Most people with BDD are usually demoralized and many are clinically depressed or have social anxiety. How then does one separate out from BDD from other conditions? The job of a mental health professional is to tease out what the problem is and whether there is an additional problem. These are some of the common problems that often get confused or co-exist with BDD.
BDD is often associated with symptoms of depression amounting to an additional problem. However, an individual with BDD will commonly state that if he or she did not have symptoms of BDD, then they would not be experiencing symptoms of depression to a degree that they would be seeking help. By this, we mean the diagnosis of depression is often secondary to BDD and if the BDD is effectively treated then the depression will improve.
However, depression also often needs to be targeted by treatments such as behavioural activation or cognitive therapy if it is focused on not engaging in ruminations. Some people with BDD have chronic low self-esteem and depression and can be extremely self-critical and self-punishing. Compassionate mind training (see books by Paul Gilbert “The Compassionate Mind” or Mary Welford “Compassionate Mind Approaches to Self-confidence” published by Robinson) may be helpful introductions for this problem.
Very occasionally, a diagnosis of recurrent depression might better account for the symptoms of BDD if the preoccupation with being ugly is limited to ruminations only during an episode of depression (which might then improve during a manic episode if a person has bipolar disorder). Further information on this can be found from Depression Alliance.
Social Anxiety Disorder
BDD is often associated with social anxiety and fears of being judged negatively by others. When it is largely due to appearance concerns then a diagnosis of BDD is made. Compared to BDD, individuals with social phobia fear that they would act in a way that would be humiliating, embarrassing or offend others. An additional diagnosis of social anxiety disorder can only be made when the person displays a broader fear that he or she will show anxiety symptoms (e.g. go red, shake) or act inappropriately (for example “be boring”) in a way that will then be judged negatively. Many people with BDD have also suffered from social anxiety in the past. Further information can be obtained from Anxiety UK.
Obsessive Compulsive Disorder
In BDD, there may be a pre-occupation with order and symmetry in appearance, which is very similar to OCD, for example wanting one’s hair to be symmetrical and to feel “right”. An additional diagnosis of OCD is only given when the obsessions are not restricted to concerns about appearance or there are other unrelated symptoms of OCD (e.g. fears of contamination). Many people with BDD have also had OCD in the past. Further information from OCD Action or OCD UK.
Body Integrity Identity Disorder
Body Integrity Identity Disorder (BIID) is a term used to describe individuals who desire one or more digits or limbs to be amputated, as they believe these are not part of their “self”. It may be regarded as a form of reverse “phantom limb”.
The preoccupation is focussed not on a feeling of defectiveness but on the sufferers’ expectation that they would be much more comfortable if one or more limbs or digits were amputated. They do not believe (as in BDD) their limbs to be defective or ugly nor do they wish cosmetically to alter the limb. BIID is more akin to a Gender Identity Disorder. BIID is not part of BDD. Further information from the BIID network.
A distorted body image is a feature of both BDD and eating disorders, which also share many other symptoms, such as a low self-esteem. A preoccupation predominantly focused on being “too fat” or overweight may lead patients to check frequently in reflective surfaces or camouflage their body. Such behaviour does not usually meet criteria for BDD, as it is likely to be associated with periods of disordered eating such as dietary restriction or other compensatory strategies to control weight or shape.
These individuals may not fulfil the criteria for anorexia or bulimia nervosa but may be diagnosed as having an “Unspecified Feeding or Eating Disorder”. An additional diagnosis of an eating disorder and BDD can occur when an individual fulfils criteria for one of the eating disorders and is also preoccupied and distressed by perceived defects in their appearance, which is unrelated to their weight and shape (for example their skin or nose).
Individuals who are preoccupied by not being muscular enough or having muscles which are too puny would however be diagnosed as having Muscle Dysmorphia. Further information on eating disorders from B-EAT.
Skin-Picking Disorder is characterized by repetitive skin picking resulting in skin lesions and significant distress or impairment. The diagnosis should not be made if the picking is solely attributable to a desire to improve the appearance or efforts to correct or “put right” (e.g. removing acne or other perceived blemishes of the skin).
It is possible that some individuals may start with BDD but their picking causes “real” defects. Alternatively, over time their BDD becomes a skin-picking disorder as the motivation alters. This is a complex area and may be relevant in the psychological treatment.
Picking usually occurs on the skin of the face, however it can be carried out on any part of the body. Individuals may start by picking at normal blemishes such as freckles or moles, pre-existing scabs, sores or even acne blemishes. Individuals may use fingernails, tweezers, pins or any other devices. As a result it can lead to bleeding, bruising, and infections. In extreme cases, permanent damage and skin disfigurement can also be experienced.
The skin picking is often accompanied by a feeling of relief or even pleasure due to the reduction in anxiety or urge. Individuals may go to great lengths to camouflage the damage they have caused through the use of make up and clothes that cover marks on the skin and avoid social situations in an attempt to prevent others from seeing their scars.
Severe personality disorder
Body image concerns that may amount to symptoms of BDD are common in a severe or emotionally unstable personality disorder (also called “borderline personality disorder”). When symptoms of BDD are prominent in a severe personality disorder, then it is usually regarded as an additional problem to the personality disorder. Personality Disorder may be treated with Dialectical Behavior Therapy, Schema Therapy, Mentalisation based Therapy and Compassionate Mind Training. These approaches often overlap and may be done in parallel with treating symptoms of BDD. However borderline personality is a complex area. Further information on BPD can be obtained from BDP World.
Taijin Kyofu-sho (TKS) is a culture bound syndrome in Japan and Asia that consists of an intense fear of offending, embarrassing or hurting others through improper or awkward social behaviour, movements, appearance or body odour. The Japanese diagnostic system distinguishes four types of TKS: a fear of blushing, of eye-to-eye contact, of having a deformed body, and emitting a foul body odour. In a survey of individuals with TKS it was found that the most common was fear of blushing, followed by a fear of appearing tense, of emitting a body odour, of having a blemish or physical deformity (which would be regarded internationally as BDD or in Japanese “shubo-kyofu”).