What is Body Dysmorphic Disorder (BDD)

Body Dysmorphic Disorder, or BDD, is an anxiety disorder whereby a person is abnormally preoccupied with an imagined or slight defect in their physical appearance.

The person’s perceived defect may not be noticeable to others, but is excessively obvious to the sufferer, who may spend several hours a day checking their appearance in mirrors or comparing themselves to others. Common focus points include a bump on the nose, superficial skin problems, or body shape and/or weight. The difficulty with this disorder is that BDD sufferers often think that the problem is solely with a physical feature and do not realize that it is in fact a psychological disorder.

BDD was first documented in 1886 by the researcher Morselli at the time naming the condition simply “Dysmorphophobia”. However BDD was only truly recognized by the American Psychiatric Association in 1987. BDD is a mental disorder, which involves a disturbed body image. The disorder combines obsessive and compulsive aspects which has linked it to the OCD (Obsessive Compulsive Disorder) spectrum of disorders among psychologists. People with BDD may engage in compulsive mirror checking behaviors or mirror avoidance, typically think about their appearance for more than one hour a day and in severe cases may drop all social contact and responsibilities as they become homebound.

Most people wish they could change or improve some aspect of their physical appearance, but people suffering from BDD, generally considered of normal appearance, believe that they are so unspeakably hideous that they are unable to interact with others or function normally for fear of ridicule and humiliation at their appearance.

They tend to be very secretive and reluctant to seek help because they are afraid others will think them vain or they may feel too embarrassed to do so. Ironically BDD is often misunderstood as a vanity driven obsession, whereas it is quite the opposite; people with BDD believe themselves to be profoundly ugly or defective. Actually, a common question asked by those learning about BDD is ‘what is it that separates someone with the disorder from the average person who might worry about their weight or wish they could change something about themselves?’ As mentioned although most people are concerned to some extent about their image/physical appearnce, a person with BDD is preocupied with how they look. Unfortunatley this proccupation creates significant emotional distress and can interfere with daily functioning and relationships with others. The obsession with the perceived flaw is so great in some sufferers that Katherine Philips, in her book “The Broken Mirror”, documents research which found that one third thought about the perceive defect or defects between 1 to 3 hours per day, and nearly 40% for 3 to 8 hours per day”. When a mirror is not present, any shiny object or surface may be used to focus on the defect, eg shop windows, cutlery etc. What is important to remember is how these substitutes typically distort one’s reflection in any case and this might even serve to exacerbate the negative feelings being experineced by the person with BDD. Still the constant for every sufferer is that there is never truly a flaw deserving of such fixation – in fact, the presence of a veritable physical abnormality or injury means that BDD cannot be diagnosed.

Some sufferers may be quite aware of the absurdity of their actions, but remain helpless to stop their self-defeating behaviour. Others are described as having tunnel vision; their negative self-image is so internalized and their beliefs so rigid that treatment is difficult.

The amount of energy which a sufferer puts into mirror-gazing and obsessing will naturally have an impact on their life in all spheres. Across the spectrum of body areas which sufferers may fixate upon, it is typical for a sufferer to prepare for leaving the house by spending literally hours applying make-up, or attempting to conceal the perceived flaw with clothes, scarves etc. Unfortunately many sufferers will avoid social outings and working in communal situations altogether. In today’s society young people are under more pressure than ever to fit a mould which circles around images of perfection in magazines and on TV. It is no surprise that, like eating disorders, onset of BDD classically occurs during the impressionable years of adolescence, when peer comments are so freely offered and received. In regards to Ireland, young people also have more money at their disposal than ever before, and therefore more occasion to cosmetically alter their appearance. For a typical, average teen this might involve make-up or the odd application of ‘fake tan’. However a sufferer of BDD will likely go to the longest lengths to ease their anxieties. Currently there are increasing numbers of cosmetic surgeries opening to cater to the growing number of Irish people who wish to have surgery and can afford it. Most candidates will elect to have surgery after measured deliberation; however, following alarming reports that between 6% and 20% of those seeking cosmetic surgery actually suffer from BDD. There have been recent calls for improved screening procedures for those seeking surgery.

BDD usually develops in adolescence a time when people are generally most sensitive about their appearance.

However many sufferers leave it for years before seeking help. When they do seek help through mental health professionals, they often present with other symptoms such as depression, social anxiety or obsessive compulsive disorder and do not reveal their real concerns. Most patients cannot be convinced that they have a distorted view of their body image, due to the very limited insight of the disorder when compared to OCD or others. According to the DSM IV, which is the fourth edition of the Diagnostic and Statistical Manual used by mental health professionals for diagnosis purposes, the following criteria must be met in order to receive a definite diagnosis for Body Dysmorphic Disorder:

  • The patient is preoccupied with an imagined defect of appearance or is excessively concerned about a slight physical anomaly.
  • This preoccupation causes clinically important distress or impairs work, social or personal functioning.
  • Another mental disorder (such as Anorexia Nervosa) does not better explain the preoccupation.

The following are some symptoms which psychologists look for in order to make a diagnosis of BDD:

  • Compulsive mirror checking, glancing in reflective doors, windows and other reflective surfaces.
  • Alternatively, an inability to look at ones own reflection or photographs of oneself; often the removal of mirrors from the home.
  • Compulsive skin-touching, especially to measure or feel the perceived defect.
  • Reassurance seeking from loved ones.
  • Social withdrawal and co-morbid depression.
  • Obsessive viewing of favorite celebrities or models the person suffering from BDD may wish to resemble.
  • Excessive grooming behaviors: combing hair, plucking eyebrows, shaving, etc.
  • Obsession with plastic surgery or multiple plastic surgery with little satisfactory results for the patient.
  • In obscure cases patients have performed plastic surgery on themselves, including liposuction and various implants with disastrous results.

In research carried out by Dr Katharine Philips, involving over 500 patients, the percentage of BDD patients concerned with the most common locations were as follows:

  • Skin – 73%
  • Hair – 56%
  • Nose – 37%
  • Weight – 22%
  • Stomach – 22%
  • Breasts/chest/nipples – 21%
  • Eyes – 20%
  • Thighs – 20%
  • Teeth – 20%
  • Legs (overall) – 18%
  • Body build / bone structure – 16%
  • Ugly face (general) – 14%
  • Lips – 12%
  • Buttocks – 12%
  • Chin – 11%
  • Eyebrows – 11%

It is important to remember that individuals with BDD often have more than once area of concern.

An absolute cause of body dysmorphic disorder is unknown and more research is needed. However current studies show that a number of factors may be involved and that they can occur in combination, including: A chemical imbalance in the brain: the theory is that an insufficient level of serotonin, one of the brain’s neurotransmitters involved in mood and pain, may contribute to body dysmorphic disorder. Although such an imbalance in the brain is unexplained, it may be hereditary. Obsessive-compulsive disorder: BDD often occurs with OCD. This is where the patient uncontrollably practices ritual behaviors that may literally take over their life. A history of, or genetic predisposition to, OCD may make people more susceptible to BDD. Generalized anxiety disorder: Body dysmorphic disorder may co-exist with generalized anxiety disorder. This condition involves excessive worrying that disrupts the patient’s daily life, often causing exaggerated or unrealistic anxiety about life circumstances, such as a perceived flaw or defect in appearance, as in BDD.

BDD is a hidden condition; therefore its incidence in Ireland, like most countries, is unknown.

The best estimate of incidence here is one in every 100 people, although this is conservative. The bulk of studies into the prevalence of BDD have been carried out in the United States. The disorder often co-presents with another illness, such as depression and/ or obsessive compulsive disorder. BDD has also been found in much higher rates among those seeking to alter their appearance cosmetically. In a dermatology setting, 12% of patients screened positive for BDD, and in cosmetic surgery settings, rates of 6%-20% have been reported.

Many individuals with BDD have repeatedly sought treatment from dermatologists or cosmetic surgeons with little satisfaction before finally accepting psychiatric or psychological help.

Treatment can improve the outcome of the illness for most people, especially as it is thought the symptoms persist unless treated, often becoming worse as the symptoms and concerns of the sufferer diversify and social contacts further deteriorate. In other words, BDD is chronic. Therefore, treatment should be initiated as early as possible following the diagnoses. The Los Angeles Body Dysmorphic Disorder Clinic website has recently been launched. Additional BDD Facts provided by Dr David Veale, Consultant Psychiatrist and accredited CBT Therapist can be found here.