Understanding Body Dysmorphic Disorder
Mirror Mirror on the Wall
by Eda Gorbis, PhD, MFCC
What is Body Dysmorphic Disorder?
Body Dismorphic Disorder (BDD) is explained by the psychiatric Diagnostic and Statistical Manual of Mental Disorders as a preoccupation with an imagined defect in appearance, and if
indeed a slight defect is present the individual's preoccupation with that defect is
markedly excessive. There is an ongoing debate among researchers regarding the exact
categorization of BDD as a disorder, but many professionals consider it to be a form or
subtype of Obsessive-Compulsive Disorder. Nevertheless, the symptoms of BDD
manifest as excessive concern with one's appearance or a particular part of one's body,
the concerns propelled by self-focused obsessions that generate significant levels of
distress that disrupt one's ability to function. BDD is marked by excessive preoccupation
so intense it makes it extremely difficult to focus on anything other than that body part or
perceived flaw, provoking requests for reassurances from others as well as checking and
seeking reassurance in any available mirror or reflection. A major symptom of BDD is a
tormenting doubt; the underlying question related to uncertainty about ones body part, or
appearance. It is important to mention that symptoms can shift from concern about one
aspect of appearance to another at any time.
Is BDD a symptom of OCD or is it an entirely different problem?
There is an ongoing debate among researchers regarding the exact categorization of BDD
as a disorder, but many professionals consider it to be a form or subtype of Obsessive-
Compulsive Disorder. BDD often subsists amidst a cluster of related anxiety disorders
including OCD, General Anxiety Disorder, Panic Disorder, as well as Bulimia and
Anorexia Nervosa. The BDD fear structure is similar to that of OCD, but the obsessions
and compulsions are specifically related to ones body.
How does someone know that s/he has BDD and isn't just concerned with a
problem with his/her appearance?
BDD is not analogous to the common feelings of insecurity or appearance related
self-consciousness that most people have experienced at one time or another. Many
people are somewhat critical of their appearance, and some people will go to great
lengths in attempt to change what they consider to be flawed. Plastic surgery is
increasing in popularity, and more people are willing to take the risk of "going under
the knife." A specific aspect of appearance can be surgically altered or "corrected"
through procedures such as rhinoplasty (or a "nose-job"). Many people who have had
this procedure are happy with the results and can move on with their life. When,
however, BDD is a factor, the nose will never be perfect — or if they are satisfied with
the nose, another obsessive fixation on a different body part will take over.
A person suffering from BDD is subjected to high levels of distress that interfere with
healthy functioning, and obsessions consume more than one that daily. Furthermore,
symptoms often disrupt interpersonal relationships, and impair social and
occupational performances. This physical fixation caused by the disorder distorts
self-perception making difficult to objectively appraise the appearance of self.
It is not uncommon for people suffering from BDD to perceive their own image so
distorted, while they may be able to appraise appropriately accurate appearances of
others, at the same time they fail to objectively appraise appearance of self. What
people with BDD perceive is actually similar to the reflection we have all seen in a
distorted carnival fun-house mirror.
How much concern about "problems" with one's appearance signals that
that person might have BDD?
BDD can be recognized when concern with ones appearance leads to excessive
distress, withdrawal from social appearances or relationships, or even avoidance of
public appearances as simple as going for a ride in a car or going to a swimming pool.
Excessive concern about perfected appearance in dress, makeup, jewelry, and hair is
also evident, which may result in grooming between one up to 12 hours per day.
These avoidances can progress to tragic proportions. In severe cases of BDD, we
often observe repeated cosmetic surgical interventions that are uncalled for,
inappropriate, and unnecessary. The problem is that cosmetic surgeons, often due to
difficulty in understanding and diagnosing BDD, are not able to identify the problem.
The most extreme case that I saw in my practice involved a patient who had
undergone 17 plastic surgeries, procedures most people would consider unnecessary
and even dangerous.
What are some of the symptoms of BDD?
Symptoms of BDD include (but are not limited to) excessive concern with a
particular body part or aspect of appearance. The distress caused by this fixation can
lead to compulsive behaviors such as repeated questioning and seeking reassurance,
endless matching of the clothing, social withdrawal, impairments or nonexistence of
interpersonal intimate relationships, inability to tolerate social situations, constant
checking for physical imperfections through touching, testing for bumps, feeling for
symmetry, searching for flaws, skin picking, measuring the waste line, noses,
counting hairs that fell out, etc.
Who gets BDD? More women then men? Younger people?
People with other anxiety disorders are more likely to be diagnosed with BDD due to
the high comorbidity of anxiety disorders. More men are treated for BDD then
women; however, more research is necessary to see the exact distribution. There is
some speculation that female BDD symptoms are more likely to be interpreted as
"normal" female behavior and are likely to be overlooked and remain untreated. The
onset of BDD is not exclusive to a particular age, though symptoms often emerge
during teen-age years.
What causes BDD?
There are some theories, but the specific causes of BDD are not known. Many
experts agree that sociological and biological factors play a role in the development of
BDD.
What is the difference between concern about one's appearance and
obsessing about supposed flaws?
When concern with ones appearance interferes with social/occupational performance it
may be a symptom of BDD. Simply put, if a persons appearance becomes the
center of their focus and they can no longer maintain a healthy perspective on life
it becomes an unhealthy obsession.
How can BDD impact a person's life?
The degree to which BDD affects ones life depends on the severity of the
symptoms/condition as well as the persons ability to use mindfulness, a nesicary practice
for treating the disorder. BDD symptoms can cause one to avoid public places and social
situations, undergo multiple and unnecessary plastic surgeries, be housebound, cause low
self-esteem, depression, anger, anxiety, eating disorders. In severe cases it can even lead to suicide.
Do people with BDD actually see themselves differently or are they
interpreting what they see differently? Do they imagine flaws and
imperfections or do they misperceive what they actually see?
People with BDD misperceive what they see. There is misinterpretation and distortion in
what is the actual flaw.
Do people with BDD experience a kind of paranoia about their perceived
flaws? Do they believe or feel that others are taking special notice of their
"defects," or staring at it or laughing at it?
People with BDD certainly do experience extreme self-consciousness. It sometimes
becomes evident begins avoiding social situations, and not wanting others to see them.
BDD leads people to sense that other people are criticizing their perceived imperfections.
Around others, they get the feeling of being scrutinized under magnifying glass. As these
fixations intensify the belief that people are looking at the perceived "defects" seems
rational. Other's actions are interpreted in reference to the particular "flaw" and it seems
that people are starring, laughing, and discussing them behind their backs.
Is the person with BDD literally delusional about the existence of the flaws or
imperfects he feels he has?
BDD just like OCD ranges in its severity; level of insight and insight may actually be
evaluated as good to poor or extremely poor. People entrenched with extremely poor
insight may be close to overvalued ideation about imperfections that he/ she feels.
What kinds of compulsive behaviors do people with BDD perform?
Compulsive behaviors of people with BDD vary depending on their "area of concern."
For example, if one is concerned with her/his nose, they might touch it, check it in the
mirror or any reflecting surfaces, get plastic surgeries, and perfect it endlessly. In general,
symptoms include seeking for reassurance, body checks, and checking ones image in any
reflecting surfaces.
Does a person with BDD typically ask family and friends for reassurance
about his appearance or try to convince them that they are ugly?
People with BDD typically ask for reassurance. However, responses to repeated
questioning lead to other questions in different forms that are underlined by uncertainty.
These compulsions result in no relief but rather and in fact reinforce the false belief
system and unhealthy fixations leading to further compulsive questioning and on and on.
Does BDD interfere an individual doing his job, managing a household or
maintaining relationships with friends and family?
One of the parts of being diagnosed with BDD is the fact that ones relationships and
functioning are handicapped by the symptoms. Person might be so concerned with having
their hair done perfectly, that they will not be able to even leave the house, or have time
to do anything else except for doing their hair.
Do people with BDD have problems leaving their homes, shopping, engaging
in work and play activities?
People with BDD believe that some aspect of their appearance is not perfect. They spend
endless amounts of time and a lot of effort trying to perfect that particular aspect of
appearance. If their "area of concern" is not perfect [it never is], they are reluctant to
leave the house or continue with the daily activities. It is not only that they know that
they are not perfect, but also they believe that they will be highly scrutinized by others
(watched under magnifying glass). All those factors make it difficult for people with
BDD to go on with even routine daily activities.
What causes BDD?
The exact causes of BDD are not known. More research is needed to answer this question.
Are there treatments for BDD? What are they?
There are excellent treatments for BDD. One of them is cognitive-behavioral therapy (CBT)
with uses exposure and response prevention. Also the addition of mindful awareness training,
cognitive restructuring, and Socratic questioning to CBT can be useful. At our Westwood
Institute for Anxiety Disorders, we have been using videotaping, and objective self-portrait
description in writings. We have also recently ordered numerous distorted mirrors
that are used in exposure exercises to help patients intensify the distortions. This
technique has been successful so far. At our institute combination of medications and
CBT are commonly used. We often employ an interdisciplinary team to work on each
case and treatment is tailored to each case. We also have five psychiatrists that are OCD
and anxiety disorder specialists.
Are there medications that are effective?
Medications may or may not be effective. Each and every case is different. For people
with high base anxiety, medications may be used to reduce the amount of experienced
anxiety. In some cases, medications can also be used to alleviate other psychological
disorders that are present and may interfere with the treatment of BDD (e.g., depression,
panic attacks). However, some kind of therapy is required in addition to the medication.
Is cognitive behavior therapy an effective treatment for BDD?
Cognitive-behavioral therapy has been proven to be highly effective in treating BDD. At
our institute we had many successful cases of people who have been treated with CBT
and got great outcomes.
What can family members do to help a person with BDD?
Family's understanding, support, and love are required. Oftentimes, people
misperceive BDD symptoms as one being shallow and self-absorbed. It is very
important for families to understand that BDD is a disorder. It requires treatment. It is
also extremely important to help one find appropriate help as soon as possible
because symptoms might worsen.
More about spectrum disorders...
Disclaimer: This information should not be considered medical advice and should not substitute the judgment of a competent psychiatrist.
Credits: Eda Gorbis, PhD, MFCC
Assistant Clinical Professor, UCLA School of Medicine (more about author).
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