Body dysmorphic disorder (BDD) is a condition that involves obsessions, which are distressing thoughts that repeatedly intrude into a person's awareness. With BDD, the distressing thoughts are about perceived appearance flaws.
People with BDD might focus on what they think is a facial flaw, but they can also worry about other body parts, such as short legs, breast size, or body shape. Just as people with eating disorders obsess about their weight, those with BDD become obsessed over an aspect of their appearance. They may worry their hair is thin, their face is scarred, their eyes aren't exactly the same size, their nose is too big, or their lips are too thin.
BDD has been called "imagined ugliness" because the appearance issues the person is obsessing about usually are so small that others don't even notice them. Or, if others do notice them, they consider them minor. But for someone with BDD, the concerns feel very real, because the obsessive thoughts distort and magnify any tiny imperfection.
Because of the distorted body image caused by BDD, a person might believe that he or she is too horribly ugly or disfigured to be seen.
Besides obsessions, BDD also involves compulsions and avoidance behaviors.
A compulsion is something a person does to try to relieve the tension caused by the obsessive thoughts. For example, someone with obsessive thoughts that her nose is horribly ugly might check her appearance in the mirror, apply makeup, or ask someone many times a day whether her nose looks ugly. These types of checking, fixing, and asking are compulsions.
Somebody with obsessions usually feels a strong or irresistible urge to do compulsions because they can provide temporary relief from the terrible distress. The compulsions seem like the only way to escape bad feelings caused by bad thoughts. Compulsive actions often are repeated many times a day, taking up lots of time and energy.
Avoidance behaviors are also a part of BDD. A person might stay home or cover up to avoid being seen by others. Avoidance behaviors also include things like not participating in class or socializing, or avoiding mirrors.
With BDD, a pattern of obsessive thoughts, compulsive actions, and avoidance sets in. Even though the checking, fixing, asking, and avoiding seem to relieve terrible feelings, the relief is just temporary. In reality, the more someone performs compulsions or avoids things, the stronger the pattern of obsessions, compulsions, and avoidance becomes.
After a while, it takes more and more compulsions to relieve the distress caused by the bad thoughts. A person with BDD doesn't want to be preoccupied with these thoughts and behaviors, but with BDD it can seem impossible to break the pattern.
Being preoccupied with minor or imaginary physical flaws, usually of the skin, hair, and nose, such as acne, scarring, facial lines, marks, pale skin, thinning hair, excessive body hair, large nose, or crooked nose.
Having a lot of anxiety and stress about the perceived flaw and spending a lot of time focusing on it, such as frequently picking at skin, excessively checking appearance in a mirror, hiding the imperfection, comparing appearance with others, excessively grooming, seeking reassurance from others about how they look, and getting cosmetic surgery.
Getting cosmetic surgery can make BDD worse. They are often not happy with the outcome of the surgery. If they are, they may start to focus attention on another body area and become preoccupied trying to fix the new "defect." In this case, some patients with BDD become angry at the surgeon for making their appearance worse and may even become violent towards the surgeon.
BDD usually develops in teenagers, a time when individuals are most concerned about the way they look to others. However, many patients suffer for years before seeking help. There is no single cause of body dysmorphic disorder; research shows that a number of factors may be involved and that they can occur in combination.
BDD can be associated with eating disorders, such as compulsive overeating, anorexia nervosa or bulimia, or it can be more of a phobia, associated instead with social phobia or social anxiety disorder.
BDD can often occur with OCD, where the patient practices unmanageable habitual behaviors that may literally take over his or her life. A history of, or genetic predisposition to obsessive–compulsive disorder may make people more susceptible to BDD. Other phobias like social phobia or social anxiety disorder may also be co-occurring.
It has been suggested that teasing or criticism regarding appearance could play a contributory role in the onset of BDD. While it is unlikely that teasing causes BDD, likewise, extreme levels of childhood abuse, bullying and psychological torture are often rationalized and dismissed as "teasing," sometimes leading to traumatic stress in vulnerable persons. Around 60% of people with BDD report frequent or chronic childhood teasing.
Similarly to teasing, parenting style may contribute to BDD onset; for example, parents who either place excessive emphasis on aesthetic appearance, or disregard it at all, may act as a trigger in the genetically-predisposed.
Many other life experiences may also act as triggers to BDD onset; for example, neglect, physical and/or sexual trauma, insecurity and rejection.
It has been theorised that media pressure may contribute to BDD onset; for example, glamour models and the implied necessity of aesthetic beauty. However, BDD occurs in all parts of the world, including isolated areas where access to media is limited or (practically) non-existent. Media pressure is therefore an unlikely cause of BDD, although it may act as a trigger in those already genetically predisposed or could worsen existing BDD symptoms.
Certain personality traits may make someone more susceptible to developing BDD.
Personality traits which have been proposed as contributing factors include:
- Introversion / shyness.
- Sensitivity to rejection or criticism.
- Avoidant personality.
- Schizoid personality.
- Social phobia.
- Social anxiety disorder.
Since personality traits among people with BDD vary greatly, it is unlikely that these are the direct cause of BDD. However, like the aforementioned psychological and environmental factors, they may act as triggers in individuals.
Serotonin reuptake inhibitors or SSRIs areantidepressants that decrease the obsessive and compulsive behaviors.
Cognitive behavioral therapy. This is a type of therapy with several steps:
- The therapist asks the patient to enter social situations without covering up her "defect".
- The therapist helps the patient stop doing the compulsive behaviors to check the defect or cover it up. This may include removing mirrors, covering skin areas that the patient picks, or not using make-up.
- The therapist helps the patient change their false beliefs about their appearance.
Cognitive-Behavioral Therapy (CBT) techniques that are so effective in treating OCD are also employed in BDD treatment. In fact, four recent studies have found significant reductions in symptoms using Cognitive-Behavioral Therapy for the treatment of BDD.
The primary technique used in both OCD and BDD treatment is a type of Cognitive-Behavioral Therapy called "Exposure and Response Prevention" (ERP). Another CBT technique that is extremely valuable is called "Cognitive Restructuring", in which clients learn to challenge the validity of their distorted body-related thoughts.
Additionally, a variant of ERP has been developed that has also been found to be extremely effective for the treatment of Body Dysmorphic Disorder (BDD). This method, sometimes called "imaginal exposure," involves using short stories based on the client's BDD obsessions. These stories are audiotaped and then used as ERP tools, allowing the client to experience exposure to feared situations that cannot be experienced through traditional ERP (e.g., having a large scar, being bald).
When combined with standard ERP for the above-noted compulsions, and other CBT techniques such as Cognitive Restructuring, this type of imaginal exposure can greatly reduce the frequency and magnitude of intrusive BDD obsessions, as well as the individual's sensitivity to the thoughts and mental images experienced in Body Dysmorphic Disorder.
One of the most effective CBT developments for the treatment of Body Dysmorphic Disorder (BDD) is Mindfulness-Based Cognitive-Behavioral Therapy. The primary goal of Mindfulness-Based CBT is to learn to non-judgmentally accept uncomfortable psychological experiences. From a mindfulness perspective, much of our psychological distress is the result of trying to control and eliminate the discomfort of unwanted thoughts, feelings, sensations, and urges. In other words, our discomfort is not the problem our attempt to control and eliminate our discomfort is the problem.
For an individual with Body Dysmorphic Disorder, the ultimate goal of mindfulness is to develop the ability to more willingly experience their uncomfortable thoughts, feelings, sensations, and urges, without responding with compulsions, avoidance behaviors, reassurance seeking, and/or mental rituals.
Using these tools, clients learn to challenge their body image issues, as well as the compulsive and avoidant behaviors they use to cope with their body-related anxiety.