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Body Dysmorphic Disorder
Symptoms and Treatment

Dissatisfaction with appearance is very prevalent in our society. Over the past three decades the popular magazine Psychology Today has conducted several surveys on how people feel about the appearance of their bodies. The changing results make for interesting reading. The dramatic changes in American culture have significantly altered peoples' perceptions of themselves. In 1972, twenty-three percent of American women were dissatisfied with their appearance but by 1997 that figure had risen to fifty-six percent. In 1972, fifteen percent of men were dissatisfied with their appearance but by 1997 that figure had risen to forty-three percent. Thirty-eight percent of men are now dissatisfied with the size of their chests compared to the thirty-four percent of women dissatisfied with their breasts. Men are getting pectoral and calf implants. Millions of women have had surgery to change the shape of their breasts or increase their size.

Dissatisfaction with how you look is practically the norm. However, when someone becomes intensely preoccupied with what they believe to be a defect in their appearance, then they may be suffering from a mental health condition called Body Dysmorphic Disorder (BDD). While there may be a real basis for the concern, as for example, where acne is present, the sufferer's preoccupation is intense and excessive. Other times the perceived imperfections may not be obvious to anyone other than the person. They feel intensely tormented and tortured by what they feel makes them ugly to themselves and to those around them. It used to be called dysmorphobia and was first described by an Italian psychiatrist, Enrique Morselli, over a hundred years ago. He was aware of the intense suffering caused by the preoccupation with the imagined defect.

BDD can be undiagnosed or misdiagnosed

This condition often goes undiagnosed and the sufferer may seek repeated cosmetic surgery to remedy the imagined defects. People with this disorder commonly complain about flaws of the head or face. They may be preoccupied with the size and shape of noses, eyes, ears and mouths, eyebrows, chins, and jaws. People may also agonize over the real or imagined appearance of wrinkles, the shade of their skin, the degree of facial symmetry, or thinning hair. This intensive and time-consuming preoccupation may also focus on other body parts, such as arms, legs, tummy, hips, and genitals. Where the person's obsessive interest is in their weight, body shape and size, a differential diagnosis of Anorexia Nervosa may be made.

BDD is often misdiagnosed as a different psychiatric disorder. This occurs because BDD can produce symptoms that mimic other disorders such as social phobia, agoraphobia, panic disorder, trichotillomania (excessive hair pulling), obsessive-compulsive disorder, and depression.

People with BDD may find themselves constantly checking their appearance in the mirror. The checking is constant because they never feel reassured. In some cases the level of dissatisfaction in their appearance may lead sufferers to shun the company of other people, in work and social situations. This is partly because being with other people may lead people with BDD to compare their perceived defective parts with others and leads to an increase of anxiety. It can also be because BDD sufferers often feel that others are staring at them, noting their defects and then mocking or criticizing them behind their backs.

BDD clues

BDD usually begins in adolescence, probably because this is a time when young people are having to cope with natural changes in their body shapes and sizes. Issues of sexuality and gender identity also arise at this time, as do impulses to move from the family nest out into the community where future potential mates reside. Many, if not all, teenagers experience anxiety about the many changes that occur within and without their bodies at this time; for most the anxiety is temporary and manageable while for others it is the beginning of a very long course of unhappiness with themselves. This condition occurs at about the same rate in males and females. The current tendency to idealize thinness, as illustrated by images of slender models in the media, has a particular impact upon girls because the development of breasts and hips seems to be in conflict with the cultural ideal. Due in the main to modern nutrition the average woman has become even larger and thus conflicts even more with the cultural ideal of thinness. Puberty seems to be occurring at even younger ages and it may be that younger children will become affected by body image disturbances. The natural change which boys undergo as they become taller and more muscular is more in tune with the cultural ideal for men.

• frequently comparing one's appearance with that of others, or scrutinizing the appearance of others;

• often checking how one looks in the mirror;

• camouflaging the perceived defect with clothing, makeup, a hat or a hand, or changing one's posture;

• seeking surgery, dermatologic treatment, or other medical treatment for appearance concerns when doctors, parents, or peers have said such treatment is unnecessary;

• constantly seeking reassurance about the perceived flaw or attempting to convince others of its repulsiveness;

• excessive grooming (combing one's hair, shaving over and over, removing or cutting hair, applying makeup or cover-up creams);

• picking at one's skin or squeezing pimples/blackheads for hours;

• avoiding mirrors;

• exercising or dieting excessively;

• frequently touching the perceived defect;

• measuring the "unpleasant" body part;

• excessively reading about the supposed defective body part;

• avoiding social situations in which the perceived defect might be exposed; and

• feeling very anxious and self-conscious around peers because of the perceived defect;

BDD can be very serious and disabling. The disorder is often associated with depressive disorders and social phobia. If someone comes and presents with a depressive disorder, it is recommended that the possibility of an associated body dysmorphic disorder be explored. This is because BDD sufferers often find it extremely embarrassing to disclose their worries. The great distress it causes can lead sufferers to serious suicide attempts.

It is difficult to know just how prevalent BDD is as there is such a great cultural preoccupation with beauty and attractiveness and giving lots of attention to the body. This may mask and normalize what might be seen in other cultures to be an excessive interest in one's appearance. For example, what would be a "normal" amount of time to spend doing one's makeup, or a "normal" amount of cosmetic surgery to have?

Hope for BDD sufferers

Psychiatric treatment is often effective in decreasing BDD symptoms and the suffering they cause. The treatments that appear most effective are certain medications, namely the selective serotonin reuptake inhibitors (SSRIs) like Prozac and Zoloft, and cognitive behavioral therapy.

The prescription-only SSRIs are not addicting and are usually well tolerated. They can significantly relieve BDD symptoms by diminishing bodily preoccupation, distress, depression, and anxiety and by significantly allowing increased control over the youth's thoughts and improving functioning. In some cases these medications are lifesaving, especially for those who have attempted suicide in their despair over their appearance.

During cognitive-behavioral therapy the specially trained therapist helps the person with BDD resist compulsive behaviors-for example, mirror checking-and face avoided situations like social situations. It's important to determine whether a therapist has been specifically trained in cognitive-behavioral therapy. Other types of talk therapy do not appear to be effective for BDD.

A comprehensive book on Body Dysmorphic Disorder is The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder by Katharine A. Phillips, M.D.

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