We all have a perceived imperfection regarding our appearance, however, most of us are able to accept it and carry on with our daily lives. An individual suffering from body dysmorphic disorder is unable to, as those with the disorder obsess over an imperfection until it becomes the only thing they see when they look in the mirror. This causes controlling thoughts that cause those with the disorder to spend an exorbitant amount of time (and money) to cover or conceal the flaw.
Body dysmorphic disorder is a psychiatric disorder that is related to obsessive-compulsive disorder.
Body dysmorphic disorder (BDD), also known as dysmorphophobia, is a relatively common disorder that affects approximately 1.7% to 2.4% of the population, with an almost equal distribution among men and women. The disorder’s onset usually appears first during adolescence; and is characterized by obsessive thinking about a flaw that is usually either imagined or hardly noticeable, compulsive checking of the perceived flaw, engaging in behaviors to minimize the appearance of the perceived flaw and hiding the disorder from others due to fear of social stigma.
Someone suffering from BDD will most likely spend hours a day obsessing over an aspect of their appearance [the most common areas being hair, skin, stomach, genitals, nose or chest]. They also tend to take excessive measures to hide from others, so people won’t notice their perceived flaw. Individuals with BDD are likely to exhibit one or many of the following behaviors or compulsions:
– Avoiding mirrors completely or removing them from the home
– Compulsive skin picking, using fingernails or tweezers to remove unwanted hair or blemishes
– Emotional problems, including depression, feelings of disgust, low self-esteem and anxiety
– Extreme exercise due to self-consciousness about physical appearance
– Excessive reading about or researching the flaw
– Leaving the house less often or only going out at night to try to ‘hide’ in the darkness
– Neglecting work, family, personal health and well-being due to fixation with the perceived flaw
– Repeatedly visiting a dermatological or cosmetic surgeon in an attempt to correct the defect
– Repetitive grooming activities (such as combing hair, shaving)
– Spending several hours a day thinking about the flaw and finding it hard to think about things
– Wearing excessive makeup or growing a beard to cover up the perceived flaw
Many people with BDD never get a diagnosis or receive appropriate treatment as few seek help from a doctor or psychiatrist. Instead, they typically seek help from a specialist who can make physical changes to the way the person looks. Additionally, BDD is not a disorder that’s on many clinicians’ radar causing many with the disorder to be misdiagnosed as having social phobia or major depressive disorder.
A red flag for the disorder is repetitive plastic surgery for the same or multiple perceived physical defects.
Plastic surgery and BDD tend to go hand and hand, as the common cosmetic procedures (i.e. rhinoplasty, breast augmentation, liposuction, collagen injections and fillers) all correspond to areas of the body that individuals with BBD focus on the most.
The typical BDD patient is perfectionistic and over-focused on small details. This causes the individual to have unrealistic expectations regarding their choice to pursue cosmetic surgery, leading to distress, dissatisfaction and new appearance preoccupations as some with the disorder ‘switch’ their area of obsessive focus after surgery. For instance, in a 2011 study, that focused on surgical and minimally invasive cosmetic procedures among persons with BDD, one participant told researchers, “After my nose job, my nose looked a little better, but my stomach took over for my nose.”
From similar studies performed on the topic, researchers are learning that BDD patients have abnormal functioning in their visual processing in the way they see faces and objects. This causes individuals to have a hard time accepting that the flaw is imagined, as seen in another patient from the 2011 study. A twenty-four-year-old male, after receiving liposuction and a male breast reduction, stated: “After the surgery… I went through a stage where I would weigh myself maybe 15 to 20 times a day. I would go to the work bathroom and lift my shirt up to look at my body.” And while he knew on some level that his appearance was now more in line with his imagined ideal, he had a hard time accepting the difference. “I know I’ve lost a lot of weight and I look better, but my mind can’t comprehend it. Physically I can see it, but psychologically I can’t.” He soon became fixated on his hair, worried that he was balding.
Researchers have also found that individuals who are dissatisfied with their cosmetic surgery may experience social isolation, family problems, self-destructive behaviors and anger toward the surgeon or their staff. Dr. Ira Papel, the head of cosmetic surgery at the Facial Plastic Surgicenter in Baltimore, gave instances of several frightening situations with former patients – including one patient after what appeared to be a successful rhinoplasty, being so disturbed by the end results they could no longer function (to the point, they lost their job and was getting a divorce) and another patient threatening their own life in the lobby of the doctor’s center.
Due to the increase of these occurrences, the use of BDD questionnaires has become routine for many surgical centers. Subsequently, demonstrating the high prevalence of BDD among cosmetic surgery patients. With the help of these questionnaires, medical professionals are able to weed out some of the BDD patients and recommend treatment instead of surgery.
Treatment for BDD includes two different kinds – cognitive behavioral therapy and serotonin reuptake inhibitors (SRIs).
Cognitive behavioral therapy has been shown to be the most effective for BDD, as it utilizes a skills-based approach to help patients develop healthier thought, emotion and behavior patterns. Patients learn to step back from and to challenge their negative appearance-related thoughts and beliefs, and to broaden the basis of their self-worth to include non-appearance factors (like personality traits and achievements). Additionally, individuals are asked to repeatedly approach anxiety-provoking situations while refraining from compulsions. This is done at a pace that is comfortable with the individual; and that allows for an opportunity for the individual to learn that the anxiety and distress will go down, and that feared consequences won’t occur, even if they don’t participate in their rituals – thus helping in significantly reducing the time spent performing appearance-related rituals.
SRIs are commonly prescribed antidepressants for various disorders and are the current medication of choice for treating BDD. Current research indicates that a majority of patients experience improvement in their BDD symptoms, including a reduction in the obsessive thoughts, compulsive behaviors, anxiety, depression and suicidal thoughts associated with BDD.
BDD is a complex psychiatric disorder that teeters between eating disorder and anxiety disorder, providing another example of the correlation between the two. Like an eating disorder, an individuals’ behavior changes based on a perception of an aspect of themselves – supplying a reminder to everyone on the topic of mental health, that how we talk to and see ourselves is extremely important to our mental well-being.
- Crerand, PhD, Canice; Menard, BA, William; Phillips, MD, Katharine. Surgical and Minimally Invasive Cosmetic Procedures among Persons with Dysmorphic Disorder. Ann Plast Surg. 2010 Jul; 65(1): 11-16.
- Davis FNP, Kathleen. What’s to know about body dysmorphic disorder. Medicalnewstoday. 2019.
- Dubick, Stephanie. When You Have Body Dysmorphia, Coping Through Plastic Surgery Can Be a Nightmare. Vice.com. 2017.
- Lieber MD, Arnold. A Guide to Body Dysmorphia, an Emotionally Painful Obsession. PSYCOM.
- MGHMS OCD & Related Disorders Program. Body Dysmorphic Disorder (BDD). Mghocd.org.
- Mental Health America. 8 Things You Should Know About Body Dysmorphic Disorder (BDD).