Body Dysmorphic Disorder

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Body Dysmorphic Disorder from Patients' Perspectives

“When I walk down the street I pay a lot of attention to the way men react to me. I keep looking at them to see if they will look at me. If they do look and give me a little smile, this makes me feel really good. It makes me feel like I really do look ok, I am attractive. But, if the guy doesn't look at me, I feel crushed. I feel like the ugliest person in the world. Of course he didn't look at me…he noticed my big nose. Even though lots of guys might give me positive attention, it's always like the last one means the most. Even if just one doesn't give me the response I want, I feel like the day is ruined.“

“I used to have the most perfect skin, but then one day I started getting pimples. In the past, I would have probably thought it was not a really big deal. But, I couldn't get my mind off of it. Every time I passed a mirror or a window, I would glance in it to see my reflection and to see how bad the pimples made me look. I would pick at them to try to make them better, but I only succeeded in making them red and irritated. It looked even worse. I started buying every skin cream there was to try to fix my skin. Despite all my efforts, my skin just seemed to get even worse and more pimples appeared. I started tanning myself - thinking that bronze skin would make my blemishes better. Now, after years of tanning, I feel like I have made my skin even worse and it looks really old now. I've ruined it. Everyone knows that good skin makes someone's face. When I'm walking down the street or talking to someone, I can barely concentrate on what I'm doing because I'm so focused on their skin and how it is so much better than mine. Sometimes I feel suicidal. If my skin were only like it used to be, then I could continue on with life…“

“My dad is practically bald, so I've always been a little worried about what would happen if I lost my hair like he has. Even though everyone tells me that I have a pretty thick head of hair, I think that they just don't notice what I've become pretty good at covering up - my hair is falling out and I'm going bald. One day, I was in the mirror combing my hair as usual, and I noticed a few hairs came out. This prompted me to more thoroughly inspect my hair, and what I found horrified me. I was certain that my hairline had receded. Since I made this discovery, I now spend about 40 minutes in the mirror everyday. I check to see if there has been any change from the previous day and if any more hair appears to have fallen out. I am really self-conscious now, and I always wear a baseball cap when I go out. I don't really like the dating scene anymore because I don't feel comfortable going to a bar to meet women wearing a baseball cap, but I can't go outside of the house without one - so I'm stuck. Plus, what woman would want a guy who is losing their hair like me? If I absolutely need to go out without my cap, like for a job interview, I spend hours styling my hair so that my hair loss is not noticeable. Then, I keep touching my hair to make sure that it is still in place. I am miserable.“

BDD - Prevalence Rates and Course of the Disorder

Approximately 5 million people in the United States have Body Dysmorphic Disorder (BDD) or dysmorphophobia. It is possible that this number may actually be too low because there are many people who have this disorder who go undetected. BDD is equally as common in women as in men.

It is very common for those with BDD to be very ashamed about their worries and to not reveal them to even their closest friends or family members. Many BDD suffers feel like all the reasons for things going wrong in their lives is due to their appearance and the idea that they “look too ugly“ for things to go right for them in their career or relationships. People with BDD frequently seek dermatological and cosmetic procedures, hoping that this will improve their concern with their appearance.

The onset of BDD is frequently in adolescence, and without intervention BDD symptoms tend to be chronic and persistent. BDD frequently interferes with an individual's ability to work and have relationships. People who suffer from BDD also commonly experience depression and social anxiety.

What Causes Body Dysmorphic Disorder (BDD)?

The answer to this question is unknown. Currently, it is believed that BDD is caused by a biological vulnerability that is triggered during stressful life circumstances (e.g., adolescence). It is also believed that social and early developmental factors may also play a role in determining who is most vulnerable to developing BDD.

What are the Symptoms of BDD?

Although everyone has aspects of their body or their appearance that they wish were different, for people with BDD these thoughts cause them extreme distress and they have trouble dismissing these thoughts. People with BDD perceive their appearance (or an aspect of their appearance) as being very flawed and perhaps even ugly or repellant to others. The focus of distress can be any aspect of one's appearance, but the five most common areas that are focused on are: skin, hair, nose, eyes, and legs/knees. Sometimes people with BDD only have one aspect of their appearance that distresses them, but it is very common to be concerned with several different features.

Sometimes, there may be a minor flaw that exists (e.g., a scar, mark from having had the chicken pox, minor acne, etc.), but the distress over this minor imperfection greatly exceeds what most other individuals would experience if they had this same flaw. Frequently others see nothing wrong with the way the person with BDD looks, and this can be even more frustrating to the BDD sufferer because no one can understand why they are so distressed. Frequently, people with BDD may be passed off as just being vain or superficial.

The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) defines BDD as a Somatoform Disorder and requires the following criteria for a diagnosis of BDD:

1. Preoccupation with a perceived defect in appearance (or excessive concern about an actual minor flaw in appearance)

2. This preoccupation with appearance causes significant distress or impairment in functioning

Thus, people with BDD are preoccupied by a perceived defect in their appearance and they frequently spend a lot of time each day thinking about or trying to alter their appearance flaws. In addition, BDD sufferers frequently alter their behaviors in many ways as a result of their worries. These behaviors often occupy a significant amount of time and greatly interfere with daily functioning. For example, they may:

  • spend a lot of time analyzing their perceived flaw (e.g., looking in the mirror, analyzing it for any change, comparing they way they look to others)
  • avoid things that will remind them of their flaw (e.g., avoiding mirrors)
  • spend a lot of time trying to improve the appearance of the perceived flaw (e.g., plastic surgery, buying numerous face creams, constantly exercising or working out, spending a lot of time grooming, skin picking)
  • try to camouflage the perceived flaw (e.g., wear a lot of make up, wear hats, tan their skin)
  • avoid situations where others might more easily see their flaw (e.g., avoid particular types of lighting, avoid going out of the house)
  • Those with BDD frequently feel anxious about their appearance and may feel very depressed. Sometimes the depression stemming from the anguish about one's appearance causes some people to consider or to actually attempt suicide.

    Treatment for BDD

    BDD can be well controlled with certain types of medications and with therapy. The kind of medications that appear to be most effective are the serotonin reuptake inhibitors (or SRIs). The type of therapy that has proven to be most effective for BDD is Cognitive-Behavior Therapy (or CBT). Other types of therapy (e.g., psychoanalytic, psychodynamic, etc.) have not been shown to be effective for those who suffer from BDD.

    CBT for BDD usually involves using the following techniques. In initial sessions, patients are educated about BDD and are taught how to monitor their thoughts and BDD related behaviors. Next, patients are shown how their thoughts, behaviors, and feelings all relate to each other, and are taught a technique commonly referred to as “cognitive restructuring“. In this technique, patients are taught how to analyze their thoughts and how to better determine when their thoughts may have errors or may be unrealistic. Although everyone tends to have thinking “errors“ at some time, certain types of errors tend to predominate in BDD. For example, BDD patients frequently engage in “mind reading“ (e.g., “I bet that person isn't talking to me because they think I look too ugly.“).

    In CBT, patients are also asked to work on assignments to directly confront their fears. Basically, patients make a list of the different situations that they currently avoid or that they might have extreme difficulty doing if they didn't engage in their BDD rituals (e.g., comparing self to others, putting a lot of make-up on, seeking reassurance from others, etc.). Next, these situations are ordered in terms of their difficulty level. Then, beginning with the least anxiety provoking items, patients are then taught how to begin confronting these situations that they fear. This is frequently referred to as “exposure“ to the feared situation. Usually, patients first work on these assignments with their therapist, but then they are later asked to work on them at home to make sure that their successes in the psychologist's office generalize to their functioning at home (as well as work, school, and social life).


    If you are interested in learning more about anxiety disorders and their treatment, and you live in the Los Angeles area, contact Dr. Nelson at (310) 963-4891 or e-mail her at DrDeniseNelson@yahoo.com.