What is body dysmorphic disorder (BDD)?
Source: the IOCDF’s body dysmorphic disorder website.
Have you ever looked in the mirror and become fixated on a pimple, scar, or other flaw that you saw on your skin? Do you worry that your nose looks weird — or that some other part of your body looks flawed or defective?
If these thoughts and feelings become time-consuming and cause significant emotional distress (such as anxiety, sadness, or self-consciousness) and/or significant problems in your daily life, this may be body dysmorphic disorder (BDD). People with BDD also engage in excessive repetitive compulsive behaviors in response to their appearance concerns. These can include comparing with others or excessively checking mirrors or grooming.
What are the common signs and symptoms of BDD?
- Frequent thoughts about perceived flaws in appearance, taking up at least an hour a day.
- Spending a lot of time staring in a mirror and/or other reflective surfaces while fixated on the perceived flaw. In some cases, however, people avoid of mirrors/reflective surfaces.
- Covering up the disliked body area. Examples of this include using hats, scarves, makeup, or changing body position or posture.
- Repeatedly asking others if you look okay. This is also known as “reassurance seeking.”
- Frequent appointments with medical professionals/cosmetic surgeons to "fix" the disliked body area.
- Repeated plastic surgery or dermatologic treatment.
- Compulsive skin picking. This includes using fingernails, tweezers, and/or other sharp implements to try to remove perceived blemishes or "fix" other perceived skin flaws.
- Avoiding social situations, public places, work, school, and/or other situations where people might see your perceived appearance flaws.
- Leaving the house less often or only going out at night to prevent others from seeing the “flaw(s).”
- Keeping your obsessions and compulsions secret due to feelings of shame.
- Feelings of disgust, depression, anxiety, low self-esteem, suicidal thinking, etc., because the perceived appearance flaws are so upsetting.
It is important to note that people with BDD look "normal" to other people. In other words, the perceived appearance flaws are, in reality, minimal or nonexistent. However, the person with BDD usually doesn’t realize this. They think their flaws are readily visible to others and look as ugly to other people as they do to themselves.
How do you tell the difference between being unhappy with your appearance and BDD?
Most people are unhappy with some aspect of how they look, but most people don't have BDD. How do you tell the difference between normal appearance concerns and BDD?
You might have BDD if:
- You spend at least one hour in total a day (adding up all the time you spend) thinking about your perceived appearance flaws.
- Your preoccupation with the perceived appearance flaws interferes with your day-to-day functioning. For example:
- You have difficulty concentrating
- You have problems with work, school, and/or other responsibilities (for example, being late, missing work or school, or being less productive)
- You avoid social situations, including not dating, canceling/missing activities with friends or family, etc.
- Your preoccupation with the perceived appearance flaws causes significant emotional distress.
- “Emotional distress” can include depression, anxiety, sadness, frustration, anger, embarrassment, shame, and/or feeling that life isn't worth living.
- At some point, you have performed repetitive behaviors in response to the appearance concerns. Examples include repetitively checking mirrors, grooming, asking others how you look or if you look okay, skin picking, and comparing your appearance with that of other people.
If you are preoccupied ONLY with thinking that you're "too fat," or that parts of your body (such as your stomach or thighs) are "too fat," it is important to determine whether or not an eating disorder is a more fitting diagnosis than BDD.
Which parts of the body are often the focus of BDD?
People with BDD can excessively worry about any body part, but the ones they report most often are related to the head or face:
- Hair
- Nose
- Skin
- Eyes
- Chin
- Jaw
- Neck
- Face size or shape
Other common areas of concern include the arms, legs, stomach, hips, weight, and body build (for example, feeling not muscular enough).
On average, people with BDD are concerned with a total of 5–7 different body parts in the past or currently. However, some people worry about just one body area, and others intensely dislike virtually everything about how they look.
How is body dysmorphic disorder (BDD) Treated?
Source: the IOCDF’s body dysmorphic disorder website.
There are both therapy- and medication-based treatment options to help those with BDD. The goal of these treatments is to improve quality of life and overall day-to-day functioning of those with BDD. At the same time, they decrease worries, distress associated with appearance concerns, and compulsive behaviors also commonly seen in BDD.
- Cognitive behavioral therapy (CBT) — CBT has been shown to improve BDD symptoms in a majority of people, both in individual therapy and group therapy. It is the only type of psychological treatment for BDD that research studies support well. Importantly, CBT must be tailored to BDD’s unique symptoms.
- Serotonin reuptake inhibitors (SRIs) — SRIs are the first-line medication treatment for BDD. These medications significantly improve BDD in a majority of people. The following medications are SRIs: fluoxetine, sertraline, escitalopram, fluvoxamine, paroxetine, citalopram, and clomipramine. High doses of these medications are often needed to successfully treat BDD (like with OCD). Adding other medications to the SRI, such as buspirone or aripiprazole, can be helpful.
Cognitive behavioral therapy (CBT) for BDD
CBT has been shown to be helpful in treating BDD symptoms both in individual therapy or group therapy. It is the only type of psychological treatment for BDD that research supports. CBT focuses on the thoughts (i.e., cognitions) and repetitive behaviors triggered by BDD. These include the excessive attention BDD patients give to specific aspects of their appearance that make up their perceived flaws.
In CBT, the therapist and individual work together to identify and challenge thought and behavior patterns involved in their symptoms. In particular, the goal of CBT is to help individuals identify their unhelpful thoughts and develop more flexible beliefs. Individuals also gradually participate in more and more challenging situations, working to change how their brain responds to triggers. This process is also called habituation, and will help to decrease anxiety in the long term.
Decreasing avoidance behaviors
Individuals with BDD learn strategies to help decrease their use of avoidance behaviors (for example, avoiding eye contact with others) and compulsive behaviors (for example, repeatedly comparing oneself to others in the room). When one uses avoidance and compulsive behaviors to help decrease anxiety or distress, these behaviors reinforce the BDD symptoms. Only by finding ways to deal with triggers without relying on these avoidance strategies or compulsions can someone overcome BDD.
In addition, CBT teaches individuals how to “see the big picture.” For example, individuals learn to view themselves more holistically and non-judgmentally when in front of the mirror instead of focusing on any perceived flaws.
How CBT works
CBT strategies are practiced in the therapy sessions and as homework assignments between sessions. This helps individuals learn new skills and to use them in many different situations. Family members may also be involved, as it is common for family members or significant others to become involved in a loved one’s compulsive behaviors (for example, repeatedly offering the individual with BDD reassurance about his/her appearance). This happens often and is understandable, as it is difficult to watch a loved one suffer. Therapists can be helpful in providing information about BDD. They can also work with family members to find more helpful and supportive strategies.
Medication for BDD
The category of medications called serotonin reuptake inhibitors (SRIs), including selective serotonin reuptake inhibitors (SSRIs), are considered the first-line medication treatment for BDD. These medications are commonly known as “antidepressants,” but they work for many other mental health conditions outside of depression — like BDD, in addition to many anxiety disorders and OCD.
There are no medications that currently have FDA approval for treating BDD, because no pharmaceutical company has been interested in pursuing this indication. However, research and clinical experience suggests that SRIs are safe and effective for a majority of people with BDD. For more in-depth information about medication treatment for BDD, read our Medication Frequently Asked Questions.
Research studies about other medications for BDD are very limited. At this time, non-SRI medications are not currently recommended as the only medication treatment for BDD.
People with BDD who improve with SRIs spend less time obsessing about their appearance and have better control over their compulsive behaviors. The distress that BDD causes, as well as anger, suicidal thinking, and daily functioning, also usually improves significantly. This often makes it easier to engage in and have success with CBT if it is needed because your symptoms don’t completely resolve with medication.
Where do I start my BDD treatment journey?
Individuals with milder or more moderate BDD symptoms may benefit from either medication or therapy alone.
Individuals who suffer from severe BDD can potentially improve with either medication or therapy alone. However, it is often recommended to combine medication and therapy — especially if the person is suicidal.
Some people’s ability to use what they are learning in therapy is limited by depression, anxiety, obsessive thoughts, rigid thinking patterns, and poor insight. These symptoms usually improve with medication treatment, making it easier to engage in therapy.
Studies have shown that, on average, about 66%–75% of people will experience a 30% or more reduction in BDD symptoms from taking an SRI. This includes noticeable improvements in terms of reduced distress and improved day-to-day functioning. Some people’s symptoms go away completely with an SRI. If your medication doesn’t feel like enough, options include increasing the SRI dose, trying another medication, or trying CBT.
What DOESN’T work?
Because they see their problems as something physical that needs to be changed, many individuals with BDD (including kids and teens) end up trying cosmetic treatments to “fix” their perceived flaws. These treatments can vary from cosmetic surgery (such as face lifts) to other procedures (such as skin smoothing treatments), can cost thousands of dollars, and rarely improve BDD symptoms. More often, individuals actually report an increase in concerns about their appearance (feeling “disfigured”) or develop new areas of concern (changing from a concern with nose size, for example, to hair thickness) following cosmetic treatment. In severe cases, some individuals with BDD consider suicide or become violent toward their physician after a cosmetic treatment. More information about cosmetic treatments and BDD.
Treatment of BDD summary:
- CBT for adults with BDD is effective in improving BDD symptoms and has also been shown to improve related symptoms such as depression, lack of insight, poor body image, low self-esteem, and social anxiety.
- SRI medications are effective for BDD symptoms, and they also improve related symptoms such as depression, lack of insight, struggle functioning, and low quality of life.
- Cosmetic treatments (e.g., cosmetic surgery and/or other cosmetic procedures) rarely improve BDD symptoms, and often make them worse.
- Appearance concerns associated with BDD are more than a matter of vanity. The serious psychological impact on individuals with BDD and their loved ones calls for increased public and professional awareness of the disorder and the development of more effective interventions.
