by Eda Gorbis, PhD, LMFT

Body Dysphoric Disorder (BDD) is described as the disease of “self- perceived ugliness” or “self-imagined ugliness.” It is also seen as a distressing preoccupation with one or more physical non-existence “defects.” In the DSM-5, BDD is classified under Obsessive Compulsive and Related Disorders. Within the general population, 1%-2% have being diagnosed with BDD, which is nearly 5 million people in the United States alone. Additionally, about 70 % of cases indicate that the onset of BDD occurs before the age of 18. People with BDD obsess over the way they look and worry excessively about their appearance. Compulsions also manifest and typically people practice repetitive behaviors such as: skin picking, seeking medical procedures to correct flaws real or imagined, and excessive grooming 

Most BDD patients have difficulty coping with their belief driven fears and develop rituals and patterns such as: 

  • Mirror checking
  • Mirror avoidance
  • Masking & camouflaging the defect

BDD patients must realize that these compulsive behaviors not only fail to reduce their anxiety, but indeed cause and stimulate it. The greatest challenge is to learn to accept that the physical defect does not exist, or even if it does, to accept it without the all-consuming desire to change it.
The “Resizing” defect is not giving into the feeling that gives patients a wrong signal. It is deeply rooted self-esteem issues of body image that are present and work against the development of proper insight and correct perspective. By its nature, BDD is highly comorbid with other psychopathologies.

How does Quarantine Effect Someone with BDD?

COVID-19 has brought many restrictions, and one of them has been to stay at home and self-quarantine. When being reframed at home, stress and anxiety worsens especially with BDD. The stress of not being able to work and the anxiety of not knowing what might happen in the future increases significantly. When self-isolated, as a BDD individual, one might have trouble controlling other comorbid disorders such as eating disorders, OCD, and depression. Someone with BDD and depression might have the tendency to commit suicide because of the feeling of hopelessness and worthlessness during this pandemic. The pandemic might bring thoughts of not being needed or feeling not important since socializing has been restricted. In addition struggling with BDD might increase the rituals of obsessions, compulsions, and self-criticism. Another possibility is that the use of substances might significantly increase due to anger that turns into rage, depression, and obsession. The increase of alcohol consumption or drug use might ultimately lead a BDD client to contemplate suicide or even take their own life.

However, during the pandemic, when many doctor offices are temporarily closed, that does restrict BDD individuals from undergoing medical procedures. This is beneficial because it might temporarily increase the improvement of BDD symptoms such as decreasing addiction of plastic surgeries, compulsions, and other medical interventions they might seek. 

BDD Treatment Challenges 

Telehealth has been a treatment method for those with BDD. Though it may help with this type of mental health disorder the most effective treatment option is in-person. In-person provides therapists the opportunity to conduct exposure therapy, where the client can use a mirror to see how they betray themselves to the world. Telehealth minimizes this type of method, however with some modifications the therapist can provide a virtual scenario. 

Mental health treatment programs including the Westwood Institute often require a period of sobriety before addressing other mental health disorders. Addiction treatment programs often cite negative affect as the number one reason for relapse, and therefore they do not address co-occurring disorders in most treatments for addiction. (University of Pennsylvania, 2010)

Consequently, patients with AUD do not receive treatment for BDD or other disorders, and vice versa. Current available treatment consists of medications and cognitive behavioral therapy (CBT). Typically, serotonin reuptake inhibitors (SRIs) such as, Clomipramine, Fluoxetine, or Fluvoxamine might help. CBT is seldom a stand-alone option and most effective when used in conjunction with a well-designed medication regiment.

Due to their recent development history, these treatments are only beginning to show signs of effectiveness. The greatest challenge is to convince the patient that his or her condition is a product of distorted mental imagery and to accept a proper referral. When patients agree to accept a referral, it is more often for a pharmacological modality, which is reported to give partial or complete symptom resolution in only 58% of patients. BDD clients have difficulties in believing how others view their physical appearance. 

Research has indicated that BDD patients’ primary motivations for accepting referral is the unbearable level of distress and anxiety, which results in alcohol abuse in 48.9% of subjects. BDD patients need to first accept re-orientation to be educated about the nature and course of BDD.

During these times of uncertainty and fear, it is important to find coping mechanisms to help with mental health issues. Especially if the patient suffers from BDD, when a negative thought arises, it is important to reach out to a family member or friend,to someone they can trust and that they know will not judge. They can help ease and calm any unsettling emotions of thoughts. For those with a therapist during quarantine, reaching out to them is key. Setting a time to speak and express concerns and request strategies to combat the negative thoughts.

About the Author

Dr. Eda Gorbis, PhD, LMFT is the Founder and Executive Director of the Westwood Institute for Anxiety Disorders in Los Angeles, California and a Clinical Assistant Professor (V) at the USC Keck School of Medicine. The Westwood Institute is often called an intensive center of 'last resort' for Obsessive-Compulsive Disorder (OCD), Body Dysmorphic Disorder (BDD), and other anxiety disorders. By integrating treatment methods with a multidisciplinary team of experts, Dr. Gorbis has brought hundreds of people with prior treatment failures to normal functioning. Her expertise was prominently featured on programs, such as "20/20," "60 Minutes," and "MTV's True Life.”  She has given over 170 conference presentations on topics related to her intensive treatment of OCD, BDD, and anxiety disorders around the world.