Body Dysmorphic Disorder
This page aims to help you understand more about Body Dysmorphic Disorder (BDD). I hope it answers some of the most common questions about its nature and treatment. It may be useful for individuals with BDD, their partners, friends, and families and to anyone who is concerned about how BDD affect people and what can be done about it. The page is for all age groups as BDD can also affect children and adolescents.
What is Body Dysmorphic Disorder?
Body Dysmorphic Disorder (BDD) is a body image problem. It is defined as a preoccupation with one or more defects in one's appearance in which most people can hardly notice or do not believe to be important. To fulfil the diagnostic criteria it must also either cause significant distress or handicap.
The older term for BDD is “dysmorphophobia” which is still sometimes used. The media sometimes refer to BDD as "Imagined Ugliness Syndrome". This isn't particularly helpful as the ugliness is very real to the individual concerned. Some patients will acknowledge that they may be blowing things out of all proportion. Others are so firmly convinced about their defect that they are regarded as having a delusion. Whatever the degree of insight into their condition, sufferers usually realise that others believe their appearance to be "normal" and have been told so many times.
When does a concern with one's appearance become BDD?
Many people are concerned to a greater or lesser degree with some aspect of their appearance but to obtain a diagnosis of BDD, the preoccupation must cause significant distress or handicap in at least one area of one’s life. For example, someone with BDD avoid a wide range of social and public situations to prevent themselves from feeling uncomfortable and worrying that people are evaluating them negatively. Alternatively a person may enter such situations but remain very self conscious. He or she may camouflage themselves excessively to hide their perceived defect by using heavy make up, brushing their hair in a particular way, changing their posture, or wearing heavy clothes. They may spend several hours a day thinking about their perceived defect and asking themselves questions that cannot be answered (for example, ”Why was I born this way?”, “If only my nose was straighter and smaller”) They may feel compelled to repeat frequently certain time consuming behaviours such as:
• Checking their appearance in a mirror or reflective surface
• Seeking reassurance about their appearance
• Checking by feeling one’s skin with one’s fingers
• Cutting or combing their hair to make it "just so".
• Picking their skin to make it smooth.
• Comparing themselves against models in magazines or people in the street
Which are the most common areas of the body involved in BDD?
Most people with BDD are preoccupied with some aspect of their face and many believe they have multiple defects. The most common complaints (in descending order) concern the nose, the hair, the skin, the eyes, the chin, the lips or the overall body build. People with BDD may complain of a lack of symmetry, or feel that something is too big or too small, or that it is out of proportion to the rest of the body. Any part of the body may be involved in BDD including the breasts or genitals.
How common is BDD?
It is not known what proportion of the population suffers from BDD, although it is recognized to be a hidden disorder as many people with BDD are too ashamed to reveal their main problem. One survey has put BDD at about 1% of the population. Mild BDD is probably more common in women and in adolescents.
When does BDD begin?
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.
How disabling is BDD?
It varies from slight to very severe. Many sufferers are single or divorced which suggests that they find it difficult to form relationships. It can make regular employment or family life impossible. Those who are in regular employment or who have family responsibilities would almost certainly find life more productive and satisfying if they did not have the symptoms. The partners of sufferers of BDD may also become involved and suffer greatly.
What causes BDD?
There has been very little research into BDD. In general terms, there are two different levels of explanation one biological and the other psychological. A biological explanation would emphasise that a person might have a genetic predisposition to the disorder which under certain stresses make it more likely for them to develop BDD. Certain stresses especially during adolescence such as teasing or abuse may precipitate the onset. A psychological explanation would emphasise a person’s low self esteem and the way they judge themselves almost exclusively by their appearance. They may fear being alone and isolated all their life or being worthless. Some may demand perfection in their appearance and an impossible ideal. Once the disorder has developed, then it is maintained by excessive self-focussed attention and ruminating, the avoidance behaviours, excessive checking, comparing and reassurance seeking.
What are the other symptoms of BDD?
Sufferers are usually demoralized and many are clinically depressed or have social phobia. Many similarities and overlaps have been noted between BDD and Obsessive Compulsive Disorder (OCD) such as intrusive thoughts and frequent checking. Many BDD patients have also suffered from OCD at some time in their life.
Are people with BDD vain?
No! People with BDD believe themselves to be ugly or defective. They tend to be very secretive and reluctant to seek help because they are afraid that others will think them vain or narcissistic.
How is the illness likely to progress?
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. Others may function reasonably well for a time and then relapse. Others may remain chronically ill. Research on outcome without therapy is not known but it is thought the symptoms persist for many years.
What treatments are available?
There has been very little research on the treatment of BDD. The NICE guidelines on BDD recommend two treatments: cognitive behaviour therapy and serotonergic anti-depressant medications. As yet, there have been no controlled trials to compare different treatments to determine which is the most effective or which treatment best suits which person.
Cognitive Behaviour Therapy
Cognitive Behaviour Therapy is based on a structured programme of self-help so that a person can learn to change the way they think and act. A person’s attitude to their appearance is obviously crucial as we can all think of people who have a defect in their appearance such as a port wine stain on their face and yet are well adjusted because they believe that their appearance is just one aspect of themselves. During therapy individuals learn alternative ways of thinking about their appearance and to refocus their attention away from themselves. They learn to give up comparing their appearance and ruminating. They confront their fears without their camouflage and stop rituals such as checking and excessive grooming. The main side effects of the treatment are the anxiety that occurs in the short term. However facing up to the fear gets easier and easier and the anxiety gradually subsides.
The second type of treatment is anti-depressant medication which is strongly “serotonergic”. The dose may need to be in the high range and taken daily for at least 12 weeks to determine it’s effectiveness. The medication may provide either a total cure or no benefit at all. If the drug is effective then a person will need to remain on it for at least a year, often longer as discontinuing the medication may lead to high rate of relapse. It is not known how the medication “works” but it may do so in the absence of depression. Such a drug may be used either alone or in combination with cognitive behaviour therapy. Medication may have side effects but for most people these are minor irritations that usually decrease after a few weeks. Alternatively the dose may be adjusted or an alternative drug may be prescribed. The drugs are not addictive but you should stop them only under medical advice. Medication is especially helpful when you are depressed as it may help in improving your motivation to take advantage of the CBT. The risk of relapse can probably be minimised by combining the medication with CBT.
NICE guidelines on Obsessive Compulsive Disorder, 2005, contains guidance on Body Dysmorphic Disorder.
The Broken Mirror (Understanding and Treating Body Dysmorphic Disorder)” by Katharine Phillips (Oxford University Press)
Overcoming Body Shame and Body Dysmorphic Disorder by David Veale and Rob Willson (Robinson) (forthcoming mid 2007)
The film “Looks that Kill” features a patient who was treated at the Priory Hospital North London. The video is available from Films of Record - (Phone) 020 7286 0333
Websites for BDD
*** For more information about the author and his work, please visit David Veale's homepage at http://www.veale.co.uk/ ***