Body Dysmorphic Disorder (BDD)
Imagine seeing yourself as the distorted images of a cracked mirror and being consumed by the necessity to improve or hide those cracks. This is how sufferers of Body Dysmorphic Disorder (BDD) view themselves, and in order to be able to help these people receive the therapy and support they so deserve, we first need to understand this debilitating condition.
BDD is characterised by a preoccupation with perceived flaws or defects in the person’s appearance, which to others is extremely minor or not observable. The condition usually develops in adolescence and affects approximately 2% of the population, occurring equally in both sexes. It is an extreme mental disorder and, unfortunately, people with the disorder are reluctant to seek help due to the fear of being thought vain or self-obsessed. In fact, the opposite is true, as sadly people with this serious disorder often believe themselves to be ugly.
Wrongly misrepresented in the media as “Imagined Ugliness Syndrome”, this cruel representation does little to help the people concerned and certainly does not reflect the extreme distress BDD causes. Such is the severity of the illness that many people present to dermatologists, cosmetic surgeons, maxillary facial surgeons, orthodontists, gynaecologists or urologists to improve their perceived defect.
Even though BDD is classified as an extreme mental disorder, people only present to mental health services when there are additional problems such as anxiety, depression or a risk of suicide. In many cases the condition is trivialised and stigmatised, and in some instances doctors will view those patients who have actual disfigurements as being more worthy of attention, even though they may be less disabled than a person suffering with BDD.
To date research shows that the exact causes of BDD are unclear, however, it is thought to be a combination of nature and nurture which includes:
- Personality traits such as being a perfectionist
- Life experiences (sexual abuse, bullying or child abuse)
- Neurobiological factors (chemical imbalance in the brain)
- Genetic predisposition (if a family member has BDD)
- People who have BDD may also suffer with OCD, anxiety or depression
While more research needs to be carried out as to the causes of the condition, there are certain factors which may act as triggers or make the condition worse such as:
- Commenting negatively on a person’s appearance
- Compliments may also have an adverse effect on people struggling with BDD as they feel pressurised to look that way all the time
In order to avoid causing any undue stress to the person, it is better not to focus on their appearance but rather to compliment them on their personality or something they have done well.
The signs and symptoms of BDD vary from person to person, affecting their ability to work, enjoy a social life or become involved in a relationship. BDD impacts dramatically on their quality of life due to the excessive amount of time spent obsessing over a specific body part or perceived flaw, only to compulsively carry out a number of behaviours to try to cover up or get rid of the defect. Body parts that are commonly fixated on are:
- Size of breasts
- Shape and symmetry of the face
- Shape and size of the body
- Bald or thinning hair
- Freckles or large moles
- Facial and body hair
Constantly worrying about their appearance to the point of obsession, or trying to improve or hide their perceived flaws, the person is compelled to repeat certain behaviours including:
- Camouflaging their appearance with make-up
- Constantly seeking validation about their appearance from friends and family
- Comparing themselves to people they see in the street, models in magazines or online
- Obsessively checking their appearance in a reflective surface or mirror
- Touching their skin with their fingers to see if it is smooth
- Concealing those parts of their body which they perceive as flawed
- Worrying excessively about a specific part of the body
These obsessions may last for hours or even days and are extremely difficult for the person to resist or control. Due to the time involved in obsessing, many people with BDD avoid social situations completely and most will suffer with low self-esteem, leading to problems at work or school.
Links to Other Mental Health Disorders
There are many other anxiety disorders people with BDD commonly suffer from such as:
- Social anxiety: an overwhelming fear of social situations where the person may be judged and evaluated negatively by other people
- Obsessive Compulsive Disorder (OCD): an anxiety disorder involving distressing repetitive thoughts
- Depression: a mental illness that causes people to experience low self-worth, low mood, loss of interest, poor concentration, disturbed sleep and feeling lethargic
People with BDD are sometimes misdiagnosed with one of these disorders due to the fact that they share similar symptoms. However, BDD can be distinguished from OCD due to the repetitive behaviours focusing specifically on their appearance.
My biggest fear is that eventually you will see me the way I see myself.— Anonymous
BDD and Suicide
Unfortunately, many GPs do not have the necessary training to make an accurate diagnosis and, as a result, individuals are not given the right treatment or support. Due to the extreme levels of distress caused by BDD and the very real fear of being thought of as vain or ridiculous, suicide rates are high. According to the BDD Foundation, 0.3% of people with BDD commit suicide each year, with 25% of people with BDD who attend a specialist clinic attempting suicide.
Correct training of GPs and proper referrals to mental health therapists, along with the support needed for individuals with this condition, will ultimately result in a decline in the number of people who suffer and die needlessly each year because of a condition which is treatable with the right help and understanding. Mental Health Awareness Week 2019 has drawn attention to BDD and the complexities of this debilitating condition, however, sufferers need help on a daily basis and a full community treatment plan needs to be put in place to ensure these people lead a life free of the constraints of their disorder.
BDD is difficult to diagnose due to the stigma attached to the condition and the shame people feel if they do reveal their symptoms. Unfortunately, if BDD is not discussed specifically then the diagnosis can be missed, resulting in patients being misdiagnosed. Without a proper diagnosis, treatment options will not have a successful outcome and the patient will be left feeling misunderstood.
A proper diagnosis is usually made by a psychologist or psychiatrist who will begin by asking a series of questions such as:
- Are you worried about your appearance or unhappy with how you look?
- What are your concerns and do these concerns preoccupy you?
- How often do you think or worry about these concerns?
- Has this preoccupation affected your social life, school, work or other areas of your life?
- Has this preoccupation affected your family or friends?
- Has this preoccupation caused you extreme distress?
After answering a series of questions, a diagnosis of BDD will be made based on the following criteria:
- If the person is overly concerned about a nonexistent appearance flaw
- If the person is preoccupied with the perceived flaw for at least an hour a day
- If the person experiences extreme distress or cannot function normally as a result of this concern
It is also important to ask relevant questions regarding BDD with those persons who present with depression, social anxiety, suicidal thoughts or who have undergone unnecessary surgery, in order to rule BDD out or to make an accurate diagnosis of BDD.
Treatment for BDD will include a combination of therapy and medication such as:
Cognitive Behavioural Therapy (CBT)
CBT will teach the person coping techniques aimed at changing irrational thoughts and negative thinking patterns, and replacing them with positive ones. There are two stages involved in CBT in the treatment of this condition: exposure and response.
- Exposure Therapy: will enable those people with BDD to confront those situations which cause irrational fear, such as not covering up the perceived flaw when out in public
- Response Therapy: will give the person the necessary training, enabling them to resist the urge to cover up their perceived flaw, to stop seeking reassurance from others regarding their appearance, and to spend less time constantly checking their appearance
These techniques take time to learn and perfect. Therefore, the person must be committed to their treatment plan if they are to succeed.
Group and/or Family Therapy
In order for treatment to succeed, it is critical that family members have a complete understanding of BDD and all its complexities. Family members and friends will become a strong support group for the person and through therapy will also learn to recognise the signs and symptoms of this condition, playing a vital role in enabling the person to live a meaningful life.
Research has shown that a partial cause of BDD is due to problems relating to the brain chemical serotonin. To date the most successful antidepressants used in the treatment of BDD are selective serotonin reuptake inhibitors (SSRIs) which control and relieve the compulsive and obsessive thoughts and behaviours associated with the disorder. People who suffer with delusions related to BDD will be prescribed an antipsychotic drug in addition to the antidepressants.
Repetitive Transcranial Magnetic Stimulation
A study taken in 2018 looked at another treatment technique for BDD which involved stimulating specific parts of the brain using electromagnetic fields. Known as Repetitive Transcranial Magnetic Stimulation, scientists are conducting tests into how it can be utilised to treat BDD, depression, psychosis and other anxiety disorders.
There are many things a person with BDD can do to ensure the best possible outcome for this condition. These include:
- Attend all health checkups
- Try taking up a physical activity or group activity which may help alleviate symptoms associated with BDD
- Note any warning signs or triggers which make your symptoms worse and discuss these with your therapist
- Educate yourself about every aspect of the disorder and how it affects the mind and body
- Always take your medication as directed and never suddenly stop taking medication, which can have serious implications
- Always attend your therapy sessions and complete homework set by the therapist
- Avoid drugs and alcohol, which can worsen your mental illness and adversely interact with your medication.
- Surround yourself with those people who understand what you are going through and treat you with empathy and compassion
- Join a support group where you can interact with others without fear of being judged. The BDD Foundation has a list of various support groups on their website, along with other useful information and advice.
Incredibly isolating and debilitating, BDD sufferers are convinced that their appearance will shock and repel others. In trying to improve their appearance, many people resort to plastic surgery or try to cover up the offending body part. However, this meets with unsatisfactory results as they tend to feel worse and find other problem areas to obsess over.
In order to remove the stigma attached to this disorder, further research needs to be carried out along with awareness programs which I believe should begin in the classroom. An understanding of the disorder will enable those sufferers to receive the help and support they need, combined with the empathy and compassion they deserve.
This content is for informational purposes only and does not substitute for formal and individualized diagnosis, prognosis, treatment, prescription, and/or dietary advice from a licensed medical professional. Do not stop or alter your current course of treatment. If pregnant or nursing, consult with a qualified provider on an individual basis. Seek immediate help if you are experiencing a medical emergency.
© 2019 Lorna Lamon