Body Dysmorphic Disorder

Introduction to Body Dysmorphic Disorder

Many people think of body dysmorphic disorder (BDD) as a relatively new diagnosis, as it is one with which many therapists and physicians are still not entirely familiar. However, the first documentation of the disorder was in 1886 by an Italian researcher by the name of Morselli. He titled the disorder “dysmorphophobia”, or “fear of ugliness”. Since then, there has certainly been more research into BDD, yet its etiology still remains largely unknown, and there is no recorded evidence of any curative treatment.

Definition of BDD

Put simply, BDD is a mental disorder in which the patient obsessively focuses on some physical defect or defects of his or her appearance, whether real or imagined. In BDD, the obsessive nature of the patient’s thoughts about his or her appearance are disproportionate to the size or severity of the perceived defect, if in fact any such defect really exists outside the patient’s mind.

When the BDD patient looks in a mirror, he or she sees things that are not there, and then focuses selectively and intently on the perceived deformity. Quite often these patients are considered by other people to be average in appearance, above average, or even very attractive, yet they see themselves as ugly or deformed.

Diagnosis of BDD

The following is taken from p.468, DSM-IV, 1994, American Psychiatric Association:

Diagnostic criteria for 300.7 Body Dysmorphic Disorder
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 in Anorexia Nervosa).

Many physicians believe BDD is closely related to anorexia nervosa, as part of a class of disorders known as obsessive compulsive spectrum disorders. Unlike anorexia, however, BDD disorder is equally common in women and men. It often has its onset around the time of puberty, although it is often difficult to pinpoint the time of onset, since studies have shown it takes, on average, 9 years to correctly diagnose.

Surprisingly, some patients report first experiencing symptoms as early as age 3 or 4.

What Causes BDD?

It is estimated that BDD affects 1-2% of the world’s population, and genetic pre-disposition does appear to be a factor in determining who may develop BDD. Environmental factors, however, can also have an effect on someone with an existing genetic pre-disposition to develop BDD. These factors include severe teasing by peers, and/or a family environment that places either far too much or even far too little emphasis on appearance.

BDD Treatment – Cognitive Behavioral Therapy

Treatment for BDD usually entails a multi-modal approach, beginning with cognitive behavioral therapy, which attempts to get patients to recognize irrational thoughts and then challenge those thoughts with more rational positive self-talk learned in therapy.

Also effective is a type of therapy called exposure and response prevention, commonly used in the treatment of phobias. In this method, patients may be asked to write a list of situations they would normally avoid out of fear or anxiety about their looks. The list is arranged in order from most anxiety-provoking to least, and patients are asked to select an item near the middle of the list.

The item should be something that would bring about a certain amount of anxiety in the patient, but nothing severe enough to cause a BDD attack with the potential to lead to obsessive thoughts of suicide or self-mutilating practices. The patient is then encouraged to use the rational self-talk learned in cognitive therapy to face the situation.

The goal is that over time, the patient will begin to see the situation and others like it in a more realistic light, thereby rendering the situation less threatening in the patient’s mind. This sort of approach then can be applied to other items on the list using this same formula.

The component of treatment known as response prevention is all about decreasing the incidence of ritualistic behaviors that have been previously used by the patient to deal with anxiety-producing situations. These behaviors may include compulsively checking the mirror, constantly adjusting one’s outward appearance by applying and reapplying cosmetics, picking at the skin, or even forms of self-mutilation. In most cases, the patient is asked to simply cut down on the amount of time usually spent on these response behaviors, decreasing the time until eventually (ideally) the behavior has ceased altogether.

BDD Treatment – Medication

Another tool used to treat BDD is medication. BDD is a brain disorder which falls under the diagnostic umbrella of “chemical imbalances”. The main neuro-chemical involved in the manifestation of BDD is Serotonin. Therefore, the usual medications of choice in treating BDD are SSRIs (Selective Serotonin Reuptake Inhibitors), traditionally used in treating depression and anxiety, which are also common in BDD patients.

BDD Treatment – Other

Traditional psychotherapy, also known as talk therapy, can also be helpful in relieving anxiety by uncovering and identifying the root causes of that anxiety in the BDD patient’s life. Also, it can often be helpful for the patient to explore more easily accessible “every day” ways of increasing serotonin levels, such as exercise, recreational activities, and/or spending time with a pet.

On the Horizon for BDD

There is a new study currently underway which takes a look at the way BDD sufferers visually process information. The goal of the study is to determine whether the brains of BDD sufferers process visual information differently from the brains of normal healthy control subjects. If that is the case, it may explain the distortions in BDD patients’ perception of their appearance.

The study will use a functional MRI to compare brain activity of BDD patients when asked to process certain visual information to the brain activity of the subjects in the control group. The hope is that the results will give researchers clues to help develop and refine treatments for the disorder.

Risks of leaving BDD untreated

BDD significantly affects the lives of those who suffer from it. Patients tend to isolate themselves from others, pushing away family members or potential romantic partners, and avoiding social situations. In extreme cases, patients may feel emotionally unable to face venturing out of their homes, even to go to work, and many of those patients will become housebound.

In addition to the potential loss of friends, jobs, and a life away from the mirror, there are even more serious risks if BDD goes untreated. Suicide is the most troubling risk factor in dealing with BDD patients.

In fact, BDD patients display a suicide attempt rate that is on par with bi-polar disorder and schizophrenia. Also disconcerting are the statistics about BDD and substance abuse. It is estimated that chemical dependency and/or alcohol abuse become a factor in close to 50% of BDD cases.

Secondary Disorders

The most common “side-effect” of BDD is depression, which can make BDD even harder to diagnose.

Treatment is also more difficult, since depression tends to produce a patient who is unmotivated to participate in his or her own healing. In addition, the BDD patient in fact has a high likelihood of becoming anorexic or bulimic.

Misconceptions About BDD

Misconceptions about BDD abound, with some people assuming it is synonymous with vanity. In fact, it is the exact opposite. People with BDD do not want to think about their looks, and do not enjoy their reflections in the mirror. They simply can’t stop their obsessive thoughts, and they become defined by what they imagine to be their “deformity”.

BDD patients suffer from distortion in their perception of their own appearance, and selectively zero in on the smallest details of their defects. They also tend to closely scrutinize the details of the appearance of others, constantly (and unfavorably) comparing them to their own defects.

BDD & Plastic Surgery

Most BDD sufferers, especially those who remain undiagnosed, fail to recognize that their problem originates in the brain. Instead, they mistakenly believe that if they could only fix their “deformed” physical appearance, all would be right with the world. So they seek out plastic surgery, assuming that the surgeon will immediately see how severe their defects are, and will correct them, thereby almost magically transforming their lives.

Unfortunately, people who suffer from BDD are rarely satisfied with the outcomes of their surgeries, and may end up even more obsessed with any imperfections left after the surgery. They may obsess over scars, or they may be driven to near-madness over the slightest asymmetry of the result. Others shift their focus to another perceived defect that was not fixed by the surgery. Either way, the BDD patient often doesn’t take long to seek out the next surgery…and the next…and so on.

As a result, these patients are highly likely to become what the world at large deems as “plastic surgery addicts”. No matter what “flaws” these patients manage to fix, it is never enough.

There is always something else that they will perceive as being “wrong” with the way they look. There seems to be no amount of reassurance by loved ones that will convince the patient, even for a moment, that he or she is not ugly or deformed.

Many doctors who study BDD believe that plastic surgeons come into contact much more often with BDD patients than do therapists of psychiatrists, and that is probably true. It is a surgeon’s ethical responsibility to take into account the mental and emotional state of his patient before agreeing to operate, and most plastic surgeons are very aware of the nature and symptoms of BDD. Therefore, many people who suffer from BDD are finally diagnosed as a result of a referral from a plastic surgeon to a qualified therapist or psychiatrist.

Learn More About BDD

If you suspect that you or someone close to you may be suffering from BDD, you should arrange to speak with a medical health professional as soon as possible. More information on BDD can also be found at:


DSM-IV, 1994, American Psychiatric Association, p. 468

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