Body Dysmorphic Disorder: Symptoms, Causes, and Treatments

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Body Dysmorphic Disorder: Symptoms, Causes, and Treatments

Jessica Gutowitz November 11, 2021
Looking in a Mirror, 1896, Henri de Toulouse-Lautrec, The Metropolitan Museum of Art (article on Body Dysmorphic Disorder)
Looking in a Mirror, 1896, Henri de Toulouse-Lautrec, The Metropolitan Museum of Art

Contents

Many people have felt dissatisfaction with their bodies at some point in their lives. The current prevalence of diet culture and messaging from all kinds of media about narrow beauty standards make it hard not to find flaws in one’s appearance. However, when a person shifts from occasional observation of potential flaws to an obsessive focus on perceived faults, they may be experiencing body dysmorphic disorder (BDD).

What Is Body Dysmorphic Disorder?

BDD, or dysmorphophobia, is a condition that occurs among 2.4% of the general population in the United States, and just under 2% globally.1 People who experience BDD have a distorted view of their own bodies and often obsess over their perceived physical flaws.2 As with any disorder, feelings associated with BDD are not simple dissatisfaction; based on the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5), to be diagnosed as BDD, a person’s preoccupation must impair their ability to function in everyday life.1,2

What Are the Symptoms of Body Dysmorphic Disorder?

Symptoms associated with BDD are widespread and overlap with conditions such as obsessive-compulsive disorder (OCD), anxiety disorders, and eating disorders. There may even be a genetic overlap between BDD and certain other psychiatric disorders: A 2004 study in the Psychiatric Quarterly found via a symptom questionnaire that more than 60% of patients with BDD also had depression, 32% exhibited anxiety, and around 25% had social phobia.3

Symptoms of BDD and related conditions include:4,5

  • depression
  • social anxiety
  • separation anxiety
  • panic
  • agoraphobia
  • bulimia
  • dieting
  • obsessions/compulsions
  • camouflaging perceived imperfections
  • comparing oneself to others
  • checking one’s appearance in mirrors constantly
  • excessive grooming
  • seeking constant reassurance from others
  • skin picking
  • frequently changing clothing
  • seeking cosmetic procedures, like surgery
  • excessive exercising or weightlifting

Types of Body Dysmorphic Disorder

The DSM-5 specifies one subtype of BDD called muscle dysmorphia, a condition in which a person becomes obsessed with the idea that their body is too small or not muscular enough.1 A person with this condition might become obsessed with muscle-building activities like going to the gym and lifting weights. Though professor and physician of psychiatry H. G. Pope coined the term “muscle dysmorphia” over 20 years ago, this subset of BDD lacks adequate research. Further research is needed to help clinicians treat people whose muscular preoccupation severely affects their health and well-being.6

Additionally, an individual’s experience of BDD varies based on their degree of insight regarding their beliefs about their body. People who exhibit a level of insight psychologists deem good or fair can recognize that their BDD beliefs are unlikely to be true or may not be true. Those who display poor insight think their beliefs are probably true. Those with delusional beliefs exhibit no insight or are convinced that their BDD beliefs are completely true.1 The DSM-5 classifies the delusional variant as a psychotic disorder, under delusional disorder, somatic type.1,7 Delusional disorder, somatic type, is a different diagnosis from BDD, but it is a similar condition, with a greater delusion severity. To be diagnosed with delusional disorder, one must experience delusions for 1 month or longer. Among other qualities, the somatic form of this disorder concerns bodily functions or sensations, and one of the most common delusions is the belief that parts of one’s body are what the client would define as “misshapen” or “ugly.”1 Compared to people with nondelusional BDD, contemporary research has shown that those with the delusional disorder are more likely to attempt suicide, have poorer social functioning, and are more likely to abuse drugs.7

… those who experienced severe childhood bullying, mostly in elementary and middle school, had more severe BDD symptoms than those who experienced less severe or no bullying.

Causes and Risk Factors of Body Dysmorphic Disorder

Childhood and adolescence are biologically and socially formative times in which people often begin to gain awareness of cultural norms, practices, and judgments. Although contemporary researchers still lack a robust understanding of what causes BDD, some propose a diathesis-stress model for its advent.8 According to this model, a disorder may form when a person experiences a biological predisposition for a condition and encounters a stressful or traumatic situation that facilitates the development of the disorder.9

Although related predisposing biological factors include genetics, brain structure, and personality traits,8 research has shown that BDD appears to be triggered more frequently by traumatic interpersonal incidents in childhood, such as bullying and teasing.8 Researchers have found that such events are most likely to contribute to BDD because of the fear of how others will perceive the individual.8 According to a 2017 study involving data gathered through the Body Dysmorphic Disorder Questionnaire, those who experienced severe childhood bullying, mostly in elementary and middle school, had more severe BDD symptoms than those who experienced less severe or no bullying. Additionally, the study indicated that childhood abuse can also make a person more likely to develop BDD in adulthood.8

Other interpersonal, cultural, and environmental factors can also contribute to BDD. For instance, cultural beliefs about the value of physical beauty, as well as social tendencies to compare appearance to both peers and media figures, can contribute to the development of BDD.8

How Is Body Dysmorphic Disorder Diagnosed?

The DSM-5 lists the following diagnostic criteria for BDD:1

  • The individual is preoccupied with perceived physical defects, which are not obvious to external viewers.
  • The individual engages in repetitive behaviors, like excessive grooming or skin picking, or mental acts, like comparing their appearance to that of others, because of their perception of their appearance.
  • Preoccupation results in “clinically significant distress or impairment” in day-to-day functioning.
  • Preoccupation is not centered around body fat or weight concerns, which might be better classified as an eating disorder.

BDD can be challenging to diagnose. Those who have the condition usually do not present their symptoms to a psychologist; they will more frequently turn to general practitioners, dermatologists, cosmetic surgeons, orthodontists, gynecologists, or urologists.10 They may try to alter their appearance through surgery or other procedures to “fix” or remove their perceived flaws rather than treating the root of their dysmorphic feelings. The condition may only be presented to a mental health counselor when associated with other conditions like depression, agoraphobia, or the risk of suicide.10 Studies show that the average age at which people develop BDD is 17; as such, pediatric and adolescent screening is crucial to preventing severity because symptoms develop gradually.11

Treatments for Body Dysmorphic Disorder

There are several different ways to treat BDD, including psychotherapy and medications. For many, a combination of approaches might constitute the most effective treatment.11

Cognitive Behavioral Therapy

Cognitive behavioral therapy (CBT) aims to improve clients’ quality of life and coping mechanisms by disrupting their dysfunctional thoughts and behaviors. It combines techniques including behavioral experiments, exposure, and response prevention. CBT also includes mindfulness techniques that can help clients broaden their understanding of their appearance beyond their perceived physical flaws. CBT treatment plans, or the specific measures taken by the therapist, can be adapted to address specific symptoms of BDD, like skin picking.11 Researchers have found CBT to be an effective treatment to reduce the symptoms of BDD. A recent analysis shows that CBT can reduce symptom severity for 2 to 4 months after treatment, with sessions ranging from 60 to 90 min over 8 to 14 weeks.11 One particular study, which tested the use of individual CBT among adolescents with BDD-related compulsions, found that the participants experienced a reduction of their symptoms by about 68%.11

Acceptance and Commitment Therapy

Acceptance and commitment therapy (ACT) is a mindfulness and acceptance-based therapy that focuses on helping people recognize that their internal psychological processes (e.g., thoughts, feelings, images, sensations) are natural. Some clients find them aversive, which can make treatment difficult because if a client cannot bear to examine and work on these internal emotions, thoughts, and so on, they will not be successful at making the changes they discuss during psychotherapy. People with BDD often suppress and avoid their own emotions.11 As such, ACT can help clients with BDD learn how to express and accept their emotions and develop coping mechanisms.11

Medications

Selective serotonin reuptake inhibitors (SSRIs) and clomipramine are the most effective medications used to treat BDD.10 SSRIs, which are most commonly used to treat depression, prevent the reuptake of serotonin in the brain to increase serotonin activity.12 When professionals use SSRIs to treat BDD, they usually prescribe a larger dosage than what would be used to treat depression; it is more comparable to a dosage that might be used to treat OCD.

Although medication can be an effective method to treat BDD, some clients may have difficulty adhering to this treatment due to preconceived notions about psychiatric medications, perceived or actual side effects, or motivation to remain committed to taking the medication. Antipsychotics to treat the co-occurring conditions can help increase treatment maintenance, as reducing these symptoms can allow the client to focus on treating their BDD and adhere to their treatment plan. For people with BDD, medication serves as a long-term treatment; studies have shown that those who take SSRIs for more extended periods are less likely to relapse, though the percentage of people who do relapse after stopping medication is relatively high, at about 18%.11

Cosmetic Treatments in People with Body Dysmorphic Disorder

Approximately 75% of people with BDD seek cosmetic procedures to “fix” the perceived physical flaws they fixate on.13 Although around 66% of people with BDD follow through with procedures, such procedures rarely reduce symptoms associated with BDD and most often lead to dissatisfaction among the clients.13 As a result, some plastic surgeons have raised questions about whether professionals in their industry should operate on patients who have BDD, a population that some research indicates may constitute as much as 15% of their clientele.14

Outlook

Environment and culture play a prominent role in the advent of poor body image and BDD.8 For instance, contemporary Western ideals often promote specific models of female beauty characterized by slenderness and youthfulness, among other attributes. With the proliferation of media and social media platforms in particular, this ideal is more pervasive than ever.15 Such imagery perpetuates the potential for BDD among the general population by narrowing understandings of beauty and excluding a wide range of diverse human attributes.16

In response to such beauty ideals, in the early 2000s, there began a global “body positivity” movement across social media that has started to dismantle aesthetic norms. Born out of the fat rights or fat liberation movement of the 1970s, body positivity promotes acceptance of one’s appearance, regardless of size, and rejection of the often-unachievable cultural standard.17 A specific hashtag—#bodypositivity—was created to mark the movement, and millions of people have used it across social platforms, including Instagram. However, the movement has garnered critique; for example, less than half of the bodies posted with the hashtag were “larger” or plus sized.16 Although it represents a step in the right direction of normalizing and celebrating global body diversity, it will not eliminate BDD entirely. However, promoting acceptance of one’s appearance, including flaws, will only reduce the number of people who become obsessed with their faults.

In this era of increasing body acceptance, people who experience BDD can feel safe reaching out for support. Psychotherapy and medication are both viable treatment options for BDD, and researchers have even developed and tested online CBT psychotherapeutic treatments for BDD.11 Help is more accessible than ever.

References

  1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
    https://doi.org/10.1176/appi.books.9780890425596.dsm05
  2. Almugaddam, F., Jafferany, M., Mufaddel, A., & Osman, O. T. (2013). A review of body dysmorphic disorder and its presentation in different clinical settings. The Primary Care Companion for CNS Disorders, 15(4).
    https://doi.org/10.4088/PCC.12r01464
  3. McElroy, S. L., Phillips, K. A., & Siniscalchi, J. M. (2004). Depression, anxiety, anger, and somatic symptoms in patients with body dysmorphic disorder. Psychiatric Quarterly, 75(4), 309–320.
    https://doi.org/10.1023/B:PSAQ.0000043507.03596.0d
  4. Baillie, A. J., Hudson, J. L., Mond, J., Schneider, S. C., & Turner, C. M. (2018). The classification of body dysmorphic disorder symptoms in male and female adolescents. Journal of Affective Disorders, 225, 429–437.
    https://doi.org/10.1016/j.jad.2017.08.062
  5. Phillips, K. A. (n.d.). Signs & symptoms of BDD. International OCD Foundation.
    https://bdd.iocdf.org/professionals/signs-symptoms/
  6. Cranswick, I., Edwards, E., & Tod, D. (2016). Muscle dysmorphia: Current insights. Psychology Research and Behavior Management, 2016(9), 179–188.
    https://doi.org/10.2147/PRBM.S97404
  7. Fay, C., Menard, W., Pagano, M. E., Phillips, K. A., & Stout, R. L. (2006). Delusional versus nondelusional body dysmorphic disorder: Clinical features and course of illness. Journal of Psychiatric Research, 40(2), 95–104.
    https://doi.org/10.1016/j.jpsychires.2005.08.005
  8. Curley, E. E., Renshaw, K., Weingarden, H., & Wilhelm, S. (2017). Patient-identified events implicated in the development of body dysmorphic disorder. Body Image, 21, 19–25.
    https://doi.org/10.1016/j.bodyim.2017.02.003
  9. Li, P. (n.d.). Diathesis stress model—Psychology. Parenting for Brain.
    https://www.parentingforbrain.com/diathesis-stress-model/
  10. Alström, K., Andersson, E., Andersson, G., Enander, J., Lichtenstein, L., Ljótsson, B., Mataix-Cols, D., & Rück, C. (2016). Therapist guided internet based cognitive behavioral therapy for body dysmorphic disorder: Single blind randomized controlled trial. The British Medical Journal, 352, Article i241.
    https://doi.org/10.1136/bmj.i241
  11. Hollander, E., Hong, K., & Nezgovorova, V. (2018). New perspectives in the treatment of body dysmorphic disorder. F1000 Research, 7(361).
    https://doi.org/10.12688/f1000research.13700.1
  12. Chu, A., & Wadhwa, R. (2021, May 10). Selective serotonin reuptake inhibitors. StatPearls.
    https://www.ncbi.nlm.nih.gov/books/NBK554406/
  13. Kelly, M. A., & Phillips, K. A. (2017). Update on body dysmorphic disorder: Clinical features, epidemiology, pathogenesis, assessment, and treatment. Psychiatric Annals, 47(11), 552–558.
    https://doi.org/10.3928/00485713-20171004-02
  14. de Brito, A., Ferreira, L. M., José, M., & Nahas, F. X. (2012). Should plastic surgeons operate on patients diagnosed with body dysmorphic disorder? Plastic and Reconstructive Surgery, 129(2), 406–407.
    https://doi.org/10.1097/PRS.0b013e31823aeee7
  15. Senín-Calderón, C., Perona-Garcelán, S., & Rodríguaz-Testal, J. F. (2020). The dark side of Instagram: Predictor model of dysmorphic concerns. International Journal of Clinical Health and Psychology, 20(3), 253–261.
    https://doi.org/10.1016/j.ijchp.2020.06.005
  16. Harringer, J. A., Lazuka, R. F., Keel, P. K., & Wick, M. R. (2020). Are we there yet? Progress in depicting diverse images of beauty in Instagram’s body positivity movement. Body Image, 34, 85–93.
    https://doi.org/10.1016/j.bodyim.2020.05.001
  17. Osborn, T. (n.d.). From New York to Instagram: The history of the body positivity movement. BBC.
    https://www.bbc.co.uk/bitesize/articles/z2w7dp3

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