Body Dysmorphic Disorder

WHAT IS BODY DYSMORPHIC DISORDER?

Body dysmorphic disorder (BDD) is a problem characterized by a person’s obsessive concern with a part of the body that he or she thinks is severely flawed or deformed.¹ The anxiety that this obsession causes is extremely troubling. People with BDD often think of themselves as ugly and abnormal. When these beliefs become strong enough, many people with BDD begin avoiding social events and other places, like work, where other people might notice their “defects.” In extreme cases, people with BDD may even become housebound or leave their homes only at night, when their “defects” are harder to see.¹

People with BDD often spend a great amount of time checking their appearance in mirrors, store windows, spoons, and other reflective surfaces.² In a study published in Behaviour Research and Therapy in 2001,² people with BDD reported that they constantly checked their appearance because they hoped that when they did, they would either look better than they remembered or finally feel comfortable with the way they looked. Some of the people reported spending as long as two hours and forty-five minutes in front of a mirror checking their appearance. Unfortunately, most of these people reported that they didn’t feel better after spending any amount of time checking their appearance.

In comparison, other people with BDD behave in a very different way. They often avoid mirrors completely or keep them covered so that they don’t have to look at themselves at all.

Many people with BDD find fault with their skin, eyes, ears, nose, hair, thighs, hips, mouth, arms, feet, stomach, breasts, or genitals.^{1, 3} They may even be extremely concerned with more than one part of their body at the same time. The supposed imperfection can be very large or very small. Other people might say that they don’t notice it or that the person with BDD is imagining the problem to be bigger than it really is. But to the person with BDD, the imperfection is glaring and embarrassing.

The obsessional concern may feel as though it’s out of the person’s control, and it might occupy most of his or her thoughts throughout the day. The person probably spends a great deal of time and goes to great lengths to change the imperfection or hide it from others. People with BDD often pick the skin of the imperfection, constantly cover imperfections with makeup or styling, or seek reassurances from other people that they can’t see the imperfection.⁴ Most likely, a person with BDD also has had plastic surgery or is currently considering it.⁵

ARE THERE OTHER PROBLEMS RELATED TO BDD?

When a person with BDD does seek help from a mental health care professional, it’s usually for the treatment of some other problem.⁴ Many people with BDD also struggle with depression, anxiety, social phobia, alcohol abuse, or substance abuse.^{6, 7} Many others battle obsessive-compulsive disorder,⁸ which shares similar characteristics with BDD.^9-11 Some evidence even points to a possible connection between BDD and the development of anorexia.^{12, 13} In severe cases of BDD, suicidal thoughts and suicide attempts are not uncommon.^{3, 14}

WHO IS AFFECTED BY BDD?

It’s believed that BDD usually begins during adolescence, but it’s also known to develop earlier in childhood.¹ The rate of BDD in the general population is unknown.¹ The best estimate is about 1 percent,^15-17 although one study of college students found the rate to be as high as 13 percent.¹⁸ Unfortunately, a true estimate of the prevalence is not known because most people with BDD never seek treatment.¹⁹

WHAT CAUSES BDD?

Most likely, BDD is caused by a mixture of risk factors and events.²⁰ Due to the similarities between BDD and obsessive-compulsive disorder, it’s believed that BDD may also be partly triggered by biological factors.²⁰ However, it’s still unclear if BDD runs in families, as does obsessive-compulsive disorder.¹ Some medical reports suggest that BDD can be triggered by the onset of an illness, such as Bell’s palsy or colitis^.21

Other theories point to life events as triggers. One theory proposes that disruptive childhood experiences, such as being teased and having poor self-esteem, can make a person vulnerable to BDD.³ One of the most unfortunate influencing factors, however, is that many people, even those without BDD, are dissatisfied with the way they look.²² Many women are concerned that they are not thin enough,²³ and many men are concerned that they are not muscular enough.²⁴ In one study, ²⁵ percent of the women and ¹⁹ percent of the men said that they had serious concerns about their appearance.²⁵

Unfortunately, many of these people probably have a distorted, unrealistic view of how they look. In clinical studies of female dieters²⁶ and males with eating disorders,²⁷ both men and women thought of themselves as being fatter than they really were. In further studies,²⁸ men and women with BDD reported very inflexible thinking styles that reinforced their distorted view of how they looked. They believed that their own view of themselves was accurate and that others saw them the same way. They were also unwilling to consider that their beliefs might be wrong. Not surprisingly, the people with more severe cases of BDD also had more inflexible styles of thinking.

Interestingly, one group of researchers proposed that the study of art or design might be an influencing factor in the development of BDD. In a study of one hundred people with BDD, ²⁰ percent had an education or job in art or design.²⁹ This finding led researchers to consider two possibilities: The first is that perhaps studying art during adolescence, when BDD often develops, somehow contributes to development of the illness. The second is that people with BDD might be more naturally drawn to the study of art and design.

WHAT TREATMENTS ARE EFFECTIVE FOR BDD?

Unfortunately, many people try to treat BDD and their dissatisfaction with their body by having plastic surgery or dermatology treatments.^{5, 30, 31} Sadly, most of these attempts fail. In a study of people with BDD who received plastic surgery or dermatology treatments, 72 percent reported no change in the severity of their BDD symptoms and 16 percent reported that their symptoms actually worsened.⁵

This study highlights the fact that BDD is a problem in self-perception: The problem isn’t how people really look, but rather how they think they look. It’s a very important difference, because psychological treatments for BDD can help only if people are able to change the way they think about themselves and the world.

According to reports published in Behaviour Research and Therapy,^{32, 33} one of the most effective psychological treatments for BDD is very similar to the treatment for obsessive-compulsive disorder—namely, cognitive behavioral therapy. This treatment for BDD typically involves two processes: evaluating the person’s beliefs about his or her body, and safely and systematically exposing the person to previously avoided situations while he or she abstains from body-checking behaviors.³⁴ In one test of this treatment, BDD was eliminated in 82 percent of the cases.³⁴ This therapy has also been proven effective in group therapy settings.³⁵

Eye movement desensitization and reprocessing (EMDR) therapy has also demonstrated positive results in treating BDD,³⁶ as has the use of antidepressants,⁴ especially fluoxetine (Prozac) and fluvoxamine (Luvox).^37-41

COGNITIVE BEHAVIORAL THERAPY FOR BODY DYSMORPHIC DISORDER

Cognitive behavioral therapy (CBT) is a form of treatment that combines elements of both cognitive therapy and behavior therapy. Cognitive therapy examines the way people’s thoughts about themselves, others, and the world affect their mental health. Behavior therapy investigates the way people’s actions influence their own lives and their interactions with others. By combining the two, CBT examines the way people can change their thoughts and behaviors in order to improve their lives.

The CBT treatment for BDD is often composed of ten steps:^{42, 43}

Conduct an assessment and provide education
Develop relaxation skills
Challenge and correct self-defeating thoughts
Inventory stressful situations and responses
Create an exposure hierarchy
Engage in exposure and response prevention
Change distressing habits
Increase self-esteem
Increase social activity
Prevent relapse

1. Conduct an Assessment and Provide Education

The first step of the CBT treatment for body dysmorphic disorder is to conduct an assessment of the person’s symptoms in order to verify that he or she is struggling with BDD and not some other similar problem. This is often done with tools such as the BDD Questionnaire, the BDD Examination Self Report, the Body Areas Satisfaction Test, and a detailed history of the person’s behaviors. These BDD assessment tools can also help the person record his or her progress as the treatment proceeds. (Click here for BDD self-assessment tools.)

Once a person has been diagnosed with BDD, he or she should learn about the basic nature and causes of the disorder (as highlighted above). It’s also important to educate the person’s family and friends about the disorder in order to help them understand how they might be playing a role in maintaining the disorder, as well as how they might be able to help during the treatment. It’s also important for everyone involved to understand that CBT is an active form of treatment that requires the person with BDD and his or her loved ones to do work outside of the therapy session. (Click here for information on assessment and education for body dysmorphic disorder.)

2. Develop Relaxation Skills

The second step of the treatment for BDD is to learn relaxation skills. People with BDD often experience physical tension in addition to their mental stress. Learning relaxation skills can help relieve both problems, and there are a variety of different techniques that a person can learn. Included here are a few of the most important. All of these techniques include focusing on slow, rhythmic abdominal breathing, which often produces a feeling of calmness. This type of breathing is often incorporated into some kind of mindfulness meditation practice, in which a person focuses on allowing his or her thoughts to arise and disappear.

Physical relaxation skills are also important, such as progressive muscle relaxation. This involves a seven-second tightening and releasing of specific muscle groups from head to toe, with emphasis on noticing the difference between the tense feeling and the relaxed feeling.

Next, a person might learn how to release muscle tension without first tensing the muscles. This is done by focusing attention on the muscles and visualizing the tension being released.

Next, cue-controlled relaxation is often helpful, in which a person is taught to relax his or her body by saying a relaxing word, such as “peace” or “relax,” with each slow exhalation.

And, finally, special-place visualization is often taught. This skill teaches the person to envision a place of safety and comfort in his or her imagination. The person can go to this “mental safe place” during the BDD treatment if he or she is overwhelmed by distressing feelings. (Click here for a full description of mindfulness and relaxation techniques.)

3. Challenge and Correct Self-Defeating Thoughts

The third step of the CBT treatment for body dysmorphic disorder is to challenge and correct self-defeating thoughts. These thoughts are often the cause of poor body image and distressing feelings. At the most observable level are automatic thoughts. These are critical thoughts that people think and say to themselves that sabotage success and happiness. Two examples of automatic thoughts might be “No matter what I do, I’m still ugly” and “No one will ever be attracted to me.” A person can be either aware or completely unaware of having a thought like this. However, in both cases the result is that the person feels sad or hopeless. (Click here for information on identifying automatic thoughts.)

Much of the CBT treatment for BDD will be spent identifying and reevaluating these errors in thinking. This can be done with the use of a thought record. The thought record helps the person with BDD look for evidence that supports and contradicts these thoughts, and then, most importantly, it helps the person create a more balanced thought. For example, if the person struggling with BDD had the thought “No one will ever be attracted to me,” the thought record would offer evidence of this thought being true and examples of it not being true in the person’s life.

The thought record also helps the person identify different types of cognitive distortions, unhelpful thinking styles that perpetuate those automatic thoughts. For example, overgeneralizing involves making broad negative conclusions about life based on limited situations, and minimizing and magnifying involve discounting the positive and enlarging the negative aspects of life. (Click here for information on identifying cognitive distortions.)

By evaluating the evidence and cognitive distortions, the goal of the thought record is to help the person with BDD find a new, more balanced thought and ease feelings of sadness and anxiety. In this example, perhaps a more balanced thought would be “Even though I sometimes think I’m not attractive, people often tell me that I am.” And instead of feeling excessively sad, such as 8 on a scale of 1 to 10, perhaps this newer thought will help the person feel less sad, say only a 5 out of 10. (Click here for instructions on using a thought record.)

As the work on challenging automatic thoughts continues, a person using a thought record will usually begin to notice common themes among his or her thoughts. These themes often point to deeper, more firmly entrenched core beliefs about one’s self that make a person more vulnerable to BDD. These core beliefs, often called schemas, include thoughts like “I’m defective,” “I’m worthless,” and “I’m unlovable.” When these core beliefs are encountered, they too need to be challenged and modified using the thought record and other techniques. (Click here for instructions on challenging core beliefs.)

It’s often very helpful early in the treatment for the person to create a list of coping thoughts to stay motivated throughout treatment. “I’ve survived situations like this in the past,” is one example of a coping thought. (Click here for instructions on creating coping thoughts.)

4. Inventory Stressful Situations and Responses

The next step is for the person to monitor his or her behavior for involvement in stressful situations. These are situations in which obsessions about body image are very distressing. For example, before going to work a woman might become very anxious about her hair and spend a great deal of time styling it. Or before going to a friend’s party, a man might become very distressed about which clothes to wear and go on a shopping spree to find the “right” outfit. However, in both of these examples, the chosen solutions––styling and shopping––can only offer temporary relief; similar situations in the future will still cause the person to feel anxious and concerned about his or her body.

It’s very important for people with BDD to record what types of situations trigger obsessions about body image. It’s also important for them to record the observable rituals and behaviors they performed to ease their anxiety, such as spending excessive amounts of time checking and restyling. From this self-monitoring, the person can then create a BDD exposure hierarchy. (Click here for information on making an inventory of obsessions and compulsions.)

5. Create an Exposure Hierarchy

The most important step of the cognitive behavioral treatment for BDD is exposure and response prevention, or exposure and ritual prevention. This treatment safely and systematically exposes a person to feared circumstances and then helps the person refrain from performing rituals and other activities to reduce anxiety. This type of exposure often results in the person’s level of anxiety diminishing over time.

The next step of the treatment, therefore, is to create a hierarchy, a graded list of feared situations that the person will expose himself or herself to, beginning with the least feared situation. The hierarchy is formed using the subjective units of discomfort scale (SUDS), which ranges from 0 to 100, with 100 being the most disturbing situation. For example, for a woman with a concern about her hair, spending only ten minutes styling it before work might be a 30 on the SUDS scale, while spending only five minutes styling it before lunch with friends might be a 90. For the sake of the BDD treatment, this hierarchy should contain eight to ten feared situations that progressively increase in difficulty, beginning with an item with a SUDS level around 20 or 30. (Click here for information on making a hierarchy of feared situations.)

6. Engage in Exposure and Response Prevention

After the hierarchy has been constructed, the person should begin exposing himself or herself to feared situations with a SUDS level around 20 to 30. It’s very important that this be done without engaging in any rituals or compulsive behaviors to neutralize anxiety. The person should engage in each feared activity on the hierarchy long enough to clearly recognize that his or her anxiety level has decreased. For example, the woman with the concerns about her hair can practice going to work after minimal styling while also limiting or refraining from checking her hair. Instead, she can use relaxation skills and coping thoughts to ease her anxiety. Eventually, she will recognize that her anxiety level has clearly decreased. Once each activity is successfully mastered, the person proceeds to the next level of difficulty, until all feared situations on the hierarchy are successfully mastered.

During this process, it’s important for the person to record his or her thoughts and feelings, before, during, and after the exposure, in order to keep track of how those thoughts and feelings change over time. It’s also important for the person to make predictions about what will happen before engaging in the exposure process. Many people predict that catastrophes will occur if they don’t engage in checking behaviors, such as “Other people will laugh at me or judge me.” After the exposure is successfully completed, the person should reassess those predictions. By comparing what was expected to happen with what actually did happen, people struggling with BDD learn to monitor their cognitive processing. They also begin to recognize that they habitually overestimate the threat of certain situations and learn to reassess their coping abilities.

After successfully confronting a feared situation, the person should find some satisfying way of rewarding himself or herself in a way that doesn’t reinforce the BDD, such as sleeping later, going to the movies, and so on. (Click here for instructions on performing exposure and response prevention techniques.)

7. Change Distressing Habits

People struggling with BDD often engage in long-standing habits that only reinforce their concerns about their bodies. Examples of these habits include constant checking in the mirror, picking at skin and other body parts, plucking hairs, and grooming excessively. One technique that’s effective for changing these behaviors is called habit reversal. The steps of successful habit reversal include making a record of the habit, making a list of the advantages and disadvantages of engaging in that behavior, identifying the situations that trigger the behavior, developing an alternative behavior, practicing that alternative behavior, and rewarding oneself for using the alternative behavior. (Click here for instructions on using habit reversal.)

8. Increase Self-Esteem

Self-esteem is the value people put on themselves, based on both facts and the opinions of themselves and others. Unfortunately, people with BDD often have very low self-esteem because they usually focus on negative, self-defeating evaluations and disregard positive evaluations. Luckily, there are many skills and techniques that help increase self-esteem. These skills include being mindful of the labels used to describe oneself, challenging self-critical thoughts, developing self-compassion, making a more accurate self-assessment, avoiding the “shoulds,” reframing past mistakes, using assertive communication skills, and practicing visualization. (Click here for skills to increase self-esteem.)

9. Increase Social Activity

Because of the nature of BDD, people with this problem often develop the habit of avoiding social situations. If left unchecked, this can sometimes create a second serious problem: social phobia. (Click here for information about the nature and treatment of social phobia.) To prevent this, it’s very important for those with BDD to become more socially active, or if it has already occurred, to seek help for social phobia. Fortunately, as people’s symptoms of BDD become less distressing, they’re likely to naturally reengage in previously avoided social activities. However, they should always take note of any situations they avoid, as this might be a sign of returning BDD. (Click here for information about social isolation and BDD.)

10. Prevent Relapse

Finally, the last step of the CBT treatment for body dysmorphic disorder is preventing relapse after treatment is complete. The key to relapse prevention is for the person to continue using the cognitive and behavioral skills learned in treatment and to recognize the early signs of returning BDD in order to take steps to prevent relapse. (Click here for instructions on preventing relapse of BDD.)

REFERENCES FOR BODY DYSMORPHIC DISORDER

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2. Veale, D., and S. Riley. 2001. Mirror, mirror on the wall, who is the ugliest of them all? The psychopathology of mirror gazing in body dysmorphic disorder. Behaviour Research and Therapy 39: 1381-1393.

3. Phillips, K. A. 1991. Body dysmorphic disorder: The distress of imagined ugliness. American Journal of Psychiatry 148: 1138-1149.

4. Neziroglu, F., and S. Khemlani-Patel. 2003. Therapeutic approaches to body dysmorphic disorder. Brief Treatment and Crisis Intervention 3: 307-322.

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23. Andrist, L. C. 2003. Media images, body dissatisfaction, and disordered eating in adolescent women. American Journal of Maternity and Child Nursing 28: 119-123.

24. Pope, H. G., Jr., K. A. Phillips, and R. Olivardia. 2000. The Adonis Complex: The Secret Crisis of Male Body Obsession. New York: Free Press.

25. Harris, D. L., and A. T. Carr. 2001. Prevalence of concern about physical appearance in the general population. British Journal of Plastic Surgery 54: 223-226.

26. Gruber, A. J., H. G. Pope Jr., J. K. Lalonde, and J. I. Hudson. 2001. Why do young women diet? The roles of body fat, body perception, and body ideal. Journal of Clinical Psychiatry 62: 609-611.

27. Mangweth, B., A. Hausmann, T. Walch, A. Hotter, C. I. Rupp, W. Biebl, et al. 2004. Body fat perception in eating-disordered men. International Journal of Eating Disorders 35: 102-108.

28. Eisen, J. L., K. A. Phillips, M. E. Coles, and S. A. Rasmussen. 2004. Insight in obsessive compulsive disorder and body dysmorphic disorder. Comprehensive Psychiatry 45: 10-15.

29. Veale, D., M. Ennis, and C. Lambrou. 2002. Possible association of body dysmorphic disorder with an occupation or education in art and design. American Journal of Psychiatry 159: 1788-1790.

30. Aouizerate, B., H. Pujol, D. Grabot, M. Faytout, K. Suire, C. Braud, et al. 2003. Body dysmorphic disorder in a sample of cosmetic surgery applicants. European Psychiatry 18: 365-368.

31. Castle, D. J., M. Molton, K. Hoffman, N. J. Preston, and K. A. Phillips. 2004. Correlates of dysmorphic concern in people seeking cosmetic enhancement. Australian and New Zealand Journal of Psychiatry 38: 439-444.

32. McKay, D., J. Todaro, F. Neziroglu, and T. Campisi. 1997. Body dysmorphic disorder: A preliminary evaluation of treatment and maintenance using exposure with response prevention. Behaviour Research and Therapy 35: 67-70.

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35. Wilhelm, S., M. W. Otto, B. Lohr, and T. Deckersbach. 1999. Cognitive behavior group therapy for body dysmorphic disorder: A case series. Behaviour Research and Therapy 37: 71-75.

36. Brown, K. W., T. McGoldrick, and R. Buchanan. 1997. Body dysmorphic disorder: Seven cases treated with eye movement desensitization and reprocessing. Behavioural and Cognitive Psychotherapy 25: 203-207.

37. Brady, K. T., L. Austin, and R. B. Lydiard. 1990. Body dysmorphic disorder: The relationship to obsessive-compulsive disorder. Journal of Nervous and Mental Disease 178: 538-540.

38. Phillips, K. A., R. S. Albertini, and S. A. Rasmussen. 2002. A randomized placebo-controlled trial of fluoxetine in body dysmorphic disorder. Archives of General Psychiatry 59: 381-388.

39. Phillips, K. A., S. L. McElroy, M. M. Dwight, J. L. Eisen, and S. A. Rasmussen. 2001. Delusionality and response to open-label fluvoxamine in body dysmorphic disorder. Journal of Clinical Psychiatry 62: 87-91.

40. Phillips, K. A., and S. A. Rasmussen. 2004. Change in psychosocial functioning and quality of life of patients with body dysmorphic disorder treated with fluoxetine: A placebo-controlled study. Psychosomatics 45: 438-444.

41. Phillips, K. A., M. M. Dwight, and S. L. McElroy. 1998. Efficacy and safety of fluvoxamine in body dysmorphic disorder. Journal of Clinical Psychiatry 59: 165-171.

42. Claiborn, J., and C. Pedrick. 2002. The BDD Workbook: Overcome Body Dysmorphic Disorder and End Body Image Obsessions. Oakland, CA: New Harbinger Publications.

43. Cash, T. F. 2008. The Body Image Workbook: An 8-Step Program for Learning to Like Your Looks. Oakland, CA: New Harbinger Publications.