When Appearance Preoccupation Becomes Illness: Body Dysmorphic Disorder

Content warning

This article references potential trauma triggers, including obsessive compulsions, anxiety, depression, abuse, bullying, and suicide. If you are in distress and need immediate help, trained counselors are available to take your call. Please find a crisis hotline in your country here.

Body Dysmorphic Disorder (BDD) is a mental illness that causes distress and preoccupation with a physical flaw. The fixation isn’t due to any other psychiatric disorder.¹

The perceived "defect" that a person with BDD is distressed by may not be noticeable to others (or may seem very slight).

However, the concern is overwhelming for the person with BDD.

According to the International OCD Foundation, an estimated 10 million people in the US have BDD.² However, it may be even more common, as those with this disorder may not always disclose their symptoms.

One research study involving 500 participants diagnosed with BDD found that the most common areas of the body associated with unhappiness included:

• Hair (56%)

• Nose (37%) 

• Weight (22%)

• Stomach (22%)

• Breasts, chest, or nipples (21%)³

Is body dysmorphic disorder a form of extreme vanity or low self-esteem?

The short answer? No. Those unaware of BDD as a recognized mental illness may mistakenly believe that the condition is related to vanity or low self-esteem. After all, most of us have experienced being dissatisfied with our appearance at some point in our lives. Especially during adolescence, preoccupation with appearance is often chalked up to normal teenage behavior. 

However, it's important to understand that with BDD, the obsession with one’s physical appearance is so intense that it can severely impact a person’s quality of life. BDD is a true mental health disorder.

Some studies estimate that 40% of people with BDD think about their disliked body parts (or parts) between three to eight hours a day, while 25% think about it for more than eight hours a day.⁴

Also, a significant amount of time is spent performing repetitive behaviors to “correct” or check the physical flaw. 

These behaviors may include:

• Comparing the disliked body part with those of other people

• Constantly covering “flaws” (with clothing, makeup, or adjusting body position)

• Seeking corrective surgery 

• Checking the mirror excessively (or avoiding it altogether)

• Spending excessive effort and time on grooming

• Skin picking

• Changing clothes excessively

• Excessive exercise⁵ ⁶

Unfortunately, these practices only provide temporary relief. The underlying dissatisfaction with one’s body usually continues to grow. 

Body dysmorphia can lead to reduced functioning in social, occupational, and other areas of daily life. For example, some individuals with BDD may avoid being seen by others and may be unable to leave home.

Is body dysmorphic disorder the same as an eating disorder?

Learning about BDD’s symptoms might call to mind other conditions involving mental conflict and distress about one’s body, such as anorexia. 

However, the two are distinct disorders, even though they can have overlapping symptoms, such as fear of being overweight when not.⁷

In someone with anorexia, there is typically more concern about general weight and size, while individuals with BDD are usually more focused on specific body parts. 

Also, those with anorexia have restrictive eating patterns, and someone with BDD may or may not.⁸

It’s also possible to have both — an estimated 39% of people with anorexia also have a BDD diagnosis.⁹

How common is body dysmorphic disorder?

BDD has a relatively high prevalence, although there's often less public awareness than conditions like anorexia or bulimia.

BDD affects roughly 1.7%–2.9% of the US population (or 1 in 50 people) compared to the 0.3% who have bulimia and the 0.6% with anorexia nervosa.² ¹⁰

Rates of BDD are similar between males (2.5%) and females (2.2%). However, there are some differences between the physical concerns they may be preoccupied with. 

For example, males are more likely to find flaws with thinning hair, while women may focus more on breast size and skin.

A study of 200 male and female participants with diagnosed BDD found differences in the focus of their obsessions.¹¹

Also, the females were excessively concerned with more body areas than the males. In the males with BDD, the body part(s) they focused on were often:

• Genitals

• Body build

• Hair (thinning hair or balding) 

In the females with BDD, the body part(s) they focused on were often:

• Skin

• Stomach

• Weight

• Breasts 

• Buttocks

• Thighs

• Legs

• Hips

• Toes

• Body or facial hair

Body dysmorphic disorder around the world

Cross-cultural studies on BDD are limited. Data comes mainly from research done in the US and UK. 

Still, BDD is reported in North America, Australia, Eastern and Western Europe, the former Soviet Union, China, Japan, South America, and Africa, among others.¹²

However, anecdotal case studies suggest that there may be slight differences between the types of physical concerns across cultures. 

For example, in Japan, preoccupation with eyelids seems to be more common than in Western cultures, in which the desire for muscle mass seems more characteristic.¹² ¹³

What causes body dysmorphic disorder?

So far, studies indicate that BDD symptoms typically emerge around the pre-teen and teen years (starting at around 12 years old).

Exactly why BDD develops in some and not others is more complicated. According to the Anxiety & Depression Association of America, BDD may develop due to both environmental and biological factors.¹⁴

Genetics, serotonin response, perfectionism, and history of trauma can also play a role in developing BDD.¹⁵

Researchers have found evidence that in those with BDD, a specific brain area called the prefrontal cortex seems to function differently.¹⁶ It’s the area that controls visual and spatial perception, response inhibition, and facial expressions. 

Studies have also found abnormal brain activation in participants with BDD when viewing objects and faces. Participants showed increased levels of brain activity in areas that process detailed visual information.¹⁷ ¹⁸

Research also indicates that the neurotransmitter (brain chemical) serotonin may be imbalanced in individuals with BDD.

Interestingly, serotonin reuptake inhibitors (SSRIs) prove therapeutic in treating BDD symptoms for many people. 

It’s important to note that while SSRIs are known to reduce BDD symptoms, they are not a cure.¹⁹

In the limited number of genetic studies conducted on BBD, findings indicate a hereditary factor. For example, 8% of those with BDD have a family member with BDD, representing a four to eight times higher diagnosis rate than within the general population.¹⁷

Socio-cultural factors have also been identified, including

• Unrealistic societal beauty standards

• Parental criticism of appearance

• Peer bullying²⁰

One study found that 69% of people with BDD had experienced some form of teasing or bullying (online or in-person).²¹

Is body dysmorphic disorder related to other mental health conditions?

In those with BDD, other mental health conditions are often present, especially depression, anxiety, obsessive-compulsive disorder (OCD), eating disorders, and substance use disorders.²²

14-42% of individuals with clinical depression have BDD.²³ ⁹

BDD is also the fourth most common simultaneous condition for those diagnosed with social anxiety disorder. 

Of all the linked psychiatric conditions, BDD shares the most similarities with obsessive-compulsive disorder (OCD), a type of anxiety disorder. 

In the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-V), BDD is classified as “Obsessive-Compulsive and related disorders.”  

Similar, but not precisely like OCD, BDD symptoms include distressing, obsessive thoughts (specific to physical appearance), and mental or behavioral compulsions resulting from the obsession (such as mirror checking or skin picking).

Studies have also found that 7% of BDD patients have an immediate family member diagnosed with OCD.¹⁷

Those with OCD were also six times more likely to have a first-degree relative with BDD than the control groups' participants.¹⁷

Far-reaching effects of BDD

Unfortunately, many people living with BDD experience lower quality of life in many areas of their life, including relationships and receiving an education.

In one UK National Health Service (NHS) Case Study, a services user describes how BDD obsession and rituals became highly disruptive: 

"As far back as I remember, I had never felt truly comfortable in my own skin. Things seemed to worsen as I started to go through puberty and dramatically changed when I entered my teenage years. I noticed rituals started to invade my life. I began obsessing over my clothes, hygiene, and mainly physical appearance. I would spend hours staring in front of the mirror, scrutinizing every inch of myself. I would try anything to mask myself, blend in, and fade into the background."²⁴

Such experiences are common for those living with BDD.

One study found that among 200 participants with BDD, 36% reported that they had missed work, and 11% dropped out of school because of their symptoms.⁴

In the same study, 27–31% of participants had been housebound (for over a week) by their BDD symptoms. More than 40% were, at some point, admitted to a psychiatric hospital.  

BDD is also associated with a high risk of suicide and self-harm. Experts estimate that 80% of people with BDD have thought about suicide, and 25% will attempt to take their own lives.⁴ ²⁵

Other studies have found that people with BDD's quality of life ratings are even poorer than those with diabetes or clinical depression.⁴ If you are currently in distress, speak with someone today. Please find and connect with a trained crisis counselor in your area here.

Can body dysmorphic disorder be cured or recovered from?

Unfortunately, there isn't a single medication or treatment that can completely relieve BBD symptoms. 

However, various treatment options can make the symptoms much more manageable and less intrusive. 

In one of the longest-term studies to evaluate people with body dysmorphic disorder, psychiatrists following BDD patients over eight years found that 76% recovered from the condition.²⁶

Participants were identified through a broader anxiety study and had relatively less severe symptoms. However, the findings are relevant, especially for someone unsure about seeking help. 

Treatment for BDD

One of the leading evidence-based treatments for BDD is cognitive-behavioral therapy (CBT). The cognitive part of the therapy involves helping patients identify irrational beliefs and reframe thoughts related to their appearance.²⁷

The behavioral part of the intervention includes neutralizing rituals and compulsions like mirror-checking.²⁷

Pharmacotherapy also improves BDD symptoms substantially, specifically the prescribed use of serotonin reuptake inhibitors (SSRIs). Responsiveness to treatment is usually strong.²⁸ SSRIs are also effective in treating depression and OCD. 

Does cosmetic surgery help with body dysmorphic disorder?

Before someone with undiagnosed BDD confides in a healthcare professional, they may first look to cosmetic surgery to relieve their distress. Some studies estimate that 7–8% of those seeking cosmetic surgery in the US have BDD.²⁹

Unfortunately, undergoing medical procedures to “fix” the disliked body part yields little benefit. On the contrary, it can even make BDD worse and lead to repeat procedures.

A study conducted with 200 BDD patients revealed that nearly all those who had received plastic surgery (21%) continued to experience BDD symptoms afterward. 

Another group of researchers surveyed 265 cosmetic surgeons and found that 65% of them had performed procedures on patients with BDD. But only 1% of these patients saw improvements in their BDD symptoms.

This frequently leads to repeated procedures or even anger towards the surgeon who was unable to help them achieve their desired results.³⁰ ²¹ ³¹

Body dysmorphic disorder is going undetected or misdiagnosed

Unfortunately, BDD is not just a highly debilitating disorder. It frequently goes undiagnosed or misdiagnosed. 

A major barrier to diagnosis is that someone with BDD often lacks awareness of their body image issues, making it difficult to seek help. 

Those affected are reportedly more likely to seek out specialists for cosmetic surgery, dermatology, or orthodontics to “correct” a body part rather than seek mental health help.   

Additionally, non-psychiatric healthcare professionals may be unfamiliar with BDD or fail to pick it up during screening.

Even when BDD patients appear in a psychiatric setting, they're less likely to disclose their symptoms to a healthcare professional. 

Again, lack of insight into their BDD symptoms is a contributing factor. But studies also show that some feel too embarrassed or ashamed to discuss it for fear of negative judgment from their doctor. 

In such cases, clinicians may rely on more observable symptoms (like social anxiety) to diagnose, increasing incidences of misdiagnosis.   

Many mental health professionals are not as familiar with BDD as they are with more common forms of mental illness like depression or anxiety.   

Concerningly, several studies that recruited patients from psychiatric settings found that even when participants were screened for BDD (and had been diagnosed), it wasn’t included in their medical records.¹³ ²² ³²

For these many reasons, experts are calling for more awareness about BDD, especially among medical professionals. In order for BDD to be appropriately treated, it must first be identified properly. 

The lowdown

Suppose you feel that you might be experiencing symptoms of body dysmorphic disorder. In that case, it's essential to speak to a qualified healthcare professional. 

BDD is a serious mental illness that can lead to disability, depression, and suicide, so its recognition and treatment are crucial. 

Therapeutic treatments like cognitive behavioral therapy and prescribed SSRIs are shown to relieve symptoms and significantly improve the quality of life for people with BDD.³³

If you are in distress and need immediate help, connect with a trained crisis counselor in your country here.

The information provided is designed to support, not replace, the relationship that exists between a patient/site visitor and their existing health care professional(s).

Have feedback? Send an email to content@healthmatch.io.

Sources:

1. The mirror lies: body dysmorphic disorder (2008)

2. Prevalence of BDD | International OCD Foundation

3. Body dysmorphic disorder | Lumen

4. Body dysmorphic disorder (2010)

5. Table 23: DSM-IV to DSM-5 body dysmorphic disorder comparison (2016)

6. Signs & symptoms of BDD | International OCD Foundation

7. Is anorexia nervosa a subtype of body dysmorphic disorder? Probably not, but read on … (2006)

8. Comparing and contrasting body-dysmorphic disorder and eating disorders (2019)

9. The mirror lies: Body dysmorphic disorder (2008)

10. Eating disorders | NIH: National Institute of Mental Health

11. Gender similarities and differences in 200 individuals with body dysmorphic disorder (2006)

12. Body dysmorphic disorder: recognizing and treating imagined ugliness (2004)

13. Understanding and treating body dysmorphic disorder (2019)

14. Body dysmorphic disorder: Understanding body dysmorphic disorder (BDD) | Anxiety & Depression Association of America

15. Personality traits as vulnerability factors in body dysmorphic disorder (2013)

16. The pathophysiology of body dysmorphic disorder (2013)

17. Body dysmorphic disorder: Neurobiological features and an updated model (2014)

18. Anorexia nervosa and body dysmorphic disorder are associated with abnormalities in processing visual information (2016)

19. The neurobiology of body dysmorphic disorder | International OCD Foundation

20. Body dysmorphic disorder (BDD) | Mind

21. Cosmetic surgery and body dysmorphic disorder – An update (2018)

22. Body dysmorphic disorder: Advances in research and clinical practice (2017)

23. Relationship between social anxiety disorder and body dysmorphic disorder (2011)

24. Body dysmorphic disorder service | NHS

25. Raising awareness for body dysmorphic disorder | The Association for Child and Adolescent Mental Health

26. Body dysmorphic disorder patients who loathe appearance often get better, but it could take years (2011)

27. A therapist’s guide for the treatment of body dysmorphic disorder | International OCD Foundation

28. Pharmacotherapy for body dysmorphic disorder (2016)

29. Surgical and minimally invasive cosmetic procedures among persons with body dysmorphic disorder (2011)

30. Does cosmetic surgery help body dysmorphic disorder? (2010)

31. Body dysmorphic disorder may be under-diagnosed in patients seeking cosmetic procedures | American Society of Plastic Surgeons

32. Who gets BDD? | International OCD Foundation

33. Treating body dysmorphic disorder with medication: Evidence, misconceptions, and a suggested approach (2009)

The author, Dawn Teh, is a health writer and former psychologist who enjoys exploring topics about the mind, body, and what helps humans thrive.