What's to know about body dysmorphic disorder

Body dysmorphic disorder is a relatively common mental health condition in which a person experiences excessive anxiety about a perceived defect in their physical appearance.

Individuals with body dysmorphic disorder (BDD) may worry about any part of their body, but the face and hair are common areas of concern.

A person may be anxious that they have a crooked smile, uneven lips, or some other feature. Some people may think their acne or facial hair is more visible and significant than it is. Others fear that their whole appearance is unacceptable.

This article looks at some of the reasons why BDD might occur, how to recognize it, and how to get treatment that can improve a person's quality of life.

What is body dysmorphic disorder?

Most people worry about some feature of their face or body at some time, but a person with BDD may spend long periods thinking about physical details that are barely noticeable or not visible to other people. This concern can become an obsession.

The condition has little to do with real physical appearance but rather an individual's body self-image, or how they see themselves.

One study suggests that BDD affects 0.7–4.0 percent of people in the United States. People aged between 15–30 are most likely to develop BDD, and it is more common in women than men.

A study published in 2010 notes that people who identify as LGBTQ+ are more likely to report symptoms than people of heterosexual orientation. The National LGBT Health Education Center also note that bullying, rejection, and other stressors may increase the risk of BDD in the LGBTQ+ youth community.

Many people with BDD experience levels of anxiety that can have a significant impact on their relationships and quality of life.

Reassuring a person with BDD that the flaw they perceive is either not real or not significant will not help.

However, if a person with BDD receives an accurate diagnosis, treatment with medication and cognitive behavioral therapy (CBT) can help.

Criteria for BDD

The Diagnostic and Statistical Manual – Fifth Edition (DSM–5) list the following criteria for diagnosing BDD:

• Preoccupation with one or more imperfections in a person's appearance that others cannot see or that are very slight.

• Carrying out repetitive behaviors, such as mirror checking, touching, rubbing or picking at the perceived flaw, or drawing comparisons with others.

• Preoccupation that causes significant distress, leaving the person unable to function effectively in social, occupational, and other areas of life.

• The concern does not relate to weight or body fat in people who have an eating disorder, such as anorexia nervosa.

Causes

Doctors do not really know what causes BDD, but there are some possible reasons why it might happen.

An inherited condition: One small study has suggested that specific genetic factors may play a role. The study notes that 8 percent of people with BDD have a close family member who has had the condition at some time.

Obsessive-compulsive disorder (OCD): BDD often affects people who have a diagnosis of OCD or who have a relative with OCD. One study notes that 8–37 percent of people with OCD also have BDD. Similar genetic factors may underlie both BDD and OCD, but more research is needed. BDD also appears to respond to the same treatment as OCD.

Visual processing and other features of the brain: In a 2004 study where people did tasks involving drawing figures and viewing images, people with BDD were more likely to overfocus on details and perceive distortions than those without BDD. It is not clear whether these factors might be a cause or a result of BDD, but scientists continue to consider that these factors may play a role.

Low levels of the neurotransmitter serotonin: Scientists have found low serotonin levels in some people with BDD, but it is not clear what role serotonin plays, if any. When used as a treatment, serotonin appears to relieve some symptoms, but researchers say the link is likely to be complex.

Childhood experiences: According to one study, people who have experienced teasing or body shaming in the past may develop BDD. Having a heightened awareness of the concepts of beauty and harmony may also influence BDD, but the study notes that this could be a result of the disorder rather than a cause.

Teaching that places value on specific ideas of beauty may also contribute to the development of BDD, but more research is needed to confirm this.

Symptoms

The main symptom a person with BDD experiences is a preoccupation with a perceived flaw in appearance or an extreme reaction to a slight physical imperfection.

The symptoms are long-term and can come and go in intensity. The person's focus may also shift from one body part to another.

Typically, the areas in which people with BDD typically fixate include:

• the skin, for example, acne, greasiness, or wrinkles
• the face, for example, concern about facial hair

Special areas of concern may include:

• the nose
• the mouth
• the teeth
• the possibility of hair loss
• the breasts
• the genitals

Click here to find out more about small penis syndrome, which relates to concerns about the genitals.

This preoccupation may lead to the following behaviors:

• extreme self-consciousness about physical appearance
• repeatedly touching, picking, measuring or staring at the defect
• excessively reading about or researching the flaw
• neglecting work, social life, family, personal health and well-being, and other aspects of life due to preoccupation with the defect
• frequently checking the feature in mirrors, reflective doors, and other surfaces
• avoiding mirrors altogether and removing them from the home
• taking care to conceal the defect, for example through wigs, clothing, or makeup
• repeatedly visiting a dermatological or cosmetic surgeon in an attempt to correct the defect
• spending several hours a day thinking about the flaw and finding it hard to think about other things
• seeking agreement from others and feeling frustrated when others do not see the defect
• frequent taking of "selfies" as a way of seeking approval

It will not help for a friend or other person to explain that there is no defect or that it is not significant. Typically, the person with BDD will not believe them.

The person may believe that others are staring at them, talking about them, or mocking them, when they are not.

BDD can affect a person's quality of life. Some people with BDD experience such distress that they feel unable to go to work or socialize. They may also experience anxiety and depression, and some people may even consider suicide.

Diagnosis

Many people with BDD never get a diagnosis or receive appropriate treatment. This is because very few people seek help from a doctor or psychiatrist.

Instead, they seek help from an orthodontist, a dermatologist, a cosmetic surgeon, or another specialist who can make physical changes to the way a person looks.

Role of cosmetic surgeons in diagnosis

A study published in 2015 notes that, according to the Diagnostic and Statistical Manual fifth edition (DSM–5), 7–8 percent of people who seek plastic surgery in the U.S. have BDD. However, the authors note that the actual number may be far higher.

The authors urge plastic and cosmetic surgeons to be aware of the signs of BDD. If they believe the person seeking help may have BDD, they should encourage them to see a doctor or a psychiatrist, rather than agreeing to do the surgery straightaway.

One way they can do this is by using a BDD questionnaire. This diagnostic tool can help identify people who may be seeking physical changes for the wrong reasons.

If a person with BDD has surgery because they are excessively worried about a particular feature, they may find that they feel worse after surgery, or that the result is not what they expected.

Surgery is unlikely to resolve the symptoms of BDD, and it can also be risky and expensive.

A cosmetologist, or a person who studies or applies beauty treatments, might also decide to refer a person for counseling if:

• the person meets the DSM's criteria for BDD
• they have repeated surgery and never seem happy with the result
• a slight defect appears to be the most important thing in a person's life
• the person's concern seems excessive in relation to the size of the defect

Treatment

Treatment options include CBT and medication.

Cognitive behavioral therapy (CBT)

CBT aims to change the way a person behaves by challenging their beliefs and thinking. A person can develop a better understanding of why they are thinking in a certain way and how this affects their behavior.

CBT can help a person stop the negative thoughts that come automatically and encourage them to evaluate themselves more realistically and positively. Individuals can also learn healthful ways to handle urges or rituals, such as mirror checking.

Online CBT courses are available, which may be more affordable than face-to-face counseling.

Medication

Evidence shows that selective serotonin reuptake inhibitors (SSRIs), which are a type of antidepressant medication, can help relieve the symptoms of BDD in at least half of the people who use them.

Examples include fluoxetine, fluvoxamine, and citalopram.

Repetitive transcranial magnetic stimulation

Authors of a 2018 study mention another new technique that may help:

Repetitive transcranial magnetic stimulation (rTMS or TMS) involves stimulating specific parts of the brain using electromagnetic fields. Scientists are looking into using this technique to treat depression, psychosis, and anxiety disorders.

Outlook

BDD is a potentially severe mental health condition in which a person becomes excessively concerned with their appearance and a minor or imagined physical defect.

A correct diagnosis and appropriate treatment can help to:

• resolve the underlying issues that are causing BDD
• relieve the symptoms and help the person to see themselves in a new way
• prevent the person from seeking unnecessary and possibly risky surgery

A combination of medication and counseling can help to achieve this, but the first step is to be aware of what BDD is and understand the need for medical treatment.