Body Dysmorphic Disorder

Body dysmorphic disorder (BDD) is a common mental health problem in which the sufferer is excessively concerned, pre-occupied and distressed about a perceived or slight defect in his or her appearance. This response will be out of all proportion to the reality, and the sufferer will spend much of the day thinking about it. The condition can be severe enough to interrupt day to day living, including social and/or occupational functioning. It is frequently accompanied by anxiety and depression, and social withdrawal is common. It is estimated that about 1 - 2% of the population suffer from this disorder, but as people commonly hide the problem it often goes undiagnosed, and therefore this figure may be conservative. Or people may present with other mental health problems, and the BDD itself may be missed. The condition is most likely to develop in adolescence, and research suggests that men and women are affected equally. If untreated, BDD can continue for years, with sufferers even resorting to cosmetic surgery although this generally gives little satisfaction.

The exact cause of BDD is unclear, but it is likely that a combination of biological, psychological and environmental factors is involved, depending on the individual. A person may have a genetic predisposition for this disorder, and then when exposed to stressful life events such as teasing or bullying, this may trigger symptoms. Sensitivity to rejection or criticism may develop. Changes in the levels of certain brain chemicals such as serotonin may have their part to play in maintaining the disorder. In terms of personality characteristics, the sufferer may have low self-esteem, and a tendency towards perfectionism, and believing themselves to be ugly will tend to compound matters as they fail to achieve some impossible ideal; any sense of being good enough, in the eyes of themselves or others, typically eludes them. Media images placing a high value on beauty probably do not help. Whilst the defect - if one exists - will be slight, it will assume immense proportions in the eyes of the sufferer. Although the type and severity of BDD symptoms vary with the individual, feelings of shame, guilt and isolation often occur. Ritualistic behaviours such as obsessively checking themselves in the mirror are common, and the most frequently focused upon features are some aspect of the face and/or skin. As well as being obsessed by their own appearance, they are likely to constantly compare with others. Sufferers fear ridicule and humiliation, and tend to avoid social situations for this reason; intimate relationships may be avoided altogether. The degree of social anxiety experienced can be very disabling. It is not uncommon for the sufferer to feel suicidal.

To access the right treatment, it is important that the sufferer, or someone close to them, recognises that they have a mental health problem; a degree of insight that their perceived defect is causing an extreme response will be helpful. An important first step is a visit to your GP who is then likely to refer you to a mental health team. Psychological and drug therapy can help with the symptoms and distress of BDD. Cognitive behavioural therapy (CBT) can be very effective, and research has indicated that over half of patients who complete a course of CBT improve markedly, with symptoms greatly eased if not totally eradicated. These effects tend to be long-lasting. Anti-depressants such as selective serotonin re-uptake inhibitors can help correct the imbalance of serotonin levels in the brain that is thought to contribute to the condition, and again there is evidence of their efficacy in treating BDD. Drug therapy combined with CBT has been shown to be more effective than either approach used alone, and many former sufferers can achieve a good quality of life.

Behavioural Symptoms

  • repeatedly checking how they look in the mirror, and making adjustments to try to cover the perceived defect; excessive grooming
  • obsessively thinking about their perceived defect throughout the day
  • frequently seeking reassurance from others about their appearance
  • constantly making comparisons between their own appearance and that of others
  • undergoing unnecessary cosmetic surgeries

Psychological Symptoms

  • sensitivity to rejection and criticism
  • low self-esteem; not feeling good enough
  • a tendency towards perfectionism
  • anxiety and depression
  • shame, guilt and isolation
  • fear of ridicule and humiliation; extreme self-consciousness
  • suicidal thoughts
  • delusional beliefs about the perceived defect
  • inability to focus on other aspects of daily living

Other Symptoms

  • problems with occupational functioning
  • difficulties in social relationships; withdrawing from others
  • over-reliance on others, such as a partner, family or friends
  • alcohol and/or drug misuse in an attempt to self-medicate

Diagnosis & Assessment

Recognising that you may have a psychological, rather than a physical problem will be important, and if you suspect you have BDD, a good first step is to visit your GP to reveal your concerns; he or she is then likely to refer you to a mental health team. To be diagnosed as having BDD, you will be excessively preoccupied with an imagined or slight defect in your appearance, which causes significant distress, and which interferes with your daily life, such as your social and occupational functioning. It may be that you avoid social situations altogether because of the discomfort such situations bring about. It will be important to rule out other mental health problems such as clinical depression or social phobia. If you suffer from several of the symptoms listed in the above section, it is likely that you do indeed have BDD.

Treatment with Medication

A large proportion of patients respond well to antidepressant medication, especially selective serotonin reuptake inhibitors such as citalopram, fluoxetine and sertraline. These have been shown to reduce the symptoms of BDD, even if depression is not present. These medications may need to be taken for at least a year, although benefits are often noticeable within the first 2 - 4 weeks of taking them. There is a risk of relapse if the person stops taking the drug, but this can be minimised if medication is used in conjunction with cognitive behavioural therapy, the effects of which tend to be long-lasting.

Psychological Therapy

It is quite common for a combination of antidepressants and cognitive behavioural therapy (CBT) to be used in the treatment of BDD, and this tends to be more effective than either approach used alone. CBT aims to challenge the negative thoughts and beliefs associated with BDD, which in turn helps to improve mood and reduce unhelpful, ritualistic behaviours. It offers a structured programme, and on completion of a course, the recipient will have learned how to help themselves should future setbacks occur.

Particularly important for the BDD sufferer will be to help them challenge their attitudes towards their appearance, and learn to see themselves in a more realistic and helpful light. Self-acceptance will be key. Therapy will also aim to re-direct the person's attention away from themselves, and to encourage them to stop continually making comparisons between the appearance of themselves and that of others. The behavioural part of the therapy focuses on reducing the unhelpful actions such as continually checking oneself in the mirror. Whilst ceasing these ritualistic and compulsive behaviours can produce anxiety in the short-term, relaxation techniques will be taught to help combat this. Avoidance will be discouraged; conversely the person will be encouraged to expose themselves to situations they previously found stressful (typically starting with low-stress situations, then building up to confront more difficult ones), and then use the coping strategies they have learned to manage their arousal levels. Eventually emotional difficulties will subside as the sufferer is successful in confronting more and more of their fears, and day to day life will feel less threatening and more manageable.

In one study, CBT was shown to significantly reduce symptoms in over 80% of patients, and these positive effects were enduring. Other people have been helped by attending support groups where they receive support and understanding from fellow sufferers, which in turn can help break down any feelings of isolation, shame and guilt. Many former sufferers of BDD go on to lead happy, productive lives, with significant improvements in their mood and general wellbeing.