Body Dysmorphic Disorder: Beyond the Mirror

Body Dysmorphic Disorder (BDD) is a common psychiatric disorder, affecting approximately 2.4% of people in the United States, characterized by intense feelings of self-hatred, usually focused on a specific body part. This isn’t just “I hate my nose,” but a debilitating and overwhelming feeling of self-hatred, including obsession with the offending body part. The emotional toll and functional impairment it can lead to is significant.

Anyone can develop BDD; it has been documented in people of various ages, genders, or any other demographic category. BDD develops most often in teenage years, and some researchers have explored the role of societal pressures, puberty and hormonal changes, as well as trauma on the course of this disorder. Research by Krebs and colleagues (2019) found that 76% of BDD cases develop before age 18, with the mean age of onset being 16.8 years.

Core Symptoms of BDD

The symptoms of BDD include:

• A preoccupation with a perceived flaw or an obsession with a real but minor flaw or difference in appearance. In the first case, no one else could see a defect or flaw, but to the person suffering from BDD, the flaw is obvious and inescapable. In the second case, there may be some aspect of the person’s appearance that is visible to others, but neutral (lack of symmetry in facial features, for example). The person experiencing BDD symptoms sees that difference as horrible, repulsive, and intolerable.
• Spending a significant amount of time trying to deal with these perceived or existing flaws. The efforts to hide the flaw might involve clothing choices or makeup, elaborate and lengthy grooming rituals, and either obsessing over their appearance in mirrors or other reflections, or completely avoiding all mirrors and reflections.

Further, these two symptoms – obsessing over a specific aspect of physical appearance, and then compulsively trying to hide or deal with that perceived flaw – must be severe enough to cause “functional impairment” in multiple areas of life. Functional impairment may look like depression or anxiety, as self-hatred and the efforts to address the flaw may lead to both low mood and severe anxiety.

BDD vs. OCD: Understanding the Difference

BDD might sound like a very unique type of Obsessive-Compulsive Disorder (OCD). In the most recent revision of the Diagnostic and Statistical Manual (DSM-5), BDD is categorized in that group of disorders. How can you tell the two disorders apart?

It might be helpful to think of BDD as a specific subtype of OCD, in which the focus is exclusively on physical appearance. People with OCD might struggle with obsessions regarding germs, religion or morality, or the need for order, neatness, or symmetry. Someone with BDD is obsessed with an aspect of their physical appearance.

A study by Phillips and colleagues (2022) found that while both BDD and OCD share obsessional thinking patterns, individuals with BDD showed significantly higher levels of poor insight about their beliefs (73% compared to 27% in OCD) and were more likely to have accompanying depression.

BDD vs. Eating Disorders: Important Distinctions

BDD is not the same as an eating disorder, but some people with BDD focus on weight and feeling fat as the problematic body part. Obsession with weight and attempts to manage this obsession via eating behaviors sounds a lot like an eating disorder, especially when the perception is “I’m fat” and the data (body mass index and actual weight, for example) does not support this.

The second diagnostic criteria of BDD – that a significant portion of the person’s time is spent trying to deal with these perceived flaws – also sounds like an eating disorder, in that the person may well engage in excessive exercise, calorie restriction, or purging behaviors, to try to mitigate the issue with weight.

How do treatment professionals discern between these two frustrating and dangerous illnesses? Careful interviewing to parse out which criteria are met for which disease, along with use of surveys and questionnaires help tease apart complex diagnostics.

Evidence-Based Treatment Approaches

Figuring out what BDD is (and isn’t) is the first step in the treatment journey. The next step is challenging but worthwhile: teaming up with mental health professionals to create a treatment plan.

According to the most recent research, people with BDD tend to respond to a combined approach using antidepressant medication and cognitive behavioral therapy. A meta-analysis by Harrison and colleagues (2021) found that cognitive behavioral therapy specifically designed for BDD yielded a large effect size (0.89), with improvements maintained at follow-up assessments.

Often family therapy is suggested as well, as it can be a route to better understanding the core beliefs that underscore the faulty cognitions that fuel this disorder.

Self-Care Strategies for BDD Recovery

As an adjunct to the treatment plan your therapist and prescriber create with you, the following practices may also support your healing journey:

Find Ways to Soothe Yourself

This can be a triggering uphill battle, as a core aspect of the disorder is self-hatred, so you might not feel like you deserve to be at ease. Initially, you might need to set that belief aside for brief periods of time and allow yourself to engage in restful, restorative, and calming activities. This might look like lying on your back on the floor with headphones on, listening to music, or sitting outdoors, feeling the sun on your face. Warm or hot water often helps people feel relaxed; perhaps lingering a little bit longer than usual in a bath or shower may be a good initial technique.

Practice Grounding Exercises

Try the following grounding exercise: sit still in a chair that allows your feet to touch the floor. If you can tolerate closing your eyes, do so. Place your hands in your lap in whatever position you find most comfortable. Now, place your consciousness in your feet. Yes, your feet. Try to become as aware as possible of the sensations on the bottom of your feet.

To start with, this is enough – to just sit quietly and ask your awareness to rest in your feet, as a way to begin developing contact with the sense of earth or ground. As you develop the habit of doing this, you can expand that sense of ground by imagining feeling your feet on the floor, then visualizing moving downward, through the floor, through the basement, and eventually into the earth.

The purpose of this type of creative visualization exercise is to settle down, practice focusing your attention and awareness on something other than your thoughts (especially your obsessive thoughts about your appearance), and to the degree you can, feel peace and solace from being connected with the earth itself.

Prioritize Basic Self-Care

Be sure to cover the basics: eat adequate quantities of nutritious foods, and prioritize sleep. Research by Tang and colleagues (2020) found that sleep disturbances were present in 72% of individuals with BDD and were associated with greater symptom severity.

Be Cautious with Substances

While recreational drugs may temporarily silence the negative self-talk, you may feel worse if you use alcohol or other substances to numb out.

Coordinate Your Care

If your focus on a body part has led you to seek medical attention from other specialists, make sure all your providers can communicate with each other. Let your surgeon know if you have been diagnosed with BDD, and let your mental health team know if you are seeking surgical (or other medical) solutions.

Finding Support and Hope

Living with BDD is challenging, frustrating, and exhausting. Toughing it out on your own isn’t necessary; you deserve help, support, and professional care and to live a life that has pleasure and contentment. 

With proper treatment and support, recovery from BDD is possible. Research by Gentile and colleagues (2019) found that 47% of patients with BDD showed significant improvement following internet based CBT treatment.

References

• Gentile AJ, La Lima C, Flygare O, Enander J, Wilhelm S, Mataix-Cols D, Rück C. Internet-based, therapist-guided, cognitive-behavioural therapy for body dysmorphic disorder with global eligibility for inclusion: an uncontrolled pilot study. BMJ Open. 2019 Mar 23;9(3):e024693. doi: 10.1136/bmjopen-2018-024693. PMID: 30904854; PMCID: PMC6475214.
  https://pubmed.ncbi.nlm.nih.gov/30904854/
• Harrison A, Fernández de la Cruz L, Enander J, Radua J, Mataix-Cols D. Cognitive-behavioral therapy for body dysmorphic disorder: A systematic review and meta-analysis of randomized controlled trials. Clin Psychol Rev. 2016 Aug;48:43-51. doi: 10.1016/j.cpr.2016.05.007. Epub 2016 Jun 13. PMID: 27393916. https://pubmed.ncbi.nlm.nih.gov/27393916/
• Krebs G, Fernández de la Cruz L, Mataix-Cols D. Recent advances in understanding and managing body dysmorphic disorder. Evid Based Ment Health. 2017 Aug;20(3):71-75. doi: 10.1136/eb-2017-102702. Epub 2017 Jul 20. PMID: 28729345; PMCID: PMC5566091.
  https://pubmed.ncbi.nlm.nih.gov/28729345/
• Phillips KA, Stein DJ, Rauch SL, Hollander E, Fallon BA, Barsky A, Fineberg N, Mataix-Cols D, Ferrão YA, Saxena S, Wilhelm S, Kelly MM, Clark LA, Pinto A, Bienvenu OJ, Farrow J, Leckman J. Should an obsessive-compulsive spectrum grouping of disorders be included in DSM-V? Depress Anxiety. 2010 Jun;27(6):528-55. doi: 10.1002/da.20705. PMID: 20533367; PMCID: PMC3985410.
  https://pubmed.ncbi.nlm.nih.gov/20533367/