorder.
Individuals with body dysmorphic disorder often have other co-occurring psychiatric disorders as well. The most common disorders are:
- Major depressive disorder
- Obsessive-compulsive disorder (OCD)
- Delusional disorder
- Social anxiety disorder
- Substance use disorders
- Eating disorders
It’s not uncommon for body dysmorphic disorder to be misdiagnosed as depression or an anxiety disorder. It’s important to let your teen’s treatment provider know about the obsession he or she has regarding a particular physical flaw.
Following are several risk factors for the development of body dysmorphic disorder in teens:
- Having a first-degree relative with OCD or body dysmorphic disorder
- Having depression, anxiety, or another mental health condition
- A history of childhood abuse, neglect, bullying, or other painful events
- Pressure to be beautiful or handsome
- Being perfectionistic
Looking for and Recognizing the Signs of Body Dysmorphic Disorder
Body dysmorphic disorder can become increasingly worse with time if left untreated. That’s why it’s so important to know what to look for so you can recognize the signs in your teen and intervene sooner than later. Look for and pay close attention to any changes from your teen’s normal behavior, mood, or personality – especially as it pertains to your teen’s feelings about his or her body or appearance.
Signs to watch for include:
- Being obsessed with their body or a specific body part (e.g. nose, skin, muscle size, hair). The most common areas of focus are the face, nose, hair, breasts, genitalia, and muscle size. However, any aspect of the body or one’s appearance can be the focus of obsession and distress for those with BDD.
- Constantly talking about the perceived flaw, always seeking reassurance about it, or trying to convince others how bad or ugly it is
- Significant distress about their body or a specific body part
- Avoiding social or physical activities, especially anything that might expose the perceived flaw they’re trying so hard to hide
- Never being satisfied with efforts to fix or improve the perceived defect
- Frequently or constantly checking how they look in the mirror (or any reflective surface)
- Avoiding mirrors to avoid seeing the perceived flaw
- Belief that others are staring at them or their perceived defect
- Attempts to hide or camouflage a perceived flaw with makeup, their hand or body position, clothes, hair, or accessories
- Excessive grooming, such as spending hours on their hair or makeup
- Frequently asking or even pleading to have surgery or see a dermatologist (or cosmetic dentist, etc.) to correct or remove the perceived flaw
- Feelings of distress about leaving the house (due to feeling self-conscious or believing they’re ugly)
- Frequently missing school, or dropping out altogether
- Spending lots of money on things they believe will fix or hide the perceived defect
- Often comparing their body or a part of their body with others
- Constantly changing clothes
- Avoiding having photos taken of them
- Wearing excessive amounts of makeup
- Excessive exercising or working out (with a focus on improving their appearance rather than their health or fitness)
- Picking at their skin
- Constant or overly restricted dieting
- Low self-esteem
- Deep-seated feelings of shame or embarrassment
- Depression and / or anxiety
- Suicidal thoughts or behaviors*
*Suicidal thoughts or behaviors should never be ignored. Don’t assume your teen is just being “dramatic” or manipulative. The risk of suicide is particularly high for individuals suffering from body dysmorphic disorder, especially if they’re also battling depression or anxiety.
Knowing the First Steps to Take
One of the greatest dilemmas for parents is knowing what to do if they believe their teen has body dysmorphic disorder. Following are the initial steps to take in order to help your teen:
1 – Talk to your teen. Sit down and have an honest conversation with your teen regarding your observations and concerns. Talk to your teen with compassion, and refrain from lecturing, criticizing, or shaming him or her. Let your teen know that you’re genuinely concerned and want to help, and that you’re always willing to listen about whatever is troubling him or her.
Don’t react, get defensive, or be surprised if your teen denies there’s a problem or accuses you of over-reacting (not uncommon behavior for teens).
2 – Set up an appointment for an evaluation. Your teen’s pediatrician or your family doctor can do an initial evaluation, including a physical examination to rule out any underlying medical issues that may be causing or contributing to your teen’s mood or behaviors.
Due to the potentially complex nature of body dysmorphic disorder, it’s imperative to have your teen evaluated as soon as possible by an experienced mental health professional. If possible, work with a psychologist and / or psychiatrist who specializes in treating children and adolescents and who has experience treating body dysmorphic disorder.
3 – Get your teen into treatment. Treatment for body dysmorphic disorder often involves a combination of psychotherapy, or “talk therapy”, and medication.
Psychotherapy – One of the most effective types of psychotherapy for BDD is cognitive behavioral therapy (CBT). This approach helps your teen identify and change negative and irrational thought patterns and behaviors associated with BDD. It also focuses on helping your teen learn healthy coping skills.
Medication – Medication is often prescribed in addition to psychotherapy in more severe cases of BDD. The FDA hasn’t approved any medication specifically for the treatment of BDD. However, there are several antidepressant medications that have been found to be beneficial in reducing obsessive thoughts and repetitive behaviors. Selective serotonin reuptake inhibitors (SSRIs), such as Celexa, Zoloft, Luvox, and Paxil, are often prescribed for BDD. The tricyclic antidepressant clomipramine (Anafranil), often used in the treatment of OCD, is also prescribed for some individuals with BDD.
If medication is prescribed, it’s highly recommended that it be under the supervision of a psychiatrist. Also, it’s important to carefully weigh the potential costs (e.g. side effects and risks) versus the potential benefits of medication, since your teen’s brain is still developing.
Family therapy – Family therapy may be an essential component of successful treatment for your teen’s body dysmorphic disorder. It can address dysfunctional family dynamics that may be contributing to or reinforcing your teen’s fixation on perceived physical flaws. It can also help everyone in the home learn how to be supportive without enabling.
Dual diagnosis treatment – This is usually necessary if your teen also has a substance use disorder – see more below
Residential treatment – See below
Hospitalization – See below
Supporting and Encouraging Your Child
Your teen will benefit greatly from your support and encouragement. Two of the most important things to keep in mind are that 1) BDD isn’t a sign of weakness and 2) it isn’t something your teen can simply “overcome” with sheer willpower and determination. Think of it as you would any other serious health condition.
Tips for parents:
- Educate yourself about body dysmorphic disorder. This will enable you to have greater empathy for and understanding of the challenges your teen faces every day
- Be patient with your teen. Remember, BDD is an illness, not something your teen can easily control.
- Don’t judge, criticize, or minimize what your teen is experiencing, not matter how illogical, absurd, or baffling your teen’s behaviors may seem to you
- Help your teen find healthy ways to manage stress and relax. For example, take regular walks with your teen or enroll him or her in a yoga class
- Seek guidance from your teen’s therapist to learn how to avoid accommodating his or her constant need for reassurance and reinforcing compulsive behaviors
- Maintain normal routines at home and have reasonable expectations (e.g. regular school attendance); enabling your teen may seem kind in the short run but will only reinforce unhealthy behaviors
- Help your teen stay focused on the goals of treatment and encourage him or her to practice the coping skills learned in therapy
- Make sure everyone at home is involved in your teen’s recovery so no one inadvertently sabotages his or her progress. A few family therapy sessions can help achieve this, while also addressing the affect your teen’s disorder may have on the entire family
- Never criticize or shame any aspect of your teen’s appearance or dissatisfaction with some aspect of his or her body
- Respect your teen’s privacy and dignity; your neighbors, relatives, and friends don’t need to know about his or her mental health issues
What to Do When Things Escalate
One of the greatest risk factors for individuals with body dysmorphic disorder is depression, which may be accompanied by suicidal thoughts. In fact, individuals with BDD have a significantly higher suicide rate than those with other psychiatric disorders. Also, those with severe BDD may refuse to leave home. The latter will make it extremely difficult for your teen to go to school, socialize, or attend therapy appointments.
If your teen is becoming increasingly depressed, actively suicidal, or engaging in self-harm, or experiencing severe, acute distress, you must take immediate steps to ensure his or her safety and wellbeing. A visit to the nearest ER or a brief hospital stay may be necessary to keep your teen safe from self-harm and / or get serious depressive symptoms under control.
If things start to escalate you can:
- Contact your child’s treatment provider asap
- Enlist the help of a close family member or friend for support or assistance
- Call an emergency hotline
- Take your child to the nearest hospital emergency room (if you can do so safely)
- Call 911
When Individual Therapy isn’t Enough
Some teens with BDD will require more treatment than individual therapy, even if medication is part of the treatment protocol. A more intensive level of treatment will likely be necessary for your teen if he or she is:
- Refusing to comply with his or her therapist’s treatment recommendations
- Experiencing severe depression, anxiety, or other psychiatric symptoms that require a higher level of care
- Actively suicidal – threatening or planning suicide, and / or engaging in suicide gestures or attempts
- Engaging in cutting, burning, or other non-suicidal forms of self harm
- Abusing alcohol or drugs
Higher levels of treatment include:
- Intensive outpatient treatment (IOP) / Psychiatric day treatment
- Dual Diagnosis Treatment
- Residential treatment
- Inpatient psychiatric treatment
Intensive outpatient treatment or psychiatric day treatment can vary in terms of the amount of time spent in treatment and how many times a week your teen is required to go. These programs are typically the next step up from regular outpatient treatment.
Dual diagnosis treatment is usually necessary if your teen has a substance use disorder in addition to BDD. Alcohol or drug abuse almost always hinders the effectiveness of individual therapy. A dual diagnosis program addresses the substance use issue as well as your teen’s social BDD (and any other psychiatric issues) simultaneously. Dual diagnosis treatment may be part of a residential treatment program or an outpatient program.
Residential treatment requires having your teen live at a non-hospital treatment facility that specializes in treating adolescents with BDD and other mental health issues. Residential treatment typically lasts between 30 to 180 days, depending on the severity of symptoms and how well your teen is progressing in treatment.
Inpatient psychiatric treatment in a hospital setting is the highest and most intensive level of treatment for adolescents with body dysmorphic disorder. Patients are monitored 24/7. Hospitalization is usually relatively brief.
Taking Care of Yourself
Trying to effectively parent, help, and encourage your teen with body dysmorphic disorder is challenging. It’s perfectly normal to experience a range of emotions, including despair and exasperation. If you don’t take adequate care of yourself, your child’s mental health issues can take a serious toll over time. A few things you can do to bolster your own strength and keep your wits about you include:
- Surrounding yourself with ample support, whether through close friends, family, church, or a local support group for parents of teens with mental health issues
- Make sure you’re getting adequate sleep
- Find healthy ways to keep your stress under control (e.g. regular exercise or meditation)
With proper treatment, your teen can learn to effectively manage his or her BDD, and perhaps even overcome it. Your love, support, optimism, and encouragement will help ensure the best possible outcome.
Managing Day-to-Day Life With Body Dysmorphic Disorder
Unless you’re a movie star, chances are you have some self-image issues. Maybe you feel your butt is too big, your waist isn’t small enough, or there is something that just bothers you. That’s normal. But when you have body dysmorphic disorder, or BDD (the mental health disorder that causes you to have a distorted self-image) that “something” is typically imaginary or minimal and yet it causes you to worry and obsess about what you perceive to be an ugly appearance. BDD can impact you to such a degree that makes it difficult to live a normal life.
Managing day-to-day life with BDD can be overwhelming.
“Body dysmorphic disorder is a relatively severe psychiatric disorder, and the best course of action is professional help,” says Leslie Heinberg, PhD, of the Cleveland Clinic, who specializes in treating people with BDD. “Patients often don’t make significant progress without some type of intervention.”
BDD, however, can be treated and managed. “Treatment usually includes an antidepressant medication called a serotonin reuptake inhibitor, or SSRI, and a type of talk therapy called cognitive behavioral therapy,” Heinberg explains.
In cognitive behavioral therapy, or CBT, you’re shown how to recognize that your self-perception is false– something that can be very hard to accept. “CBT for body dysmorphic disorder is similar to obsessive compulsive disorder,” she says. “You need to expose people to their fears so they can be desensitized.”
“Much of the work of behavioral treatment is to help patients limit the compulsive behaviors, such as camouflaging behaviors or reassurance-seeking,” she says, “and patients will be taught delay strategies or thought-stopping techniques.”
Behaviors of concern include:
- Constantly seeking assurance about your appearance
- Constantly trying to hide a perceived flaw under makeup or clothing
- Spending hours in front of a mirror, or avoiding mirrors altogether
- Constant grooming or exercising
- Changing clothes over and over again
Cognitive interventions designed to help you think about your appearance in a more balanced way can help decrease obsessive thoughts. Ways to take care of yourself each and every day include getting adequate sleep, follow a healthy diet, and getting exercise as “these can help symptoms from being more magnified due to fatigue and poor health,” says Heinberg.
Why Treatment and Management Is Essential for BDD
“Living with BDD means living with an extreme and exaggerated negative perception of your appearance,” Heinberg says. “Someone with this disorder may worry obsessively about their self-image almost every waking moment.”
Almost 50 percent of people with BDD develop a drug or alcohol problem. Up to 50 percent seek unnecessary surgery– in fact, people with BDD make up about 15 percent of cosmetic surgery patients. Studies show that about 75 percent of people with BDD sometimes feel that life is not worth living, and 25 percent attempt suicide.
In a study published in the journal Suicide and Life-Threatening Behavior, researchers interviewed 200 people with BDD and found that 78 percent had thought about suicide. People who had BDD and an anorexia-type eating history were almost twice as likely as other people with BDD to actually attempt suicide.
Recovery Is Possible
A study published in the Journal of Nervous and Mental Disease found that people with BDD have a good rate of recovery. Although the study was small, it is the longest study of BDD treatment over an extended time period. Of the 15 participants, 76 percent were in recovery from BDD after eight years. For about half of the patients, it took five years to reach recovery.
Living with BDD means working hard with a therapist to overcome your fears. Here’s what else you need to know:
- As you expose yourself and your fears to others, you gradually become less sensitive.
- You may need medication to help deal with anxiety or depression.
- The prognosis for recovery is good, but you need to stay in treatment.
- Avoid seeking surgery as a solution.
- Avoid cutting yourself off from other people.
- Make sure to get enough sleep and exercise.
- Eat a healthy diet.
- Don’t self-medicate with drugs or alcohol.
- If you have any thoughts of hurting yourself or giving up, you need to tell someone and talk to your doctor right away.
Finally, make sure you have a good support system of friends and family members. They can help you stick with your treatment if you get down and discouraged. Consider joining a BDD support group — ask your doctor or therapist about one in your area or online. The Anxiety and Depression Association of America has a Web site where you can learn more about BDD, find support groups, and link to articles about living with BDD.
The average woman looks into a mirror about eight times per day, according to an overview article in The Daily Mail, and women might also use sunglasses, windows, phone cases, and other reflective surfaces to check on appearance issues when no mirrors are handy.
For some people, these daily checks are a source of extreme misery. That’s because these people see one or two things in the mirror that they assume are horrific, ugly, terrifying, and impossible to ignore.
The issue is body dysmorphic disorder (BDD), and according to the Anxiety and Depression Association of America, it’s a mental illness characterized by negative thoughts about appearance. Typically, people with this disorder focus on one specific body part, and they feel unable to overcome their feelings about that body part.
People with BDD may become convinced that their noses are just a little too long, or their hair is just a little too thin. They may be convinced that their eyes aren’t symmetrical, or that their ears stick out from their heads just a little too much.
These aren’t passing thoughts that might drift into and then out of a person’s mind on a regular basis. These are persistent obsessions about the body part that can cause a person extreme mental anguish.
Unless this condition is treated, it can lead to physical consequences as well.
Observing Signs and Symptoms
It’s hard to know how many people have BDD. For example, in an overview article published in Dialogues in Clinical Neuroscience, researchers say that it could impact as few as 0.7 percent of adults to as many as 2.4 percent of adults. That’s a huge gap, and it could be explained, in part, by the fact that many BDD symptoms are intensely private.
The thought patterns and obsessions about appearance characterize BDD, and most thoughts just aren’t visible. As a result, people with BDD might be able to keep their disorder hidden, especially in the early stages. But if left untreated, the condition tends to grow stronger and more severe, and when that happens, symptoms can get bigger and harder to control.
Someone with BDD may constantly ask for reassurances about appearance. This person might ask if his/her nose really is crooked, or if a haircut makes the nose less crooked, or if someone is looking at the crooked nose. This body part may come up in conversation over and over again, and it might be hard to ignore.
In addition, people with BDD may search for solutions to their issue by:
- Meeting with multiple cosmetic surgeons
- Buying bogus treatments online, like braces or splints
- Spending money on haircuts, hats, or clothing
- Purchasing a great deal of makeup or hair dye
These people may also spend hours and hours in front of the mirror every day, examining the body part and worrying over how they can minimize that body part. Sometimes, this extreme focus can keep people from working, meeting with families, or engaging in hobbies. The perceived defect consumes most of the person’s time.
Causes and Risks
Researchers aren’t quite sure what causes BDD, but according to Mayo Clinic, genes could play a role. The disorder is more common in people with family members who also have the disorder, so there might be some sort of genetic marker that’s passed from one generation to the next that causes these unusual thinking patterns.
Research quoted by the National Association of Anorexia Nervosa and Associated Disorders also suggests that unusual brain patterns could play a role. Researchers used specialized equipment to examine the brains of 14 people with BDD, measuring electrical activity while people looked at photos of their bodies.
Researchers found that people with BDD had lower levels of activity in some parts of the brain when compared to healthy controls.Studies like this seem to suggest that people with BDD have unusual brain cells that just don’t respond in a conventional way to very real and very common stimuli.
They see the world differently, and that makes them behave differently, too.
But this shift in thinking isn’t benign. People with BDD have severe lifestyle disruptions as they don’t have enough time to handle daily life and the demands of the disorder. The hours they spend looking at or attempting to fix the perceived problem are hours they should be spending in activities that bring them prosperity or joy. They can lose relationships, jobs, and opportunities because they can’t shift their thoughts to something that’s rewarding.
Writers for PsychCentral also suggest that BDD can lead to complete isolation. People with the disorder may become convinced that the defect makes them unfit to socialize with others. They don’t want to inflict their extreme ugliness on people they care about, so they may refuse to leave the home altogether. They may think that they’re doing others a favor by staying away from social situations.
In time, BDD can lead people to drastic decisions. The International OCD Foundation suggests that up to 80 percent of people with this disorder have thought about or attempted suicide.
People with BDD can’t magically cure their thought behaviors. Often, they need help from trained professionals in order to shift their opinions about their body part defects and their overall attractiveness.
People with BDD may believe that surgery could help them to feel better, particularly if the surgeon they meet specializes in the body part that seems to cause the most distress. But often, surgeries don’t make people feel better. After all, the problem doesn’t lie with physical anatomy. The problem lies in the way the person thinks about or reacts to that anatomical feature. A better approach involves tackling those thought patterns directly, so people can think differently about their bodies, no matter what they might look like.
Therapists might ask their patients to measure how others respond to the body part of concern. If the issue is one of a crooked nose, for example, therapists might ask people to pull hair back, remove hats, skip makeup, and walk from one side of the grocery store to another while counting how many people look only at their nose. The therapist might take the walk at the same time, doing the same counting. Then, the two might discuss the number (which is probably low). When they do, they might be able to start to combat the inner voice that tells the person that the crooked nose is unbearable. If few people looked at it, chances are, that thought isn’t accurate.
Practicing good self-care might also be vital for people with BDD. They might need to learn how to eat well, sleep through the night, exercise, and meditate. They might work on assertiveness or communication skills. They might pick up hobbies they’ve let fall away. These are steps that can remove obsessive tendencies, helping people to focus on life’s pleasures.
This kind of work takes time to complete, and sometimes, it’s best for people to do that work in an inpatient setting. Here, people work on changing thoughts and behaviors around the clock, and they’re free of daily stresses that could spark a relapse. But some people do quite well with BDD work done on an outpatient basis. It just depends on how much social support the person has at home.
Someone with a tight and supportive family can lean on those people during therapy, and they can feel safe and secure at home. Someone like this can do well in outpatient care. But someone living in a difficult home or in a lonely home might need the added support of a residential community. It’s really a personal decision.
Healing Is Possible
Without treatment, BDD can lead to a great deal of pain and misery, but the disruptive thought patterns that come with this disorder don’t have to persist.
With therapy, people can learn to look past a perceived flaw, and they can start to focus on the beauty that’s within them and around them. Help is available, and healing is possible.
Body Dysmorphic Disorder
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What Is Body Dysmorphic Disorder?
Body dysmorphic disorder (BDD) causes people to believe that parts of their body look ugly. People with BDD spend hours focused on what they think is wrong with their looks. Many times a day, they do things to check, fix, cover up, or ask others about their looks. They focus on flaws that seem minor to others.
What Are the Signs & Symptoms of Body Dysmorphic Disorder?
People with BDD:
Focus to extreme on their looks. With BDD, people find it hard to stop thinking about the parts of their looks they dislike. They focus on specific things — like a pimple on their skin, or the shape or looks of their nose, eyes, lips, ears, or hands.
Feel upset about their looks. People with BDD feel worried, stressed, and anxious about their looks almost all the time.
Check or fix their looks. With BDD, a people feel the strong need to check their looks over and over. For example, they check their looks in a mirror, ask others how they look, or “fix” their looks many times a day.
Try not to be seen. Some people with BDD feel so bad about their looks they don’t want to be seen. They may stay home, keep to themselves, or use makeup, hats, or clothes to cover up. Some people with BDD avoid looking in mirrors because it is so stressful.
Have a false image of their looks. People with BDD don’t see their body as it really is, or as others see it. The flaws they focus on are things that others can hardly notice. They feel sure they look ugly, even though it’s not true.
How Is Body Dysmorphic Disorder Diagnosed?
A trained mental health therapist who understands BDD can diagnose it. They ask questions and listen carefully to the answers to know if a person has BDD or another disorder.
How Is Body Dysmorphic Disorder Treated?
BDD can be treated with:
- Cognitive behavioral therapy (CBT). CBT is a type of talk therapy. It can help people with BDD learn that what they think affects how they feel. In CBT, people learn to notice their thoughts. They learn to challenge the thoughts that make them feel bad. They learn they can change the way they see their body. Slowly, and with lots of support, in CBT people learn to focus less on flaws. They learn to stop checking and fixing their looks.
- Medicine. Medicines that help serotonin work well are used to treat BDD. These are sometimes called SSRI medicines. SSRI medicines can help people obsess less about their looks and feel less distress. With less distress, they can make more progress in the CBT.
Most of the time, CBT therapy and medicine are used together to treat someone with BDD.
What Causes Body Dysmorphic Disorder?
There is still much to learn about the exact causes of BDD. But experts believe that these things play a role in causing BDD:
- Genes. BDD may be partly inherited. It tends to run in families.
- Serotonin. Serotonin is a normal and necessary chemical found in the brain. A poor supply of helps explain why BDD happens.
- Brain differences. Studies have shown that some areas of the brain look and work differently in people with BDD.
BDD is not caused by anything the person or their parent did. It is a mental health condition that needs treatment. BDD is not a person’s fault.
What’s It Like for Someone With Body Dysmorphic Disorder?
The thoughts and worries that are part of BDD take up a person’s time and drain their energy. With BDD, a person never feels OK about how they look, no matter what others say. Because of BDD, they often miss out on being with friends, going to school or work, or doing normal activities. This can make them feel alone, sad, or depressed.
Some look for treatments or surgery they don’t need, hoping to “fix” a flaw. But this doesn’t relieve or improve BDD. It can be hard for the person to see that the problem with BDD is not the way they look. It’s the false way BDD makes them see themselves.
What if I Have Body Dysmorphic Disorder?
If you think you might have BDD:
- Talk to a parent, therapist, doctor, or other adult you trust. Tell them what you’re going through.
- Ask them to help you find a CBT therapist.
- Meet with a CBT therapist to find out if you have BDD.
- Keep all your appointments for therapy. It takes time and effort to change the way you see yourself.
- Be honest and open with your therapist. Let them know if you feel depressed.
- Let others give you support. It helps to know you’re not alone.
- Be patient. It takes time and effort for CBT therapy and medicines to relieve BDD. Work hard in therapy and don’t give up.
You also can visit online BDD sites for more information and support, such as:
- BDD Foundation
- Online Body Dysmorphic Disorder Support Group
Reviewed by: D’Arcy Lyness, PhD Date reviewed: October 2018
Living with Body Dysmorphic Disorder (BDD)
How Do I Know it’s BDD?
Everyone gets intrusive thoughts, but having them doesn’t mean you have a disorder. For people who do have BDD, these thoughts can be debilitating, causing extreme anxiety and discomfort. No matter how hard you try to get rid of them, they won’t go away. The primary difference between BDD and a healthy amount of vanity, is the severity of anxiety a person has about their features.
While no longer classified as OCD, BDD is on the anxiety spectrum. It is also usually combined with another personality feature or disorder. In women, BDD may be paired with borderline personality disorder — a mental disorder characterized by unstable moods, behavior and relationships. In men, BDD may be paired with narcissism, a disorder where you think you’re more important than others. Learn more about co-occurring disorders, aka comorbidity, here.
- You have one pore on your nose that’s slightly larger than the others. When you check in the mirror, it looks like a moon crater and you think you’re deformed.
- Your hair is starting to thin out and you obsessively think everyone is staring at your bald spot. To hide from the anxiety, you always wear a baseball cap.
- You’re not completely comfortable with your weight. You know you put on some pounds after getting into a serious relationship. Even though you feel healthy, you’re obsessed with checking your weight on a bathroom scale.
How can my family help with my BDD?
BDD is not as tricky to discover as other anxiety disorders. Family and friends often recognize a sufferers over obsession with their appearance. It can be trickier to spot in teenagers because of the pressure at that age to look a certain way. The goal of family and friends should be to encourage you to seek professional treatment, and to not provide sought after reassurance. Doing so can make the disorder worse.
Is Recovery Possible for Me?
Yes! But know that treatment can be emotionally painful because it requires you to look deeply at your identity and appearance. Exposure Response Prevention Therapy (ERP) is the recommended treatment for BDD. ERP is when you voluntarily expose yourself to the source of your fear over and over and over again, without acting out any compulsion to neutralize or stop the fear. By repeatedly facing something you’re afraid of, you force your brain to recognize how irrational it is.
Examples of ERP treatment:
- You may first be required to ask people to look at your flaw or comment on your appearance.
- Then, you may have to take pictures of yourself in a way that intensifies or enlarges the flaw.
There are other treatment options as well. Mindfulness-based Cognitive Behavioral Therapy, also known as CBT, teaches people to identify, understand and change negative thinking patterns and behaviors. Patients are taught problem-solving skills during therapy lessons and then instructed to practice them on their own time in order to build positive habits.
Can medication help?
Medication can help alongside ERP, but it shouldn’t replace it. Doctors should always be consulted before considering medicinal options.
The main family of medicines used to treat anxiety and depression are known as Selective Serotonin Reuptake Inhibitors, or SSRIs. SSRIs enhance your natural serotonin activity and are used to treat major depressive disorders and anxiety conditions. Examples include Lexapro, Prozac, Paxil and Zoloft.
What is the goal of therapy?
Some people with BDD recover completely through ERP and CBT. But for many, their obsessions never fully go away. Recovery has more to do with managing the condition, than it does with eliminating it. However, that doesn’t mean you can’t lead a healthy, happy life. By prioritizing treatment and positive lifestyle habits, sufferers often gain confidence and freedom. Even if some anxiety is still present by the end of therapy, you’ll no longer feel debilitated by the condition. Leaving the house, getting dressed up with friends, or posting photos online won’t be met with severe anxiety. There is a more balanced approach to accepting differences in appearance.
It is not uncommon to hear someone complain about their body or express dissatisfaction with a particular body part. As a culture, we are entrenched with the faulty ideas of body perfection,. Living in a society that continually reminds us that we are not good enough can lead to Body Dysmorphic Disorder.
Self-demoralizing phrases like, “I look so fat in this”, or “I hate my body”, have become all too commonplace. Generally, we are harsh on ourselves, judging our appearances rigidly against incomparable standards, viewing ourselves only in terms of how we appear instead of what we can do.
The Damage Goes Beyond Just Feeling Bad About Your Body
Research has revealed the damaging consequences of this mindset. It has been observed that when individuals experience poor body image, they will often turn to dieting as a solution. A disturbed body image is a significant component of eating disorders and plays an important role in the development and continuation of eating disorders .
Research has also shown us that low self-esteem is often connected with health-compromising behaviors in adolescence such as disordered eating problems, substance abuse, suicide-ideations, and early sexual activity .
The Red Flags for Body Dysmorphic Disorder
With many negative implications associated with poor body image and low self-esteem, it is important to be aware of red flags that can reveal a more serious problem. How can an individual discern poor body image from a more serious mental illness, like Body Dysmorphic Disorder?
Body Dysmorphic Disorder is a chronic mental illness in which individuals cannot stop from thinking or obsessing about a perceived flaw in their appearance. This mental illness is classified as an “obsessive-compulsive spectrum disorder”, as obsessions over body image are involved, and compulsions to act on thoughts are repeatedly done to reduce anxiety .
Research has found that body dysmorphic disorder affects approximately 2.4% of the general population in the United States, which means that up to 7.5 million individuals struggle with this mental health condition . These numbers are likely an underestimate of the true population size of those impacted by body dysmorphic disorder, as many individuals with this condition are often hesitant to reach out for help or reveal their struggle.
This obsession often becomes incapacitating, in that the sufferer is unable to function normally due to the shame they feel about their appearance. This may lead to severe disruptions in one’s life, such as loss of job, financial distress, severed relationships, and more.
There Are Many Signs That Someone May Have BDD
If you suspect that you or your loved one may be dealing with Body Dysmorphic Disorder, be aware of these following signs and symptoms:
- Avoidance of social engagements and situations
- Extreme self-consciousness and preoccupation with physical appearance
- Repeated cosmetic procedures with minimal satisfaction
- Excessive or redundant grooming habits
- Deep fear that others are judging you based on your perceived flaw
- Unable to normally function in other facets of life, such as in a career or within a family unit
- Constant need for reassurance from others about appearance
- Corresponding anxiety or depression
- Hyper focusing on a particular body part or face
Some of the most common preoccupations with body dysmorphic disorder include anomalies on the skin, such as acne, scarring, spotting, etc., nose size or shape, and hair, such as baldness or excessiveness. Preoccupations can be focused on any body part, and physical anomalies are usually imagined defects in appearance .
Why These Signs Should be Taken Seriously
These signs and symptoms may indicate a more serious problem is at hand rather just being unhappy with a part of one’s appearance. Body Dysmorphic Disorder can affect countless individuals, including males and females from a multitude of backgrounds, races, and cultures.
If left untreated or unaddressed, Body Dysmorphic Disorder can lead to serious consequences, including suicidal ideations and attempts, increased anxiety and depression, and eating disorders.
Body dysmorphic disorder can cause a severe impairment in overall quality of life, making daily activities difficult. Many individuals with body dysmorphic disorder are unable to attend school, hold a job, or even engage in relationships. Studies have found that more than 40% of individuals with BDD had been psychiatrically hospitalized .
Assistance Is Available for BDD
Perhaps your fixation over your perceived body image flaws has become intensely destructive in your own life. Fortunately there is assistance available and forms of treatment that can help you overcome Body Dysmorphic Disorder. A recommended plan of treatment for Body Dysmorphic Disorder would include a combination of psychotherapy and medication.
Forms of therapy that have been shown to help alleviate symptoms of Body Dysmorphic Disorder include Cognitive Behavioral Therapy (CBT) and Exposure and Response Prevention (ERP).
If you or your loved one is suffering with Body Dysmorphic Disorder, take the steps today toward seeking the help and treatment you need to overcome this struggle. You can find freedom from this overwhelming burden of self-destruction as well as hope and healing for recovery.
About the Author: Crystal Karges, MS, RDN, IBCLC is a Contributing Writer for Eating Disorder Hope.
Crystal is a Masters-level Registered Dietitian Nutritionist (RDN) with a specialty focus in eating disorders, maternal/child health and wellness, and intuitive eating. Combining clinical experience with a love of social media and writing. As a Certified Intuitive Eating Counselor, Crystal has dedicated her career to helping others establish a healthy relationship with food and body through her work with EDH and nutrition private practice.
: Stice, E. (2002). Risk and maintenance factors for eating pathology: A meta analytic review. Psychological Bulletin, 59, 1105-1109.
: American Psychological Association. Task force on the sexualization of girls. (2007). Report of the APA Task Force on the Sexualization of Girls. Washington, DC: American Psychological Association. Retrieved from: www.apa.org/pi/wpo/sexualization.html
: International OCD Foundation. Body Dysmorphic Disorder, http://www.ocfoundation.org/uploadedfiles/bdd%20fact%20sheet.pdf
: Bjornsson, A. S., Didie, E. R., & Phillips, K. A. (2010). Body dysmorphic disorder. Dialogues in Clinical Neuroscience, 12(2), 221–232.
The opinions and views of our guest contributors are shared to provide a broad perspective of eating disorders. These are not necessarily the views of Eating Disorder Hope, but an effort to offer discussion of various issues by different concerned individuals.
We at Eating Disorder Hope understand that eating disorders result from a combination of environmental and genetic factors. If you or a loved one are suffering from an eating disorder, please know that there is hope for you, and seek immediate professional help.
Published on July 19, 2017.
Edited And Updated By: Crystal Karges, MS, RDN, IBCLC.
Reviewed By: Jacquelyn Ekern, MS, LPC on July 19, 2017.
Published on EatingDisorderHope.com