Body Dysmorphic Disorder (BDD) is a disorder marked by an obsessive idea of perceived defects or flaws in one’s appearance. A flaw that to others, is considered minor or not observable.
Concerns range from looking “unattractive” or “not right” to looking “hideous” or “like a monster” and can be associated with shame or disgust. Preoccupations can focus on one or many body areas, most commonly from the neck up: the head, face, skin (i.e. perceived acne, scars, lines, wrinkles, paleness), hair or nose. However, any body area can be the focus of concern. Some individuals are concerned about perceived asymmetry and the complaint can either be very specific (i.e. bumpy nose) or sometimes vague (i.e. “inadequately firm” eyes). In response to this preoccupation, the individual feels driven to constantly check their appearance and other compensating behaviors (i.e. comparing, camouflaging, overuse of cosmetics) which are time-consuming and cause even more distress. Unfortunately, the COVID- 19 pandemic triggered many people who have this condition because with more frequent video calls like Zoom and just being at home more, they found themselves having to look at their appearance more than ever. In this next article, I will provide awareness and knowledge of BDD in the hopes of bringing people with BDD out of hiding and increase access to treatment as BDD does not go away on its own.
Most people care about looks but people with BDD care too much. It’s important to discern the difference between normal appearance concerns about parts of the body that people are aware of but tend not to focus on for more than a brief moment. In contrast, individuals with BDD are greatly distressed, spend a lot of time ruminating about their perceived flaw (greater than 1 hour per day), and may eventually become depressed, not function in their lives (i.e. not leaving their homes, working or socializing), and at some point have suicidal thoughts. In fact, over 70% of people with BDD will have suicidal ideation over the course of their lives and their completed suicide rate is 45 times higher than the general population in the United States; that’s more than double the suicide rate of Major Depression. Furthermore, BDD is not as rare as you may think. The prevalence rate is 2% (5-10 million people) of the U.S. population which makes it more common than bipolar disorder or schizophrenia.
BDD usually begins during adolescence, but may not be diagnosed for many years. BDD is underdiagnosed and is often not reported due to shame, embarrassment, and humiliation for how they see themselves. Moreover, individuals with BDD often look normal, even attractive, but won’t tell others due to the fear that people will stare and judge, trivialize their concerns, or reassure them, which will confirm the presence of a defect. Many clinicians never ask about it and the condition can be masked by other disorders like depression, social phobia, obsessive-compulsive disorder (OCD) or substance abuse. BDD looks a lot like OCD with the focus on physical appearance. Individuals with BDD may go to dermatologists and plastic surgeons, rather than seek appropriate mental health care. The tragedy is even with plastic surgery, people with BDD usually don’t like the outcome and if they do like it, they will move on to obsess about another body part to take its place. You can’t fix a psychiatric problem with plastic surgery.
Cultural concerns about physical appearance and the importance of proper physical self-presentation may influence or amplify preoccupations about an imagined physical deformity but there are other factors. Emerging data supports a strong genetic vulnerability that accounts for around 45% variance of dysmorphic concerns. Studies using a functional MRI scan show that BDD brains have perceptual/visual processing abnormalities; they see faces differently and overfocus on detail and have difficulty seeing the big picture. People with BDD have a temperament/personality style that tends to be perfectionistic and hypersensitive to criticism and rejection. It may also be reinforced by a learned behavior if raised in a family with the message that one’s worth is equal to one’s appearance or a history of being rejected or teased by one’s peers.
The COVID-19 pandemic brought about the loss of control for all of us in our daily lives. There was a period where no barber shops, hair salons or gyms were open so nobody was going to look their best. We had to accept how we looked and that was even more challenging for people with BDD. For most people, the main concern was about not getting the virus and less of a concern about our appearance and perhaps that was a potentially helpful message for people with BDD to internalize. Curiously, some people with BDD found comfort in wearing a mask so their face became invisible to the world while others were distressed by the mask as it worsened their acne.
The mainstay of BDD treatment is cognitive-behavioral therapy and medication. Similar to the treatment of Obsessive Compulsive Disorder (OCD), high dose SRIs/SSRIs (like Prozac, Zoloft or clomipramine) can help with lessening BDD behaviors: less avoidance, less preoccupation with appearance, more ability to resist and control obsessions, less emotional pain (decreased depression and anxiety), less hostility, and anger and improved daily functioning; these medications can reduce BDD symptoms in about 2/3 of patients. Cognitive-Behavioral therapy focuses on modifying negative beliefs into more adaptive beliefs such as shifting “My nose defines my value as a person” to “My nose does not define me.” Or answering the questions, what is the worst that could happen and how could I survive it? Exposure Response Prevention based on OCD treatment helps to perform compulsions (such as mirror checking) less and less over time. Over time, the goal is to build confidence and help the individual to uncover strengths and courage to survive challenges and teach about relapse prevention. The key is to know one’s triggers (such as spending too much time on social media), be accountable for one’s behavior, and constantly walk away from compulsive behaviors (such as maintaining control over mirror use).
Isolation and BDD go hand in hand but BDD is treatable and a person can live a happy and healthy life once they engage in treatment and recover from BDD. We are so much more than our appearance and BDD effects the core of who a person is and how one views oneself. One (and perhaps our collective culture) must work on acceptance that allows one’s body to be okay and that nothing needs to be changed. With acceptance, a person is dropping the resistance to what is being (mis)perceived, and there is allowance for a bigger picture and the limitations of human life, the human body, and understanding. Acceptance allows a person to connect into that bigger context, which reroutes the energy of resistance into the direction of wisdom and how to build value and identity outside of one’s appearance.
If you would like to learn more about BDD, there are some excellent articles on the International OCD Foundation website, iocdf.org and videos on YouTube. I also recommend the following books: The Broken Mirror by Katharine A. Phillips, Feeling Good About the Way You Look by Sabine Wilhelm, BDD Workbook by James Claiborn and Cherlene Pedrick, and Cognitive Behavioral Therapy for Body Dysmorphic Disorder by Sabine Wilhelm, Katharine Phillips, and Gail Steketee. Please share this article if you think anyone could benefit from reading this.