Body dysmorphic disorder (BDD)

What is body dysmorphic disorder?

Body dysmorphic disorder (BDD) is a mental illness. People who have this illness constantly worry about the way they look. They may believe an inconspicuous or non-existent physical attribute is a serious defect. They respond to this by performing repetitive acts such as mirror checking or comparing their appearance with others.

The severity of BDD varies. For example, some people know their feelings aren’t rational or justified, while others are almost delusional in their conviction.

BDD causes severe emotional distress. It is not just vanity and is not something a person can just ‘forget about’ or ‘get over’. The preoccupation can be so extreme that the affected person has trouble functioning at work, school or in social situations. Any part of the body can be targeted.

It is thought that between one and two per cent of the population may have BDD, with men and women equally affected. BDD usually starts in the teenage years, when concern over physical appearance is common. Suicide rates among people with BDD are high. If you suspect you have BDD, see your doctor or a mental health professional.

Symptoms of BDD

Symptoms can vary according to which body part (or parts) is targeted, but general symptoms of BDD include:

• thinking about the perceived defect for hours every day
• worrying about their failure to match the ‘physical perfection’ of models and celebrities
• distress about their preoccupation
• constantly asking trusted loved ones for reassurance about their looks, but not believing the answer
• constantly looking at their reflection or taking pains to avoid catching their reflection (for example, throwing away or covering up mirrors)
• constant dieting and overexercising
• grooming to excess – for example, shaving the same patch of skin over and over
• avoiding any situation they feel will call attention to their defect. In extreme cases, this can mean never leaving home
• taking great pains to hide or camouflage the ‘defect’
• squeezing or picking at skin blemishes for hours on end
• wanting dermatological treatment or cosmetic surgery, even when professionals believe the treatment is unnecessary
• repeat cosmetic surgery procedures, especially if the same body part is being ‘improved’ with each procedure
• depression and anxiety, including suicidal thoughts.

Areas of concern with BDD

Common areas of concern for people with BDD include:

• facial skin
• face, including the size or shape of the eyes, nose, ears and lips
• size or shape of virtually any body part, including buttocks, thighs, abdomen, legs, breasts and genitals
• overall size and shape of the body
• symmetry of the body or particular body parts.

Treatment for BDD

BDD is not always easy to treat but the treatments that seem to help the most include a combination of:

• Cognitive behaviour therapy (CBT) – training in how to change underlying attitudes in order to think and feel in different ways. This includes learning to tolerate the distress of ‘exposing’ their perceived defect to others and in not performing rituals related to appearance concerns.
• Coping and management skills – training in how to cope with symptoms of anxiety. For example, the person may learn relaxation techniques and how to combat hyperventilation.
• Medication – including antidepressant medications, particularly selective serotonin reuptake inhibitors (SSRIs). These medications help reduce many BDD symptoms, including the compulsive thoughts, depression and anxiety. Generally, medications are used in combination with psychotherapy.

Some people with body dysmorphic disorder seek cosmetic surgery to ‘correct’ an actual or perceived physical flaw. Medical experts are divided on the ethics of performing cosmetic surgery under these circumstances (sometimes called ‘non-therapeutic mutilation’ or extreme body modification).

Any medical or surgical procedure carries health risks. Unnecessary attempts to change appearance through surgery may lead to dissatisfaction with the results and could worsen a person’s BBD.

What causes BDD

The cause of BDD is unknown. Theories include:

• A person with BDD has a genetic tendency to develop this type of mental illness. The trigger may be the stress of adolescence.
• Particular drugs, such as ecstasy, may trigger onset in susceptible people.
• BDD could be caused by chemical imbalances in the brain.
• A person with low self-esteem who has impossible standards of perfection judges some part of their body as ugly. Over time, this behaviour becomes more and more compulsive.
• Western society’s narrow standards of beauty may trigger BDD in vulnerable people.

BDD has similarities to other conditions

BDD is similar to other conditions, including:

• Obsessive compulsive disorder (OCD) – characterised by recurring unwanted thoughts and images (obsessions) and repetitive rituals (compulsions). As people with BDD are obsessively preoccupied with an aspect of their appearance, it has been proposed that BDD may be a form of OCD. In addition, some people diagnosed with BDD have or have had OCD.
• Social phobia – a type of anxiety disorder, characterised by fear of interaction with people. A person with social phobia may worry about being judged, criticised, ridiculed or humiliated. If the avoidance is triggered by concerns about their appearance, the underlying problem may be BDD.
• Agoraphobia – a type of anxiety disorder characterised by the fear of situations or places from which escape seems difficult. In extreme cases, a person with agoraphobia is housebound. However, a person who stays home out of fear of publicly exposing their defect may have BDD instead of agoraphobia.
• Anorexia nervosa – BDD is often misdiagnosed as anorexia nervosa because of the preoccupation with appearance. However, anorexia nervosa is characterised by the drive to control one’s weight. It’s possible for a person to have anorexia nervosa and BDD at the same time.
• Hypochondriasis – the preoccupation with the development of disease. However, the person with BDD is preoccupied with their looks, not their health.
• Trichotillomania – the irresistible urge to pluck or pull out hairs. If the behaviour is triggered by concerns about appearance, the underlying problem may be BDD. Picking or squeezing at skin blemishes for hours at a time is a similar condition to trichotillomania.

Diagnosis of BDD

Diagnosis of BDD is difficult for many reasons, including:

• People with BDD are more likely to seek help from dermatologists and cosmetic surgeons than psychologists and psychiatrists.
• People with BDD are ashamed and don’t want to seek help from mental health professionals.
• This type of mental illness doesn’t get much publicity, so some health professionals may not even be aware that BDD exists.
• BDD is similar to many other conditions and misdiagnosis is possible.

Where to get help

• Your GP (doctor)
• Local community mental health centre
• Psychologist
• Psychiatrist
• Australian Psychological Society Tel. (03) 8662 3300 or 1800 333 497
• Mental Health Foundation of Australia (Victoria) Tel. (03) 9427 0406
• Lifeline Tel. 13 11 14