Body Dysmorphic Disorder (BDD) is characterised by a preoccupation with one or more perceived defects or flaws in appearance, which is unnoticeable to others. Sometimes the flaw is noticeable but is a normal variation (e.g. male pattern baldness) or is not as prominent as the sufferer believes.
The older term for BDD is “dysmorphophobia”, which is sometimes still 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, and does not reflect the severe distress that BDD can cause.
As well as the excessive self-consciousness, individuals with BDD often feel defined by their flaw. They often experience an image of their perceived defect associated with memories, emotions and bodily sensations – as if seeing the flaw through the eyes of an onlooker, even though what they ‘see’ may be very different to their appearance observed by others. Sufferers tend repeatedly to check on how bad their flaw is (for example in mirrors and reflective surfaces), attempt to camouflage or alter the perceived defect and avoid public or social situations or triggers that increase distress. They may at times be housebound or have needless cosmetic and dermatological treatments. There is no doubt that the symptoms cause significant distress or handicap and there is an increased risk of suicide and attempted suicide.
What if I have a “real” defect?
People with BDD often ask this question. The key is to understand that BDD is a problem of excessive worry and shame about appearance that will persist despite reassurance. It is often associated with fears of rejection or humiliation. Some sufferers acknowledge that they may be blowing things out of proportion. Others are so firmly convinced about their defect that they do not believe others (for example family members, friends or health professionals) trying to reassure them that it is unnoticeable or unimportant.
Whatever the degree of insight into their condition, sufferers are likely to have been told that they look “normal” many times. They have often been teased or bullied in the past about their appearance (e.g. acne, “big ears”) but this probably reflects far more about the bully than their target. Furthermore their appearance has usually changed since the teasing began.
A “real” defect such as a facial disfigurement that others can easily notice can also cause marked distress. You may not have BDD but you can still be helped to feel and function better – see for example www.changingfaces.org.uk.
When does concern with appearance become BDD?
Many of us are concerned with some aspect of our appearance but to amount to BDD the preoccupation must last for at least an hour a day, cause significant distress and/or interfere with at least one area of life. For example, some people with BDD avoid social and public situations to prevent feelings of discomfort and worry about being rated negatively by those around them.
Instead, they may enter such situations but remain very self-conscious. They may use excessive camouflage to hide their perceived defect – heavy make- up perhaps, or a change of posture, a particular hair style or 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”).
People with BDD may feel compelled to repeat certain time consuming behaviours such as:
- Checking their appearance in a mirror or reflective surface
- Checking by feeling their skin with their 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
- Discuss their appearance with others
- Camouflaging their appearance
People with BDD may also avoid certain places, people, or activities because of concerns over their appearance (e.g. bright lights, mirrors, dating, social situations, being seen close-up).
These behaviours all make sense if you feel you look ugly as they are designed to make you feel safe (for example camouflage) or to determine whether you look as bad as you think you do (for example checking in a mirror). However they lead to an increase in preoccupation and distress with your appearance.
How does BDD affect emotion?
The kinds of emotional distress that the preoccupation of BDD can cause includes:
Even if a sufferer’s concern about their appearance is not noticeable to others excessive, their distress is very real.
What are the effects of BDD on life?
By definition, the impact of BDD on a person’s quality of life is going to be significant, but it can be severe. Some individuals end up with lives so limited that they effectively become housebound. Many sufferers are single or divorced which suggests that they find it difficult to form or maintain relationships.
BDD at its worst can make regular employment or family life impossible. Those in regular employment or who have family responsibilities would almost certainly find life more productive and satisfying if they did not have the symptoms of BDD. Partners, friend, and family members find it very distressing when they are unable to help the person they love stop feeling ugly and regain control of their lives.
Which parts of the body are 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 skin, nose, hair, eyes, chin, lips and the overall body build. People with BDD may complain of a lack of symmetry, or feel that something is too big, too small, or out of proportion to the rest of the body. Any part of the body may be involved in BDD including the breasts or genitals.
‘Muscle dysmorphia’ is the term sometimes used to describe BDD in which the person is preoccupied with muscle size, shape and leanness. People with muscle dysmorphia often believe that they look ‘puny’ or ‘small’, when in reality they look normal or may even be more muscular than average. This can then lead to preoccupation with diet (e.g. very high protein supplements) and life can end up revolving around workouts.
Some damage their health by excessively working out and others report use of anabolic steroids in an attempt to increase lean muscle. Similar to other presentations of BDD, there are other repetitive behaviours (e.g. camouflaging with clothing to make one’s body appear larger, mirror checking, reassurance checking). Sufferers then neglect important social or occupational activities because of shame over their perceived appearance flaws and the amount of time taken up by their appearance-related activities.
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. People with BDD are quite the opposite from being vain or deliberately self-obsessed; BDD is a serious disorder that affects at least one per cent of the population. It shares similarities with obsessive-compulsive disorder, health anxiety, and social phobia.
BDD affects men and women equally, and most commonly begins in adolescence. Because of the stigma attached to BDD and the current poor level of awareness, on average a person with BDD will suffer for ten years before seeking help.
BDD by proxy
BDD by proxy is a little known variant of BDD in which an aspect or aspects of another person’s appearance are the focus of preoccupation. Most commonly the other person is the sufferers partner or child. People with BDD by proxy have often had BDD or OCD themselves at some time.
In many ways the behaviours (checking, comparing, avoidance and so on) in BDD by proxy are similar to those of ‘self-focused’ BDD and it can cause hours of preoccupation and great distress. There has been relatively little research in this area, but clinical experience has shown that the same treatment approach used for ‘self-focused’ BDD can be effective for BDD by proxy.
How common is BDD?
BDD usually develops in adolescence, a time when people are generally most sensitive about their appearance. However many sufferers leave it for 15 years before seeking appropriate help. They are most likely to consult dermatologists or cosmetic practitioners. 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. Therefore, it is not easy to know what proportion of the population suffers from BDD.
It is recognized as a hidden disorder as many people with BDD are too ashamed to reveal their main problem. Surveys have put BDD at about 2% of the population. It is more common in adolescents and young people. We know very little about cultural influences in BDD – for example, it may be more common in cultures that put an emphasis on the importance of appearance. In the West, it is equally common in men and women although milder BDD may be more common in women.
Are there any differences between men and women with BDD?
There are more similarities than differences between men and women with BDD. However men may be more concerned about their genitals, body build, and thinning or balding hair. Women may be more concerned with skin, stomach, weight, breasts, buttocks, thighs, legs, hips and excessive body hair. Women are more likely to check mirrors excessively, change their clothes, and pick their skin whereas men were more likely to lift weights excessively.
What is the typical course of BDD?
BDD usually begins in late adolescence (16-18 years). However milder symptoms of BDD often precede this from about the age of 12-14. However it may take up to 15 years before presentation to mental health professionals.
What causes BDD?
There has been very little research into BDD, which urgently needs funding so that we can understand it fully and develop better treatments.
There may be a genetic predisposition or vulnerability to the disorder, which would make a person more likely to develop BDD in certain situations. Thus some people with BDD may have a relative with BDD, OCD or depression. Thus poor attachment to a carer and certain stresses during adolescence such as teasing, bullying or abuse may make the person more vulnerable.
For some, perfectionism may be a factor but it is not generally true of people with BDD. They may however appreciate aesthetics more in their self or others and have had training or interest in art or design.
Once BDD has started, it is maintained by the way a person judges themselves almost exclusively by their “felt impression” or what they see in a mirror. This image may be like a ghost from the past, for example, when they were teased or rejected. The person with BDD may fear being alone and isolated all their life or being worthless. Once the disorder has developed it can be maintained by excessive self-focus, rumination, avoidance behaviours, and excessive checking, comparison and reassurance seeking.