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We all have some part of our appearance that we don’t care for or wish we could improve. It could be a crooked nose, acne, loose skin, or any other superficial blemish.
For some people, this dislike runs deeper. They may become fixated on problems that only they can see. Over time, they might become obsessed with trying to fix these problems. In some cases, they may even go to extremes, like getting repeated plastic surgery.
This level of dislike for one’s physical flaws is a condition called “body dysmorphia.” It can cause a person significant distress, but it is treatable.
What is body dysmorphia?
Body dysmorphia is also known as body dysmorphic disorder (BDD). It was previously called “dysmorphophobia” (Nicewicz, 2021).
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) describes body dysmorphic disorder as “a preoccupation with a perceived defect or flaw in one’s physical appearance that is either not noticeable or only slightly observable by others” (Nicewicz, 2021).
Researchers estimate that BDD affects 1.9% of adults in the general population and up to 7.4% of adults in the inpatient psychiatric setting. It is encountered much more often in cosmetic healthcare settings. It affects males and females equally in inpatient and outpatient psychiatric settings, but out in the world, it’s more common for women to have BDD (Nicewicz, 2021).
Body dysmorphia most commonly starts during the teenage years (Nicewicz, 2021).
Symptoms of body dysmorphic disorder
Body dysmorphic disorder is an obsessive-compulsive type disorder. Persons with BDD become focused on flaws in their appearance. These “flaws” are often only minimally visible to others or not visible at all. This causes repetitive negative thoughts and distress. The person may then engage in behaviors that they hope will relieve their anxiety by “fixing” the flaws (Perkins, 2019).
Compulsive behaviors that are often seen in BDD include (Perkins, 2019):
- Camouflaging or trying to cover up certain areas of the body
- Comparing themselves to others
- Seeking cosmetic surgery
- Checking their appearance in a mirror
- Skin picking
- Excessive grooming
- Excessive exercise or weight lifting
- Frequently changing clothes
- Excessive tanning
- Excessive shopping
- Social anxiety and avoidance
They may feel like the only solution to their problems is cosmetic surgery. People with BDD are rarely satisfied with the results though. This can result in pursuing additional surgeries. They may also begin to obsess over other body parts or become hopeless, which can lead to suicidal thoughts (Perkins, 2019).
BDD by proxy
BDD by proxy is a type of body dysmorphia where the person becomes hyper-focused on the appearance of another person. This can be a partner, a friend, a family member, or even a stranger (Perkins, 2019).
A person with BDD by proxy will engage in the same rituals to “fix” the appearance of the other person, in an effort to relieve their anxiety. This anxiety often leads to a decreased quality of life (Perkins, 2019).
The treatment for patients with BDD by proxy is the same as that for patients with body dysmorphia focused on their own body (Perkins, 2019).
Muscle dysmorphia is another subtype of body dysmorphia. In this type of BDD, the person is preoccupied with his or her body build. It is seen more often in men than in women (Perkins, 2019).
A person with muscle dysphoria worries about their muscles appearing too small or being weak. They often spend an excessive amount of time exercising to build muscle. Muscle dysphoria treatment is the same as other types of body dysmorphia (Perkins, 2019).
What causes body dysmorphia?
We don’t know exactly what causes body dysmorphic disorder. It is thought to be a combination of psychological and biological factors (Phillips, n.d).
Research suggests that a history of abuse or neglect during childhood increases the risk of developing BDD. Individuals with BDD also reported more traumatic life experiences in childhood than those without BDD (Nicewicz, 2021).
There’s ongoing research on the neurobiology of BDD. Studies have found that people with body dysmorphia have evidence of differences in (Lai, n.d.):
- Executive function (planning and organizing)
- Emotional processing
- Visual processing
- White matter connection in the brain
There is also likely a genetic component. If you’ve been diagnosed with BDD, you’re much more likely than the general population to have a relative also diagnosed with BDD or with OCD (Lai, n.d.; Grant, 2004).
Body dysmorphia and eating disorders
Body dysmorphia and eating disorders have many overlapping symptoms. Both disorders involve (Grant, 2004):
- Distorted body image
- Intrusive thoughts about appearance
- Over-emphasis of appearance on self-worth
- Repetitive behaviors such as body checking or measuring
- Dieting or exercising excessively
There are important differences between these two disorders, though. Eating disorders disproportionately affect women, while BDD has a more even distribution between men and women. BDD is also more common in first-degree relatives of people with obsessive-compulsive disorder (OCD), while eating disorders are not (Grant, 2004).
The biggest difference seems to be the way that people with each condition respond to treatment. The majority of people with body dysmorphia respond well to selective serotonin reuptake inhibitors (SSRIs) like sertraline (brand name Zoloft; see Important Safety Information), unlike people with anorexia nervosa. Some data also suggest that people with BDD often respond well to cognitive-behavioral therapy (CBT). This type of therapy is often less effective with anorexia nervosa (Grant, 2004).
What are the treatments for body dysmorphia?
Treatment for body dysmorphic disorder is generally a combination of medication and cognitive-behavioral therapy (CBT).
The current first-line treatment uses medicines called selective serotonin reuptake inhibitors (SSRIs). These antidepressant medicines have been found to improve symptoms and quality of life in people with BDD. This is particularly true in severely ill patients. Other medications such as buspirone (brand name Buspar; see Important Safety Information), atypical antipsychotic medications, or clomipramine can be added if symptoms remain (Hong, 2019).
A meta-analysis of seven randomized controlled trials concluded that CBT was an effective treatment for symptoms of BDD. Many people did still experience some distressing symptoms after CBT, indicating that a longer course of treatment might be needed for BDD than for other mental health disorders (Krebs, 2017).
Other possible treatments are still under investigation but have shown some promise. These include using the hormone oxytocin, which has shown some success with treating similar symptoms in people with OCD and autism. Repetitive transcranial magnetic stimulation (rTMS) and bilateral deep brain stimulation have also shown promise in treating complex, treatment-resistant BDD in randomized controlled trials (Hong, 2019).
Does cosmetic surgery help?
People with body dysmorphia often seek out cosmetic surgery and other cosmetic procedures to correct perceived flaws. Unfortunately, this is rarely successful. Many people report feeling the same or more dissatisfaction after cosmetic procedures (Higgins, 2017).
In the past, many surgeons have declined to perform surgery on people with untreated body dysmorphic disorder. There have been reports of surgeons being sued, assaulted, or even killed by people with BDD who were unsatisfied with surgical results (Higgins, 2017).
Currently, some surgeons are exploring whether people with more mild symptoms or who are in treatment might be appropriate candidates for cosmetic surgery. Further studies are needed, but it is possible that some people involved in a multidisciplinary treatment plan could see benefits from cosmetic procedures (Higgins, 2017).
Seek the support you need
If you are struggling with overwhelming dissatisfaction with your body and you think you may have body dysmorphia, it’s important to get help. Mental health professionals can offer you the support you need to manage your symptoms and live a productive life.
- Grant, J. E., & Phillips, K. A. (2004). Is anorexia nervosa a subtype of body dysmorphic disorder? Probably not, but read on… Harvard review of psychiatry, 12(2), 123–126. doi: 10.1080/10673220490447236. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1622894/
- Higgins, S., & Wysong, A. (2017). Cosmetic surgery and body dysmorphic disorder – an update. International journal of women’s dermatology, 4(1), 43–48. doi: 10.1016/j.ijwd.2017.09.007. Retrieved from https://pubmed.ncbi.nlm.nih.gov/29872676/
- Hong, K., Nezgovorova, V., Uzunova, G., Schlussel, D., & Hollander, E. (2019). Pharmacological treatment of body dysmorphic disorder. Current neuropharmacology, 17(8), 697–702. doi: 10.2174/1570159X16666180426153940. Retrieved from https://pubmed.ncbi.nlm.nih.gov/29701157/
- Krebs, G., Fernández de la Cruz, L., & Mataix-Cols, D. (2017). Recent advances in understanding and managing body dysmorphic disorder. Evidence-based mental health, 20(3), 71–75. doi: 10.1136/eb-2017-102702. Retrieved from https://pubmed.ncbi.nlm.nih.gov/28729345/
- Lai, T. M., Li, W., & Feusner, J. (n.d.). The neurobiology of body dysmorphic disorder. International OCD Foundation: BDD. Retrieved from https://bdd.iocdf.org/professionals/neurobiology-of-bdd/
- Nicewicz HR, Boutrouille JF. Body dysmorphic disorder. [Updated 2021 Jan 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK555901/
- Perkins A. (2019). Body dysmorphic disorder: The drive for perfection. Nursing, 49(3), 28–33. doi: 10.1097/01.NURSE.0000553273.24557.58. Retrieved from https://pubmed.ncbi.nlm.nih.gov/30720669/
- Phillips, K. A. (n.d.). Signs & Symptoms of BDD. International OCD Foundation: BDD. Retrieved from https://bdd.iocdf.org/professionals/signs-symptoms/
Dr. Steve Silvestro is a board-certified pediatrician and Senior Manager, Medical Content & Education at Ro.