Body Dysmorphic Disorder
Read “BODY DYSMORPHIC DISORDER (BDD)” by Michael Bennett, MBA, CAP, CAPP, ICADC, CCJS-MACe, CCFF
What is Body Dysmorphic Disorder (BDD)?
- Thinking too much about an imagined or slight flaw in a person’s own looks. (APA, 2000). If there is a slight flaw, the person’s concern is extreme.
- These unhappy feelings are consuming. These feelings cause harmful beliefs and attitudes that affect thoughts, emotions and behaviors. These can then harm all areas of a person’s life, such as their social activities and job.
- No other mental disorder, for example eating disorders, cause these consuming feelings.
What are the common signs and symptoms of BDD?
- Fixation and thoughts about appearance
- Mirror checking-Spending too much time staring in a mirror/shiny surface at the real or imagined flaw
- Avoidance of mirrors/shiny surfaces
- Their belief is very strong even if evidence does not support it (this is also called Overvalued Ideation or OVI)
- Covering up the “afflicted area.” (e.g. hats, scarves, make-up)
- Repeatedly asking others to tell them that they look okay (also referred to as ‘reassurance seeking’)
- Frequent unnecessary appointments with medical professionals/surgeons
- Repeated unnecessary plastic surgery
- Compulsive skin picking. Often, nails and tweezers are used to remove blemishes/hair
- Avoiding social situations, public places, work, school, etc.
- Leaving the house less often or only going out at night to prevent others from seeing the “flaw”
- Keeping the obsessions and compulsions secret due to feelings of shame
- Emotional problems, such as feelings of disgust, depression, anxiety, low self-esteem, etc.
How do you tell the difference between being unhappy with a part of your appearance and BDD?
Many people are unhappy with some part of the way they look, however, this is on a scale. When thinking about the body part becomes incapacitating and interferes with the person’s quality of life and functioning, then the person is diagnosed with BDD. This stress can appear in many ways, but often through anxiety and depression.
What parts of the body are the focus of BDD?
- Most often, the flaw or slight imperfection is located on the head or face (e.g. hairline, nose, acne, neck, etc.)
- However, any body part may be the focus. Some common areas include: arms, legs, stomach, hips, etc.
Who struggles with BDD and when does it start?
BDD can affect anyone. However, body image concerns most commonly begin in adolescence when children begin to compare themselves to their peers. Some research suggests that BDD may affect at least 1 in 200 people, however no exact number is known.
Are only women diagnosed with BDD?
No, an equal number of men and women are diagnosed with BDD. Men are often concerned with their hairline or how muscular they are.
Can BDD get worse as the person ages?
Yes. Often, if a person struggles with image concerns at a young age, they become more unhappy as they struggle with the physical changes that come with age (gray hair, loss of hair, wrinkles, weight gain, etc.).
What are the effects of BDD?
The stress of BDD can be very severe. The stress can lead to an unending search of unnecessary medical and surgical procedures, avoiding daily activities, avoiding job duties, avoiding social situations, suicidal thoughts and attempts, etc. Research shows that up to 80% of people with BDD think about or try to commit suicide.
Are BDD and obsessive compulsive disorder (OCD) related?
Recent research suggests that BDD is an “obsessive-compulsive spectrum disorder.” This is because there are both obsessions and compulsions. Obsessions are unwanted thoughts or images that cause anxiety and distress. Compulsions are repeated mental or behavioral acts done to reduce the anxiety caused by obsessions. With regard to BDD, obsessions appear as unwanted negative thoughts about appearance that lead to compulsions. These compulsions usually involve disguising or coping with the imagined flaw.
Can BDD be treated?
Yes. Cognitive Behavior Therapy (CBT) is used to challenge the beliefs that appearance can be perfect and that others focus on those flaws. Exposure and Response Prevention (ERP), using both thoughts and real life situations, are also used to prove whether these thoughts are accurate. For example, a girl who is concerned with a slight bulge in her stomach may be asked to go in public wearing a tight fitting t-shirt then observe how many people are actually staring at her stomach. Another technique may be to take a picture of her in the tight fitting shirt and have people rate her attractiveness.
Does plastic surgery cure BDD?
People with BDD often try to “fix” the flawed body part with surgery. However, not only may it cost a lot of money, but, even with surgery, people with BDD, will never be satisfied with the area of concern.
Are there medicines that can help reduce BDD?
Usually, a recommended treatment plan for BDD would be a combination of CBT and medicine. Medicine may aid in decreasing symptoms of depression and anxiety that commonly accompany BDD. The most common medication prescribed for BDD are anti-depressants, specifically Selective Serotonin Reuptake Inhibitors (SSRI).
Where can I find more information?
BDD Central (www.bddcentral.com) Association for Behavioral and Cognitive Therapies (www.aabt.org ) National Alliance on Mental Illness (www.nami.org ) Mental Health America (www.nmha.org ) Authors: Fugen Neziroglu, PhD and Jill C. Slavin, PhD, BioBehavioral Institute, Great Neck, NY. Reprinted with permission from the International OCD Foundation (IOCDF), PO Box 961029, Boston, MA 02196, 617.973.5801 http://www.ocfoundation.org
Body Dysmorphic Disorder (BDD)
By Michael Bennett, MBA, CAP, CAPP, ICADC, CCJS-MACe, CCFF
Michael Bennett is an international and state certified additions professional and a certified criminal justice specialist. He is also a clinically certified forensic counselor. Michael has worked as a behavioral health counselor, program manager and administrator for over 40 years. He has also been an international accreditation surveyor for CARF and provided consultation services to behavioral healthcare organizations throughout the United States for over 20 years.
Many of us are concerned about our appearance. Some of us are troubled about our appearance more than others. When these worries become so excessive so that they occupy a significant amount of our time, and our attention is focused on a specific body part or a specific body feature, we may be suffering with Body Dysmorphic Disorder (BDD). Perhaps our nose and/or ears don’t seem to be shaped correctly or maybe one ear seems higher or lower than the other. Maybe our eyes are too close together or are too far apart. Maybe we think that we have an unsightly scar or other blemish or wrinkles, etc. When reassurance from others, perhaps even our doctor and/or therapist, does little to convince us that there’s nothing horribly wrong and we cannot stop obsessing about whatever it is that we perceive is wrong to the point that this worry significantly interferes with how we are able to function each day, then we may be experiencing BDD.
Those with BDD often avoid mirrors or, conversely, use them for checking far more often than others. They frequently avoid social contacts, tending to isolate themselves from others because of their perceived “physical abnormality”. They sometimes go to great lengths to hide their “physical defect” due to the anguish and torment that they suffer. Some even become agoraphobic or “homebound” for days or even weeks. Whatever the concern, it is much different than the usual; “I need to lose a little weight,” or, “Do you think my nose is a little too big?”, questions that many of us might ask. Those with BDD spend a significant amount of time and energy each day obsessing about whatever it is they feel is wrong with their body to the point that it interferes with work, school, relationships, etc.
BDD was first identified in 1886 by Italian psychiatrist Enrico Morselli, who named the disorder “dysmorphophobia” (Morselli, 1891). Sigmund Freud also encountered BDD while treating a patient in the late 1930’s. Freud described his patient as being so preoccupied about his nose that he was unable to function outside of his obsessive thoughts (Gunsted, 2003). BDD is a somatoform disorder wherein the affected person is overly concerned with his or her body image. Somatoform disorders are a group of mental disorders that are characterized by physical symptoms that suggest a medical disorder. However, somatoform disorders are a psychiatric condition because the physical symptoms that are present cannot be fully explained by a medical disorder, substance abuse, or another mental disorder.
BDD is an excessive concern about, and preoccupation with, a perceived defect of one or more physical attributes. Different patients express different concerns and most have more than one. This preoccupation causes clinically significant distress and this distress interferes with work as well as family and social relationships. BDD can co-occur with depression and anxiety and causes withdrawal and/or isolation probably due to the association of increased anxiety. Low self-esteem also appears to be characteristic of those with BDD.
BDD occurs equally in both men and women and it is estimated that approximately one to two percent (1–2%) of the world’s population meets the diagnostic criteria for Body Dysmorphic Disorder. (Phillips & Castle, 2001) The disorder appears to develop during adolescence to young adulthood: a period of life when the concern about physical appearance is heightened. Many suffer with BDD for years before actually seeking help. BDD is regarded as a spectrum of Obsessive Compulsive Disorder (OCD) along with hypochondria and trichotillomania. In each of these conditions the individual practices unmanageable habitual behaviors that can literally take over their life. A primary example of this ritualistic behavior is the practiced avoidance of certain situations and/or persons or groups of persons. A history of, or a genetic predisposition to OCD is believed to make an individual more susceptible to BDD.
BDD is linked to a diminished quality of life and, as stated previously, can be co-morbid with major depressive disorder, anxiety, social phobia, and social anxiety. The disorder is generally diagnosed in those who are extremely critical of one or more aspects of their physical-image and/or their self-image or physique, even though others may not be able to perceive a readily noticeable blemish, defect or disfigurement. The physical attributes that are most frequently the object of obsession for those who suffer with BDD are the hair, the skin and the nose. (Phillips, 2005)
Individuals with BDD have been found to have high rates of suicidal ideation, to attempt suicide and to complete suicide more often than others. Lifetime rates of suicide ideation range from 58% to 78% for those suffering with BDD (Phillips & Menard, 2006), with adolescents having even higher rates at 81%. (Phillips, Didie et al, 2006) Rief et al (2008) reported that the rates of suicidal ideation and attempted suicide among individuals with BDD have been shown to be seven times greater than those without BDD. Most profoundly, Phillips and Menard (2006) reported a preliminary finding suggesting that completed suicide among patients diagnosed with this disorder is 45 times greater than those found in the general population. (Phillips & Menard, 2006)
Social situations are frequently difficult for those with BDD, because they fear people may point out their imagined defect or avoid contact with them because of it. BDD can cause the sufferer to believe that s/he is unable to interact with others or function normally in social situations due to fear of ridicule and humiliation about their appearance. They can have difficulty maintaining relationships with others including peers, coworkers, classmates, family, and spouses. Some patients skip school and/or work repeatedly and may even become housebound (agoraphobic). Approximately 30% of those with BDD become housebound at some point for at least one week because of their disorder. (Phillips, Didie, et al 2008). This isolation and the avoidance of intimate relationships can act as a deterrent in seeking help.
The sufferer may falsely arrive at the conclusion that correcting his or her “deformity” is the only goal or is his or her primary objective and that, if there is a disorder, it was simply created by his or her “abnormality”. This erroneous belief leads to the false hypothesis that, should his or her “physical defect” be eliminated, the disorder and all of its associated “issues” will disappear. This error in thinking leads some sufferers to seek corrective surgery, sometimes by their own hand. However, surgery does not rectify the problem as the individual’s physical appearance is not the actual issue. In order for the sufferer to experience any improvement in his or her quality of life, the disorder (BDD) must be addressed rather than the object of the obsession. One study demonstrated that as many as one third of nasal reconstructive surgery requests were made by individuals with BDD. (Picavet & Prokopakis et al, 2011)
Diagnostic Criteria from the DSM-IVTR (2000)
A. Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person’s concern is markedly excessive.
B. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size as in Anorexia Nervosa).
Patients with Body Dysmorphic Disorder feel compelled to engage in ritualistic behaviors to confirm the perceived defect or avoid its recognition by others. These behaviors can include behaviors such as compulsive mirror checking or conversely, compulsive mirror avoidance, compulsive grooming (e.g., hair combing, hair plucking, picking skin, applying makeup), and repetitively comparing the perceived defect with the bodies of others. Sometimes patients overly or repeatedly solicit reassurance from others that their defect is “normal” and/or “not that bad.”
Thoughts and behaviors relating to the perceived physical defect occupy one hour or more per day and in some cases consume up to eight hours per day. Individuals with poorer insight are likely to spend more time dealing with the imagined or exaggerated blemish. Shame and embarrassment frequently keeps those with BDD from seeking treatment. If you or a loved one have any signs or symptoms of BDD outlined in this article, you should immediately discuss them with a qualified mental health or medical services provider. Body Dysmorphic Disorder usually doesn’t get better on its own. In fact, if untreated, it will probably get worse over time and can lead to suicidal thoughts and behavior.
Common symptoms of BDD can include but are not limited to:
- Obsessive thoughts about perceived appearance defect(s)
- Obsessive and compulsive behaviors related to perceived appearance defect(s)
- Major depressive disorder symptoms.
- Delusional thoughts and beliefs related to (a) perceived appearance defect(s)
- Social and family withdrawal, social phobia, loneliness and self-imposed social isolation
- Suicidal ideation and possible suicide attempts
- Anxiety; possible panic attacks
- Chronic low self-esteem
- Feeling self-conscious in social environments
- Strong feelings of shame
- Avoidant personality: avoiding leaving the home or only leaving the home at certain times
- Dependent personality: dependence on others, such as a partner, friend or family
- Inability to work or an inability to focus at work due to preoccupation with appearance
- Problems initiating and maintaining relationships (both intimate relationships and friendships)
- Alcohol and/or drug abuse
- Perfectionism (undergoing cosmetic surgery and behaviors such as excessive moisturizing and exercising with the aim to achieve an ideal body type and reduce anxiety)
Common compulsive behaviors associated with BDD include but are not limited to:
- Compulsive mirror checking, glancing in reflective doors, windows and other reflective surfaces
- Alternatively, inability to look at one’s own reflection or photographs of oneself; also, removal of mirrors from the home
- Attempting to camouflage the imagined defect: for example, using cosmetic camouflage, wearing baggy clothing, maintaining specific body posture or wearing hats
- Use of distraction techniques to divert attention away from the person’s perceived defect, e.g. wearing extravagant clothing or excessive jewelry
- Excessive grooming behaviors: skin-picking, combing hair, plucking eyebrows, shaving, etc.
- Compulsive skin-touching, especially to measure or feel the perceived defect
- Unmotivated hostility toward people, especially those of the opposite sex (or same sex if homosexual)
- Seeking reassurance from loved ones and/or professionals
- Excessive dieting or exercising, working on outside appearance
- Comparing appearance/body parts with that/those of others, or obsessive viewing of favorite celebrities or models whom the person suffering from BDD wishes to resemble
- Compulsive information-seeking: reading books, newspaper articles and websites that relate to the person’s perceived defect, e.g. losing hair or being overweight
- Obsession with plastic surgery or dermatological procedures, often with little satisfactory results (in the perception of the patient) In extreme cases, patients have attempted to perform plastic surgery on themselves, including liposuction and various implants, with disastrous results
- Excessive enema use (if obesity is the concern)
The following is a list of the percentage of individuals who were concerned with a specific physical feature from a study completed by Dr. Katherine Phillips in 2005:
|• 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%)
• Facial Features (General) (14%)
• Face Size/Shape (12%)
• Lips (12%)
• Buttocks (12%)
• Chin (11%)
• Eyebrows (11%)
• Hips (11%)
• Ears (9%)
• Arms/Wrists (9%)
|• Waist (9%)
• Genitals (8%)
• Cheeks/Cheekbones (8%)
• Calves (8%)
• Height (7%)
• Head Size/Shape (6%)
• Forehead (6%)
• Feet (6%)
• Hands (6%)
• Jaw (6%)
• Mouth (6%)
• Back (6%)
• Fingers (5%)
• Neck (5%)
• Shoulders (3%)
• Knees (3%)
• Toes (3%)
• Ankles (2%)
• Facial Muscles (1%)
Treatment for BDD can be challenging as those with BDD most frequently present in dermatological or plastic surgery settings rather than in psychiatric, psychological or mental health offices. However, new and promising treatments are available to help those who suffer with BDD. Behavioral therapy, and especially cognitive behavioral therapy (CBT), is helping many individuals. Psychotropic medications such as the selective serotonin reuptake inhibitors (SSRIs, such as Zoloft, Luvox, Celexa, Paxil and Prozac) and serotonin reuptake inhibitors (SRIs such as Anafranil) are being used along with behavioral therapy to help many individuals overcome their BDD.
Cognitive behavioral therapy (CBT) is a short-term, objective based treatment that is focused on the “here and now”. It has been shown to be effective in addressing both BDD and OCD. During CBT sessions, the therapist and BDD sufferer focus on identifying and changing the thinking (obsessions), the intertwined behavioral patterns (compulsions) and the distorted beliefs. Strategies are developed to overcome avoidance and other ritualistic behaviors, many of which the individual may not have even been aware of prior to becoming engaged in therapy. Once an individualized and specific treatment plan is agreed upon, the BDD sufferer is asked to help repeat “exposure exercises” that will briefly increase his or her anxiety. It is this work that will naturally extinguish the BDD obsessions and compulsions over time. These specific and targeted strategies are repeated while in session and also practiced as homework under the therapist’s trained expertise and guidance. They are gradually increased until the symptoms are diminished. Successful therapy not only improves the individual’s struggles with his or her BDD but can also ameliorate any correlated depression and social anxiety symptoms.
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Hunt, TJ; Thienhaus, O; Ellwood, A (2008). “The Mirror Lies: Body Dysmorphic Disorder”. American Family Physician 78 (2): 217–22.
Morselli E. (1891). “Sulla dismorfofobia e sulla tafefobia: due forme non per anco descritte di Pazzia con idee fisse”. Boll R Accad Genova, 6, 110-119.
Phillips, K. A., Didie, E. R., Menard, W., Pagano, M., Fay, C., & Weisberg, R. B. (2006). “Clinical Features Of Body Dysmorphic Disorder in Adolescents and Adults”. Psychiatry Research, 141, 305-314.
Phillips, K. A., Didie, E. R. Feusner, J. & Wilhelm, S (2008). “Body Dysmorphic Disorder: Treating an Under-Recognized Disorder”. Am J Psychiatry 2008;165:1111-1118.
Phillips, K. A.; Castle, D. J (2001). “Body Dysmorphic Disorder in Men”. BMJ 323 (7320): 1015–6.
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Phillips, K. A. & Menard, W. (2006). “Suicidality in Body Dysmorphic Disorder: A Prospective Study”. American Journal of Psychiatry, 163, 1280-1282.
Picavet, Valerie A. M.D.; Prokopakis, Emmanuel P. M.D., Ph.D.; Gabriëls, Lutgardis M.D., Ph.D.; Jorissen, Mark M.D., Ph.D.; Hellings, Peter W. M.D., Ph.D. “High Prevalence of Body Dysmorphic Disorder Symptoms in Patients Seeking Rhinoplasty”. Plastic & Reconstructive Surgery: August 2011 – Volume 128 – Issue 2 – pp 509-517
Rief, W., Buhlmann, U., Wilhelm, S. Borkenhagen, A., & Brähler, E. (2006). “The Prevalence of Body Dysmorphic Disorder: A Population-Based Survey”. Psychological Medicine, 36(6), 877-885.