Body Dysmorphic Disorder (BDD)
Do you spend a lot of time focusing on your physical flaws? Have these thoughts interfered with your overall wellbeing? You may have body dysmorphic disorder.
What is body dysmorphic disorder (BDD)?
We all have days when we feel insecure about a certain aspect of our appearance or think we don’t look our best. But if you find yourself spending a lot of time obsessing over, hiding, or trying to correct what you see as flaws, you may have body dysmorphic disorder (BDD). This condition affects both men and women of any age, although most cases begin in adolescence.
If you have body dysmorphic disorder, you may feel like there’s an uncrossable divide between your perception of your body and what your family and friends tell you. Even though you view certain aspects of your appearance as abnormal or ugly, the reality is, others don’t see you the same way. While you know, objectively, that your loved ones are correct, you can’t escape the stress and anxiety your body image causes you. If this sounds like you, know that you’re not crazy, self-obsessed, or vain. BDD is a real psychological disorder that can improve with treatment. The first step is recognizing the signs.
Common features people with BDD focus on
With body dysmorphic disorder, any aspect of the face or body is fair game, but the most common things people focus on are:
- facial features, such as the nose
- skin (moles, freckles, scars, acne)
- muscle size or tone
- size and shape of genitalia or breasts
- hair (including facial and body hair)
You may feel like there’s nothing you can do to feel better about the way you look—at least short of plastic surgery or a magic wand. But with the right coping techniques, you can develop the ability to “step outside yourself” and view your appearance in a more holistic and positive way.
Body dysmorphic disorder vs. normal insecurities
It’s normal to fixate on a large pimple or the size or your thighs from time to time. But if your preoccupation with your appearance causes you significant distress or interferes with your day-to-day life, those are signs that you’re dealing with a bigger problem. When you look in the mirror, is there a particular feature that jumps out at you that you’d like to change? Do you feel the need to seek constant reassurance from your family or friends, even though you don’t believe them when they tell you it looks fine? If the drive to improve your body or erase a particular “flaw” dominates your thoughts and actions, you may have BDD.
Signs and symptoms of body dysmorphic disorder
If you suffer from body dysmorphic disorder, you may:
Repeatedly check your reflection in the mirror or stay away from mirrors altogether. Do you check your reflection compulsively, even when you’re alone? On the other end of the spectrum, do you avoid mirrors because seeing your reflection causes you distress?
Isolate yourself so others will not see the offending body part. This includes avoiding work, school, social events or public places out of stress over others seeing you. Or leaving the house only at night or at times where you’re less likely to see other people.
Spend a lot of energy camouflaging or covering up the perceived flaw. You may wear strategic clothing, makeup, or accessories to disguise the area you’re worried about. You may also position your body in a way to minimize the “flaw.” Or cover it with hats, scarves, baggy pants, etc. or wear clothing inappropriate for the weather.
Go to lengths to avoid having your picture taken. Do you avoid social gatherings, such as birthday parties, where photos will be taken? Do you police the photos others take and post to social media, making sure your “flaw” isn’t visible?
Undergo plastic surgery, sometimes more than once, to correct the perceived imperfection. Do you believe that plastic surgery will solve all of your problems? Have you already undergone a procedure but are still not happy with the results?
Pick your skin compulsively, leading to injury. Skin picking is also a symptom of Obsessive-Compulsive Disorder (OCD). However, if it is done with the intention of improving appearance, it more likely points to BDD.
Obsess over the “flawed” body part and what others think about it. Do you spend a lot of time and energy thinking about your flaws? Do these flaws make you feel depressed, anxious, ashamed, or profoundly ugly? Do you worry about what others are seeing and thinking when you’re socializing?
Seeking reassurance. Do you repeatedly ask your close friends or family members if you look okay, or about the appearance of the feature you dislike? Do you still feel bad and unattractive, despite their reassurance?
Compare yourself negatively to others. This includes celebrities and photos of yourself at a younger age. The focus is on how bad your “flaw” looks in comparison to others.
Feel depressed, anxious, or have suicidal thoughts. This may co-occur with dissatisfaction over a recent cosmetic procedure.
Put a lot of effort into changing the feature, with excessive exercise, weight lifting, or tanning. If you suffer from BDD, you might also feel unhappy with your hair. Do you feel you need frequent haircuts? Do you avoid going out after you’ve had one? You may also use your hair to cover up “imperfections.”
Spend a significant amount on personal grooming. Do you find that a significant amount of your paycheck or allowance goes toward products and services designed to enhance your looks? But then, do you quickly grow disillusioned with them and think you can find a better treatment? If so, your compulsion may point to a larger issue than simply wanting to look your best.
Muscle dysmorphia: a common subtype of BDD
Muscle dysmorphia is a subtype of body dysmorphic disorder centered on the belief that your muscles are not large enough. Although this can affect both genders, it is more common in men. Like body dysmorphic disorder in general, it can be difficult to recognize. You might start out feeling accomplished, since often sufferers are applauded for their discipline and commitment to their health. But if you identify with the following symptoms, it may be time to re-evaluate:
- Excessive exercise and weight lifting, often for many hours a day.
- A fixation on counting calories
- Avoiding restaurants due to an imagined lack of control over food options.
- Arranging meals to achieve a “perfect” combination of carbohydrates, fats, proteins, and vitamins.
- Adhering to a rigid meal schedule.
- Either excessively checking or avoiding mirrors and reflective surfaces.
- Wearing multiple layers of clothing to appear bigger
- Using of steroids or other performance enhancing drugs.
- Your self-worth is based exclusively on the size of your muscles
Muscle dysmorphia vs. eating disorders
While sometimes referred to as “bigorexia” or “reverse anorexia,” muscle dysmorphia is not exactly an eating disorder, despite sharing some similarities with one. Although your self-image may drive you to follow a precise, time-consuming diet, the goal is to increase the size of your muscles, rather than lower your body fat. Also, not all sufferers of muscle dysmorphia have disordered eating.
Causes of body dysmorphic disorder
The specific causes of body dysmorphic disorder are unknown. Like most other mental disorders, it is the result of a variety of factors. These include irregularities in brain structure, genetics, and life experiences. Past traumas such as childhood neglect, abuse, or criticisms about your body may all play a role. In a culture that emphasizes youth and a narrow standard of attractiveness, it can be easy to feel inadequate. Certain personality traits, such as anxiety or perfectionism, can also put you at risk for developing BDD.
Getting help for body dysmorphic disorder
If you recognize yourself from the list of symptoms and have decided to seek help, give yourself credit. That itself is a significant step and shouldn’t be taken lightly. Research shows that many people with BDD have seen a dermatologist for ten years before they seek out a mental health professional. You may feel ashamed of your compulsion, fearing that others will label you as “vain” or “self-absorbed” if you ask for help. But like other disorders rooted in anxiety, support is available.
What to expect when seeing a professional
If you’re nervous about starting the treatment process, here’s what you should prepare to discuss with your therapist or psychiatrist:
Psychosocial history: In order to get to the bottom of your condition, a therapist may ask you to discuss any past experiences of bullying, teasing, or abuse. You may want to consider your family’s values, and any perceptions you might have internalized from friends or the media about the “right” way to look.
How your viewpoint has affected your life: Think about any changes that have occurred since you started spending more time correcting the “flaw.” Consider both positive and negative outcomes. Have you lost friends or relationships? Have your grades dropped, or has your performance at work worsened because you don’t have time to focus on other pursuits? On the flip side, have you found that you’re receiving more compliments on your muscle gains or new makeup routine? If so, how does this balance out the compromises you may have made in other parts of your life?
Life and treatment goals: Before your appointment, think about your life goals and how your body fixation has impacted them. With the help of your therapist, you can break the treatment process down into manageable steps. Be prepared to talk about the pros and cons of your journey to recovery. What do you think are your biggest obstacles to accepting yourself, “flaws” and all?
Family support: If your family has expressed concern, you may want to think about including them in your treatment. They can provide your therapist with insight into your life history and current situation. By discussing treatment plans with family members in the home, they can help you recognize and dismantle negative patterns.
Treatment options for body dysmorphic disorder
Treatment for body dysmorphic disorder includes both individual and group therapy as well as medication. If your symptoms are milder, they may improve from either treatment alone, but therapy and medication work together for faster results. This is especially true if you or your loved one is having suicidal thoughts.
Cognitive behavioral therapy (CBT). This is the only psychological treatment for BDD supported by research. It focuses on changing the thought and behavior patterns set off by the condition. Your therapist will help you identify situations that cause anxiety and develop healthier coping mechanisms. Through CBT, you can learn to step outside yourself and view your body through a more objective, and forgiving, lens.
As you progress through treatment, your therapist will guide you through more challenging situations. This process, called habituation, helps rewire the way your brain responds to triggers. You will also learn to identify any avoidance behaviors (like crossing the street to get away from reflective surfaces) and compulsive responses. These could include skin picking or a constant need for reassurance.
Medication for body dysmorphic disorder. Although, in the United States, the Food and Drug Administration hasn’t yet approved any medications that treat BDD specifically, research has shown that serotonin reuptake inhibitors (SSRIs) can be very effective. A form of antidepressant, SSRIs may help ease the obsessive thoughts and behaviors that are hallmarks of BDD. They may also reduce the symptoms of anxiety and depression that often co-occur with BDD. With your mind more at ease, you may also find it easier to engage with CBT.
If your child has body dysmorphic disorder
Body dysmorphic disorder most often begins around age 12 or 13. As a parent, you may at first have trouble differentiating between adolescent insecurities and something more serious. Research shows that BDD is often under-recognized and under-diagnosed. It also shares symptoms with other mental health conditions such as depression, obsessive-compulsive disorder, and social anxiety. The good news is, the treatment plan is often similar and can help with these co-occurring disorders. Here are some ways to support your child or loved one:
Educate yourself about BDD. This disorder is often confusing to those on the outside. In reality, the physical flaws that sufferers are so focused on are actually unnoticeable or very slight. However, it is important not to minimize their pain but rather approach the problem from a place of empathy and understanding.
Nurture a supportive environment to encourage treatment. Spend quality time with your loved one and assure them that you care. Even if they reject your reassurances about their appearance, they will feel your support. Try not to force treatment or make them feel guilty.
Hone your listening skills. Sometimes just letting someone know that you’re willing to lend an ear goes a long way. If they do confide in you, try to withhold judgment and keep your reactions in check. As you encourage them to seek treatment, focus on how they could benefit from the support of a professional who understands the condition, rather than how their behavior worries you.
Take care of yourself. Recognize that your loved one will go through ups and downs as they grapple with their condition. Keep the difficult times in perspective and don’t neglect your own self-care. It may help to see a therapist yourself or join a support group.
Self-help for body dysmorphic disorder
If you have body dysmorphic disorder, you’re often fixated on a particular body part and then find it difficult to control how much you think about it. To practice diverting your attention, try living every day in the present moment. Easier said than done? There are two strategies that may help: mundane task focusing and a more formal meditation practice. These coping mechanisms complement each other. If you incorporate both into your routine, they will start to feel natural.
Mundane task focusing
Many of us go through household tasks on autopilot. When washing the dishes or brushing your teeth, are you really thinking about what you’re doing? Or is your mind wandering, planning ahead for the day or possibly worrying about your appearance? Write down a list of tasks you routinely engage in when your thoughts are most likely to stray.
The next time you vacuum the floor, for example, try practicing mindfulness. Engage your senses and take note of how the vacuum feels against the carpet. What noises do you associate with this job? Do the smells in your home change as move the vacuum through the room?
If you feel your attention slipping, don’t beat yourself up. Just gently bring your mind back to the present moment. Practicing awareness helps bring your focus away from your body and any negative self-talk.
While it may not seem natural at first, meditation gets easier with practice. First, find a comfortable sitting position and check in with your body. Ask yourself, what am I thinking and feeling? What are my body sensations? Spend 30 seconds gathering these impressions without acting on them or trying to push any thoughts away.
Next, close your eyes and direct your focus to your breath. Take note of the way it moves in and out of your body. At this time, try to clear your head. It might help to picture any thoughts as clouds, passing through your mind as they would through the sky. Spend about 1 to 2 minutes doing this.
Next, expand your awareness to the rest of your body. Allow yourself to think and feel without judgment. If you find yourself starting to dwell on certain emotions, gently tell yourself to ‘relax’ or ‘let go.’ Continue this for another 1 to 2 minutes. As you start to grow more comfortable with meditation, you can increase the amount of time you practice. The goal is to center yourself and take your focus off repetitive thoughts about your appearance.
Reducing negative predictions
Once you become more skilled at managing your thoughts, you can use these coping strategies to talk yourself down before you face a triggering situation. This could be anything from a birthday party to a work conference with a room full of strangers.
If you have BDD, you may find yourself defaulting to negative predictions about how a particular event will go. You may start to imagine the worst: that everyone will point and laugh, for example, or that you’ll find yourself sitting alone because nobody wants to associate with you because of your flaw. In truth, though, reality is much less distressing.
The next time you catch yourself spiraling into anxiety, try writing your worst fears down in a thought diary. Once you acknowledge them, try coming up with a more realistic outcome. Instead of thinking, “Nobody will talk to me.” Try, “maybe I will meet someone new and we’ll have an interesting conversation.” It is important though, not to go to the other extreme. Otherwise, you will set yourself up for disappointment. For example, rather than imagining, “everyone will tell me I’m beautiful,” or “I will meet the love of my life,” consider smaller, yet still positive, expectations.
Authors: Anne Artley and Melinda Smith, M.A. Last updated: October 2019.