Body Dysmorphic Disorder
As a therapist I sometimes work with clients who struggled with Body Dysmorphic Disorder, and because of it's close links to eating disorders, I wanted to have a closer look at it here. In this first post, I will look at what BDD really is, and how it can affect a person's life; in the follow -up post, I will be looking at the links between BDD and eating disorders, and current thinking on the best ways to approach and treat it.
WHAT IS BDD?
BDD, or Body Dysmorphic Disorder, is a complex disorder characterised by an extreme concern about one or more perceived defects in your physical appearance (different from the much more common body image dissatisfaction) ; Due to the sufferer's belief that they look “hideous,” individuals with BDD suffer from overwhelming distress and can have trouble focusing on anything besides their perceived defect/s. This contributes to a severely diminished quality of life, and in extreme cases, BDD may lead to social isolation, repeated hospitalisation, and even suicide.
BDD is considered to be similar to that of Obsessive-Compulsive Disorder (OCD), and learning how to recognise and identify this severe mental illness can be life-altering, and possibly life-saving, if you, or someone you love, are struggling with this condition.
BDD is classified in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition) and defined, like all mental disorders, by certain criteria and behaviours. For a diagnosis of BDD , three criteria need to be met.
First, the sufferer must be either preoccupied with an imagined defect in their appearance or excessively concerned about a slight physical anomaly.
Secondly, the sufferer must be significantly distressed by their preoccupation or excessive concern with their appearance and/or be impaired in terms of what social or work-related activities they are able to participate in.
3: NOT SOMETHING ELSE
Finally, the sufferer's preoccupation must not be better diagnosed under the heading of a different mental illness, such as anorexia, where concern about body image is also a factor (1) (I'll look more at the connection between BDD and eating disorders in the follow-up post)
LIVING WITH BDD
Social situations are incredibly difficult, because people with BDD feel they are going to be so negatively judged by others, and this makes dating and intimacy almost impossible.
Self-medication with alcohol is a common method used to help endure social situations; another response can be complete avoidance, resulting in social isolation and even becoming housebound, with severe consequences for other areas of life such as jobs and study.
Other people can struggle to understand the extent of the disability the person with BDD faces. Friends and family will frequently try to convince BDD sufferers that their perceived flaw is small or even invisible to others, but this will have little or no impact.
Appearance comparison can be a constant struggle for individuals with BDD, (as it can for those with eating disorders); they frequently and silently compare their specific body parts with those of others, often concluding that they are less attractive (2). These comparisons increase levels of body dissatisfaction, mainly due to the fact that, like with eating disorder sufferers, comparison is usually only made with people we already consider more attractive.
Living with BDD can make even everyday, normal activities challenging and overwhelming, creating an overall poor quality of life. Individuals with BDD are at increased susceptibility for suicide, with research finding that in approximately 80% of individuals with BDD report suicidal thoughts, and about one quarter having attempted suicide (3).
In fact, People with BDD are at a high risk for depression and suicide and have been shown to have a greater degree of self-reported distress than people with depression, diabetes, or bipolar disorder (3).
HOW COMMON IS BDD?
BDD affects about 1 in 50 people, so that's up to 7.5 million people in the U.S.A. alone. It is possible the figure is a lot higher, as people with BDD are often very reluctant to reveal their symptoms to other people (4)
Children can get BDD too, but they are often unable to articulate their problems; instead, signs that they are ill can include refusing to attend school and making plans for suicide.(5)
Because BDD is a mental illness associated with high morbidity (ratio in a population of people getting ill or unhealthy) and mortality (ratio in a given population of people dying from the illness), early intervention is vital for overall improved functioning ,quality of life, and improved chances of a full recovery.
SYMPTOMS AND BEHAVIOURS
If you have BDD, you may be excessively concerned with any part of your body, but there are common areas of preoccupation, including:
Some people have a very precise complaint about a particular feature; others have a vaguer perception of being ugly (6).
Sufferers will attach really strong meanings to their beliefs about their appearance, and project these anxieties and beliefs on to other people, who they assume are judging them negatively because of it. This can obviously be incredibly disabling socially.
The sense of being disfigured remains very real and sufferers spend a lot of time either examining the perceived defect, by staring in the mirror for excessively long periods of time, trying to disguise it through long grooming rituals, or even trying to change the perceived flaw with DIY surgeries,such as reshaping their nose by filling it with tissue paper . I had a client once who used a small paring knife to painstakingly file off corners of her teeth that she considered uneven.
Sufferers will often go on to cosmetic surgery procedures, because it feels like the only option for a 'normal' life. Unfortunately, sufferers often find the preoccupation isn't resolved by the surgery and they continue to feel just as bad (if not worse, because a potential lifeline has disappeared); on the occasions that patient satisfaction is achieved and the BDD sufferer feels the 'flaw' has been resolved, 50% have been shown to develop a new preoccupation with a different body part (7)
WHAT CAUSES BDD?
BDD is under-researched compared with other disorders of body image such as eating disorders, but,as with eating disorders there are biological and psychological explanations for its development.
The Biological model is where you have a genetic predisposition to the condition, which can emerge if you're exposed to certain life stressors such as bullying or abuse. In this model, once it has developed, it is thought to be perpetuated by an imbalance in neurotransmitters such as serotonin
The Psychological model has more in common with earlier ideas about the development of eating disorders. In this model BDD is seen to be related to low self-esteem and a tendency to judge yourself according to appearance. A person may develop harmful and negative beliefs linking a perceived defect in their appearance to their value as a person: “If I am unattractive I am worthless"(8)
In this model, the BDD is then maintaining factors are by extreme self-focused behaviours such as appearance checking and comparing the feature perceived to be defective with that of other people (again as with eating disorders). As further research is carried out, it is likely that a more inclusive model will be developed.
(1) American Psychiatric Association, 2000. Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision. American Psychiatric Association.
(2) A behavioural model for BDD (Neziroglu, et al., 2008)
(3) Philips, KA: Quality of life for patients with body dysmorphic disorder. Journal of Nervous and Mental Disorders 2000;
(4) bdd:IOCDF website, KPhillips, M.D.,
(6) Veale, D: Body dysmorphic disorder. Postgraduate Medical Journal 2004;80:67-71
(7) Grant, JE, Kim, SW, Crow, SJ: Prevalence and clinical features of body dysmorphic disorder in adult and adolescent psychiatric inpatients. Journal of Clinical Psychiatry 2001;
(8) Veale op.cit