Coping Strategies For Body Dysmorphic Disorder (BDD)

Introduction

Definition of body dysmorphic disorder (BDD)

Body dysmorphic disorder (BDD), or body dysmorphia, is a mental health illness that is characterised by anxiety over one’s appearance and body image.

You may have BDD if you:

• Obsessively worry about certain areas of your body 
• Often compare the way you look to how others look
• Excessively groom yourself, for example by applying lots of makeup, or taking a long time to choose an outfit
• Experience significant disruption to your everyday life due to worries about your appearance

BDD may also occur alongside other mental health conditions including obsessive-compulsive disorder (OCD), eating disorders, depression, and anxiety. 

Prevalence of BDD

Within the United Kingdom, it is suggested that 0.5% of the population has body dysmorphia. To put this into perspective, this is 5 in every 5000 people, all ranging in age from young children to older adults. Rates may be slightly higher due to underreporting of BDD symptoms. BDD can affect both males and females, however, BDD is often reported more among females.

Importance of coping strategies for BDD

Many people do not seek help with their BDD due to feelings of shame and embarrassment. However, it is important to seek help and learn coping strategies to improve your self-esteem and reduce the impact that BDD has on your quality of life. Symptoms of BDD may not go away, or get worse if treatment is not sought. Therefore, it is important to see your GP if you are experiencing BDD symptoms.

Psychotherapy as a coping strategy

Cognitive behavioural therapy (CBT)

Cognitive behavioural therapy is a type of talking therapy that helps you change the way you think and behave, and is often the main type of therapy recommended for those with BDD. During a CBT session, you will work with your therapist to break down your problems and understand your thoughts, actions, and feelings. These sessions usually take place once a week and can last anywhere between 30 to 60 minutes. Depending on the severity of your body dysmorphia, as well as what suits your needs best, CBT may be given in a group or a 1-to-1 format. Research suggests that CBT can help reduce BDD severity and related symptoms (e.g., depression).¹ Regardless, further research is required to understand the long-term effects of CBT on body dysmorphic disorder.²

Exposure and response prevention therapy (ERP)

ERP is recommended for all severities of body dysmorphic disorder. This type of therapy encourages you to face your fears by exposing yourself to situations that make you anxious. You will work with your therapist to understand your rituals (e.g., excessive grooming) and avoidance behaviours (e.g., avoiding changing rooms) to put in place a plan to help you overcome them. The first exposure should be mild to moderately challenging with a favourable rate of success, which can help to build your confidence and increase the likelihood of adherence to the therapy. Your therapist should:

• Validate your anxiety
• Be encouraging
• Be able to quickly incorporate ritual reduction

The ultimate goal of ERP is to help you tolerate distress and acquire new information to evaluate your negative beliefs.¹ Oftentimes, ERP is combined with CBT for the treatment of body dysmorphic disorder.

Acceptance and commitment therapy (ACT)

There are two essential parts of acceptance and commitment therapy:

• Acceptance – of miseries and failures
• Commitment – to changing for the better and creating a purposeful life

ACT therapy involves mindfulness and staying present, steering away from ‘being on auto-pilot’ to being more aware of your surroundings and bodily sensations. In addition, this therapy helps you to tolerate thoughts, rather than trying to change and generate alternative interpretations to problems.⁴ There has been some research suggesting the benefit of ACT for BDD, and some individuals with BDD can find ACT helpful.⁵ However, guidelines within the United Kingdom do not specifically mention the use of acceptance and commitment therapy for BDD. 

Medications as a coping strategy

Selective serotonin reuptake inhibitors (SSRIs)

SSRIs are a type of antidepressant that increase the amount of serotonin within your brain. Serotonin is an essential neurotransmitter (a chemical messenger that carries signals within the brain) that positively influences your mental health and well-being. SSRIs work by blocking reuptake (where serotonin is reabsorbed by nerve cells), which means more serotonin is able to carry more signals between the nerve cells.

Antidepressants can be prescribed for a variety of mental health conditions including OCD, depression, and BDD. The most common types of SSRI prescribed to those with BDD include fluoxetine, paroxetine, sertraline, and citalopram. SSRIs are most likely to be prescribed when:

• CBT (and ERP) is not working for your BDD
• You have moderate to severe body dysmorphic disorder

You may have to take SSRIs for up to 12 weeks before you see any improvements in your mental well-being, however most people feel better after 2 to 4 weeks. There can be some things that affect your ability to take SSRIs:

• Some people may not be suitable for SRRIs, including those who are breastfeeding,  pregnant, or under 18 years of age
• Those taking other medications (e.g., St. John’s Wort) 
• Risk of side effects from taking SSRIs may include: gastrointestinal issues like diarrhoea and nausea, loss of libido, and feeling anxious.

Therefore, it is important you seek guidance and advice from your GP before, during, and after taking SSRIs.

Other medications

Other types of antidepressant can be effective for the treatment of body dysmorphia. One type of tricyclic antidepressant, known as clomipramine, can be useful for treating BDD. Tricyclic antidepressants work in a slightly different way to SSRIs. Instead of just affecting the reuptake of serotonin, tricyclic antidepressants work by also affecting the reuptake of noradrenaline (a hormone that acts as a chemical messenger). In higher doses, tricyclic antidepressants are more likely to cause unwanted side effects because they affect other chemicals within your body. For example, clomipramine tends to have side effects such as dry mouth, sweating, and constipation. The effectiveness of clomipramine over the use of SSRIs still remains unstudied, however many patients respond well to taking clomipramine for BDD.⁶

Many other types of antidepressants are not routinely recommended for the treatment of BDD, however they may be considered for other mental health conditions (e.g., depression). These may include:

• Serotonin and norepinephrine reuptake inhibitors (SNRIs), such as duloxetine and venlafaxine
• Monoamine oxidase inhibitors (MAOIs), such as isocarboxazid and phenelzine
• Atypical antidepressants, such as mianserin and trazodone

Self care coping strategies

Mindfulness meditation

Paying attention to the present moment can improve your mental well-being. This is also known as mindfulness. Mindfulness helps you to listen to how your body feels, as well as notice the things you smell, hear, touch, see, and taste. Practising mindfulness has shown improvements in mental health, as it is thought that mindfulness practice can help you to stand back from your thoughts and evaluate unhealthy thinking patterns.⁷

You may enjoy practising mindfulness in everyday life by:

• Mindful meditation – dedicating some time to sitting quietly and focusing on your breathing, thoughts, and feelings
• Mindful exercise – listening to how your body feels when it is moving.
• Mindful eating – attentively eating by paying attention to what your food looks like, how it tastes, and what it feels like in your mouth
• Mindful colouring and drawing – concentrating on the colours, and the feelings of drawing and being creative

Regular exercise

Exercise is known to improve mental health and mood. Regular physical activity can help you:

• Have better sleep – as you will feel more tired at the end of the day
• Feel happier – exercise releases endorphins (chemical messengers that alleviate pain and promote pleasure) that boost your self-esteem and happiness
• Cope with your thoughts – exercise releases cortisol (a hormone that controls your mood) that reduces the amount of stress you feel. In addition, exercise can act as a distraction to racing thoughts, and thoughts about your body

It is important that exercise is done in moderation, is varied, and is not obsessively carried out. Some people with BDD may find that they excessively exercise, which may exacerbate BDD symptoms – this is common in a type of body dysmorphia known as muscle dysmorphia. Therefore, consulting with your GP or healthcare practitioner may be beneficial before starting an exercise plan, particularly if you have a diagnosis of BDD.

Healthy eating habits

Eating regularly can keep your blood sugar level stable. It is important to keep blood sugar levels stable as this can have an impact on your mental health. Eating foods like fruit, vegetables, and slow-release carbohydrates can help you feel energised throughout the day. In addition, staying hydrated is important to help you maintain your concentration and prevent dehydration. However, some drinks act as a stimulant (e.g., tea, coffee, energy drinks, chocolate) or depressant (e.g., alcohol) which may make you feel anxious, irritable, or depressed. Keeping note of when foods and drinks aggravate your BDD symptoms may help you decide what works best for you. You may find it easier to plan your meals ahead on days you feel better so you don’t have to worry about food preparation on days you feel unwell. 

Social support system

A social support system may include your family and friends. It is really useful to have a social support network that can offer a space to talk, as well as offer practical advice. Joining support groups is another way you can talk about how you are feeling. These groups can help provide you with support from those who are able to understand your feelings and empathise with what you are going through. Support groups may be useful to:

• Offload your feelings when you are finding things difficult
• Get new ideas about how to manage your BDD
• Receive encouragement and feedback from others

Avoiding triggers

Those with BDD may have certain triggers that encourage unhealthy thinking patterns. 

Triggers may include:

• Image-centric social media platforms (e.g., Instagram, Tiktok)
• Easily accessible mirrors
• Bullying 

Triggers may be reduced by:

• Not placing mirrors in places where you often go (e.g., bathroom)
• Moving weighing scales out from your bedroom
• Limiting the amount of time you spend on social media

Many other triggers may intensify BDD symptoms and may be unique to an individual's BDD diagnosis.

Other coping strategies

Avoiding comparisons

Obsessively comparing yourself to others can fuel your body dysmorphia. Therefore, it is important to combat this by celebrating your successes and noticing what you have done well. You may ask your friends or family what they like about you, and keep a list of these to look back on when you feel yourself comparing your body to others. 

Limiting time spent on appearance

Practising ritual reduction strategies may help increase positive feelings towards yourself and your body. Techniques may include setting a timer for getting ready in the morning, only having a quick check of yourself in your mirror before leaving the house, and getting rid of excessive mirrors within your home. You may even find it useful to practise wearing no makeup on a video call with a close friend or family member. There are many strategies and resources that can be used to help reduce the amount of time spent on your appearance.

Journaling

Keeping a journal may help you to express your emotions. A mindfulness journal can help you to practise mindful living and staying present. In addition, a gratitude journal can help you to learn to be grateful for your body and flaws. Journalling can look different for everyone and can take the form of writing, video, or talking. Sometimes, you may need a little bit more help to start journaling by using journal prompts. 

Art and music therapy

Although there has been little research to suggest art and music therapy should be used for the treatment of BDD, art and creative therapies may be useful if you find it difficult to put what you feel into words. Music and art therapy is not necessarily about creating a masterpiece, but rather providing an outlet for your feelings. 

Summary

Body dysmorphic disorder (BDD) refers to a condition whereby an individual has a preoccupation with their own appearance and associated flaws, which are unnoticeable by others. Psychotherapy, in particular CBT, has been proven useful for the treatment of BDD. Medications such as selective serotonin reuptake inhibitors and clomipramine can also be effective to alleviate BDD symptoms in some people. Experts recommend a combination of both CBT and medication for the most beneficial effect. Self-care techniques such as mindfulness, healthy eating, exercise, journaling, and art therapy can be useful for some people with body dysmorphia.