What Is Body Dysmorphic Disorder?

Introduction

Body dysmorphic disorder (BDD), also known as body dysmorphia, is a mental health condition where someone is preoccupied by a perceived or minor physical defect which is often not noticed by others. 

It can affect people of any age, but is most common in young adults and teenagers. Having BDD does not mean that you are self-obsessed or vain, and it can be a debilitating condition. 

BDD shares many similarities with obsessive compulsive disorder (OCD), in that you develop obsessive thoughts and repetitive behaviours in response to those thoughts. 

The most common areas that people with BBD will focus on are:

• Face - such as nose, wrinkles, complexion and blemishes/moles
• Hair - such as thinning and baldness
• Skin appearance
• Breast size
• Muscle size and tone
• Genitalia¹

Symptoms

Obsessive thoughts about physical appearance

These can include:

• A strong belief that you have a flaw that is undesirable or makes you look deformed
• The belief that others are looking at you or focusing on the perceived defect
• Placing too much importance on appearance and often mistake attractiveness for happiness 

Repetitive behaviours

• Repeatedly seeking reassurance from others
• Repeatedly checking yourself in the mirror
• Repeatedly engaging in behaviours to hide or fix the perceived problem, such as applying makeup, wearing certain clothes, or certain styles
• Repeatedly comparing yourself to others
• Skin picking
• Excessively exercising or grooming

Avoiding social situations

People with BDD often feel embarrassed or ashamed by their appearance, and one safety behaviour to manage this is avoiding social situations. They do this due to thinking that others will notice their imagined or minor defect and react negatively to it. 

This can lead to isolation, which negatively impacts their overall mental health and can result in a cycle of engaging in avoidant behaviours, which reinforces their preoccupation with their physical appearance. 

Seeking reassurance from others

People with BDD will often seek reassurance from others regarding their appearance, but giving such reassurance can be unhelpful. Whilst the objective fact might be that they do not have their perceived flaw, someone with BDD will not see it the same way. It is important not to get drawn into debates about the person’s appearance. 

It is far better if the person with BDD is able to assure themselves that the perceived flaw either does not exist or is not as major as they perceive it to be. 

Self-harm or suicidal thoughts

BDD is often associated with depression and anxiety. Without the right support, the condition is unlikely to get better, therefore symptoms of anxiety and depression will get worse alongside it. This ongoing cycle of worsening mental health and perpetual preoccupation with imagined or minor flaws often leads to self-harm, suicidal thoughts and ultimately, it can lead to suicide attempts.  One study found that up to 80% of people with BDD have experienced suicidal thoughts, attempted suicide or completed suicide.² 

Causes

Genetics

There aren’t many studies that support a genetic link for BDD; however, some studies have shown that 8% of people with BDD have a family member with the condition.³ However, it is unclear whether this was influenced by environmental factors or not. Studies are inconclusive on whether BDD itself is hereditary, but a susceptibility to developing BDD may be hereditary. 

Environmental factors

These can include a history of being bullied or teased about their appearance, causing feelings of inadequacy or shame. 

Social media also plays a big part in the development of BDD, especially in teenagers and young adults. Witnessing images online where celebrities have been photoshopped to look perfect creates feelings of inferiority and hopelessness that they cannot achieve that level of perfection. 

Neurological factors

A study in 2000 suggested possible visual perception disturbances and/or visual-spatial information processing could influence distortions of their own image. 

In 2010, another study found that people with BDD performed poorly in recognising emotions in facial expressions compared to a control group. This adds to the idea that disturbances in visual information processing may contribute to perceived flaws, especially relating to the face.³

Diagnosis

Evaluation by a mental health professional

Getting help early is vital in optimising treatment for BDD. This would involve an initial consultation with your doctor, who will refer you to your local mental health service for more specialist assessment to establish a diagnosis and correct treatment pathway. 

Specialist assessment is required because BDD could be mistaken for a general dissatisfaction with body image, or another mental health condition such as anorexia.

In some instances, even more specialist assessment is needed. This is often when someone with suspected or diagnosed BDD wants to get surgery as a result of their preoccupation with their physical image. In this case, a professional who specialises specifically with BDD would be called upon to undertake a detailed assessment.

It is important to get the right kind of help because BDD is often associated with depression, anxiety, self-harm and suicide attempts. Treating BDD, alongside other mental health conditions and associated risks, requires regular input from a mental health service that can monitor progress and manage any deterioration or risk. 

Criteria for diagnosis

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), a diagnostic manual primarily used in the United States, there are 3 criteria for a BDD diagnosis:

1. There is a preoccupation with an imaginary physical defect or a minor imperfection, and the obsession is disproportionate
2. This preoccupation causes significant distress and impacts negatively on mental health and functioning
3. The preoccupation cannot be better defined by other mental disorders such as anorexia or general dissatisfaction with body size²

Treatment

Cognitive behavioural therapy

Cognitive behavioural therapy (CBT) is recommended by the National Institute for Clinical Excellence (NICE) as part of the treatment for BDD.⁴ This will focus on recognising negative thought cycles and changing your beliefs about your appearance through cognitive restructuring.⁴ It will also use exposure and response prevention (ERP) to help you to reduce negative behaviours associated with BDD.

Medications

Evidence indicates that selective serotonin reuptake inhibitor (SSRI) antidepressants are effective in treating BDD. NICE recommends starting with fluoxetine because it is the most effective SSRI for BDD.⁴

If you have not experienced symptoms of BDD for 6 to 12 months after starting, then you can start to gradually reduce your dose.⁶ 

It is important to speak to your healthcare professional about reducing or stopping medication. Sometimes reducing medication can result in an increase in symptoms of BDD and depression. 

Suddenly stopping antidepressant medication can result in withdrawal symptoms, such as: 

• Irritability 
• Restlessness 
• Trouble sleeping 
• Sweating  
• Increased anxiety 
• Increased suicidal thoughts⁵ 

Support groups

Support groups are advised as part of treatment and recovery from BDD, as these can provide a safe place to talk to people with similar experiences. You can gain support from others further along in their recovery and learn what has helped them. You may also be in a position to help others, which will help increase your self esteem and confidence. 

Lifestyle changes

It is important to not restrict your diet or engage in unhealthy activities. Positive changes such as eating healthily, exercising regularly (not excessively), and utilising relaxation techniques will all help in reducing feelings of anxiety and depression, which in turn will help to reduce symptoms of BDD. 

Prognosis

BDD can be treated but may require ongoing management

Treatment for BDD consists of medication, CBT and support groups. After 6 to 12 months without symptoms, it is generally thought that you can gradually reduce your medication.⁶ Medication for BDD is helpful but not advised as a long-term therapy. 

Your treatment will also involve CBT, which will help you develop strategies for managing negative thoughts and emotions, and your therapist will work with you to create a robust relapse prevention plan. The strategies learned in CBT will often need to be practised regularly to prevent a deterioration in your mental health. Attending support groups will help you meet people in a similar situation to yourself. 

Importance of seeking treatment early

Seeking help early is vital, as BDD is a condition that is unlikely to get any better on its own. If left untreated, it can lead to an increase in obsessive thoughts, repetitive behaviours, anxiety and depression. 

In some cases, people spend a lot of money on surgeries, and in the most serious cases, people engage in self-harm and experience suicidal thoughts. If help is not provided, some people attempt or succeed in ending their own lives. Cases like these highlight the importance of seeking help early.

The right treatment can help you recover, and, as with any mental illness, the earlier that you get help, the better the chances of recovering quickly. 

Summary

Whilst BDD is a fairly common condition (more common than schizophrenia or anorexia), it requires more research and is often under-diagnosed. It has serious implications and negatively impacts the person’s life, mentally, functionally, socially and physically.

BDD is characterised by a preoccupation with an imaginary or minor physical flaw, resulting in obsessive thoughts and repetitive behaviours that only maintain the condition and make it worse. It is often associated with anxiety, depression, suicidal thoughts and suicide attempts. People with BDD are unlikely to recover without the right support.

For this reason, it is important to seek professional support. This consists of ongoing assessment, medication, therapy and support groups. Ongoing support may be needed, but generally, people who engage well with mental health services do well in their recovery and are often able to come off medication. 

References

1. Body dysmorphic disorder - Symptoms and causes [Internet]. Mayo Clinic. [cited 2023 May 4]. Available from: https://www.mayoclinic.org/diseases-conditions/body-dysmorphic-disorder/symptoms-causes/syc-20353938

2. Bjornsson AS, Didie ER, Phillips KA. Body dysmorphic disorder. Dialogues Clin Neurosci [Internet]. 2010 Jun [cited 2023 May 4];12(2):221–32. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181960/

3. Li W, Arienzo D, Feusner JD. Body dysmorphic disorder: neurobiological features and an updated model. Z Klin Psychol Psychother (Gott) [Internet]. 2013 [cited 2023 May 4];42(3):184–91. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4237698/

4. Obsessive-compulsive disorder and body dysmorphic disorder: treatment [Internet]. NICE. 2005 [cited 2023 May 4]. Available from: https://www.nice.org.uk/guidance/cg31/chapter/Recommendations

5. Stopping or coming off antidepressants [Internet]. NHS. 2021 [cited 2023 May 4]. Available from: https://www.nhs.uk/mental-health/talking-therapies-medicine-treatments/medicines-and-psychiatry/stopping-or-coming-off-antidepressants/

6. Body dysmorphic disorder (BDD) [Internet]. NHS. 2021 [cited 2023 May 4]. Available from: https://www.nhs.uk/mental-health/conditions/body-dysmorphia/ 

This content is purely informational and isn’t medical guidance. It shouldn’t replace professional medical counsel. Always consult your physician regarding treatment risks and benefits. See our editorial standards for more details.

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Karl Jones

BA Hons in Learning Disability Nursing, Diploma in Mental Health Nursing (Oxford Brookes
University)

Karl has 12 years of experience in learning disability and mental health nursing in a variety of
settings. He has worked predominantly in general hospitals specialising in suicide prevention and the
psychological impact on long term health conditions. Most recently he has worked as a clinical
educator in the field of mental health. He is currently focusing on writing as a career with the aim of
imparting his knowledge to a wider audience.

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