Body Dysmorphic Disorder (BDD)

What body dysmorphic disorder feels like

People with BDD are convinced that something about their appearance is ugly, abnormal or deformed. The concern is not vanity. It causes intense shame, anxiety and distress, and can feel impossible to ignore. Many people have poor insight and are fully convinced the flaw is real.

Common areas of concern:

• skin: acne, scars, lines, color, pores
• hair: thinning, excess body or facial hair
• nose, face shape, teeth, lips
• body size or shape, stomach, breasts, genitals
• muscle dysmorphia: believing one's body is too small or not muscular enough, more common in men, often with excessive weightlifting, strict diets and steroid use

Signs and symptoms

• spending at least an hour a day, often many hours, thinking about the perceived flaw
• frequently checking mirrors, or avoiding them completely
• excessive grooming, makeup or changing clothes
• hiding the area with hats, clothing, hair, or body positioning
• skin picking to "fix" imperfections
• constantly comparing appearance with others
• asking others for reassurance, which brings only brief relief
• taking many photos or avoiding being photographed
• avoiding social situations, school or work
• seeking cosmetic treatments, dermatology or surgery repeatedly

BDD is often associated with depression, social anxiety disorder, obsessive-compulsive disorder and substance use. Rates of suicidal thoughts are high, so this needs to be asked about and taken seriously.

Causes and risk factors

No single cause is known. Contributing factors include:

• Genetics: BDD and OCD run in families.
• Brain differences: a tendency to focus on small details rather than the overall picture.
• Life experiences: teasing or bullying about appearance, childhood trauma or neglect.
• Personality traits: perfectionism, sensitivity to rejection.
• Cultural pressures and social media, which may worsen existing concerns.

BDD vs normal appearance concerns and eating disorders

If the concern is only about body fat or weight in someone who meets criteria for an eating disorder, that diagnosis usually takes priority, but the two can occur together.

Diagnosis

A mental health professional diagnoses BDD through an interview, sometimes using screening questionnaires. Diagnosis requires preoccupation with perceived defects, repetitive behaviors or mental acts in response, and significant distress or impairment. Dermatologists and cosmetic surgeons are often the first to see people with BDD, and screening in these settings is recommended.

Treatment

Cognitive behavioral therapy

CBT designed for BDD is the most effective psychological treatment. It includes:

• exposure and response prevention: gradually facing feared situations, such as going out without camouflage, while resisting checking or reassurance seeking
• mirror retraining: describing the whole body in neutral terms
• cognitive restructuring: challenging beliefs about appearance and its importance
• attention training: shifting focus away from self-monitoring

Treatment typically involves 12 to 24 sessions, and online CBT programs can help.

Medicines

SSRIs, such as fluoxetine, sertraline, escitalopram or fluvoxamine, reduce preoccupation and distress, even in people with poor insight. Higher doses and longer trials (12 weeks or more) than for depression are often needed. Clomipramine is an alternative.

Combined treatment

Moderate to severe BDD usually responds best to CBT plus an SSRI.

Cosmetic procedures

Cosmetic surgery, dermatology treatments and dental work rarely relieve BDD and often worsen it, as the focus shifts or dissatisfaction continues. Guidelines advise mental health treatment first.

Outlook

Without treatment, BDD tends to be chronic. With CBT and medication, many people improve substantially, spend less time preoccupied and return to normal activities. Relapse prevention strategies help maintain gains.

Frequently asked questions

What are the signs of body dysmorphia?

Signs include spending hours a day worrying about a perceived flaw, frequent mirror checking or avoiding mirrors, excessive grooming, hiding body parts, skin picking, comparing with others, seeking reassurance, avoiding social situations, and repeated cosmetic procedures.

Is body dysmorphic disorder a form of OCD?

BDD is classed as an obsessive-compulsive related disorder. Like OCD, it involves intrusive thoughts and repetitive behaviors, and it responds to similar treatments, but its focus is specifically on appearance.

Can cosmetic surgery fix body dysmorphic disorder?

Usually not. Most people with BDD remain dissatisfied after cosmetic procedures, and their concern often shifts to another body part. CBT and SSRIs are the recommended treatments.

What is muscle dysmorphia?

Muscle dysmorphia is a form of BDD in which a person believes their body is too small or not muscular enough. It is more common in men and can lead to compulsive exercise, extreme diets and anabolic steroid misuse.

Can body dysmorphic disorder be cured?

Many people recover or improve greatly with treatment, especially CBT combined with an SSRI. Symptoms can return under stress, but skills learned in therapy help manage them.