Body Dysmorphic Disorder

What is Body Dysmorphic Disorder?

Body Dysmorphic Disorder (BDD) is when a person has a preoccupation with a perceived flaw in their physical appearance. Although in reality there might be a slight flaw, the distress is excessive. BDD has similarities to obsessive-compulsive disorder (OCD); however, there are some important distinctions.

Like OCD, people with BDD have obsessions about their physical defects, which cause them anxiety and distress, and they try to alleviate by engaging in compulsions. Like OCD, the compulsions do not provide any pleasure for the person, but do offer short-term relief. People with BDD often have less insight than those with OCD, and more delusional beliefs.

A common misconception about BDD is that it’s about vanity. Although some of the thoughts expressed by people with BDD might be interpreted this way, the foundation of the disorder is about how this defect impacts the person’s entire being. It’s beyond a standard of beauty or a general sense of attractiveness, and hits a core belief of being worthless, unlikeable, or a failure due to the perceived physical flaw.

Common Obsessions in BDD

The delusional nature of BDD is most evident in the obsessions that people have. Their focus is on one or more body parts and how they don’t look how the person believes they should, or what’s considered normal. Although BDD can affect any body part, some of the most common focuses are on the nose, chin, lips, chest, genitals, and legs. The concerns can be related to shape, size, color, position, symmetry, etc.

Common Compulsions in BDD

Unlike OCD, BDD compulsions typically have a clear and direct connection to the obsessions. Although there is frequently a delusional component to the obsessions in BDD, the compulsions are understandable, but to an unreasonable and extreme level.

Among the most common compulsions are camouflaging, comparing with others, checking mirrors, seeking cosmetic treatments and surgery, excessive grooming, reassurance-seeking, and touching the perceived flaw. Avoidance is also extremely common among people with BDD, whether it be skipping events where others could notice the perceived flaw or covering mirrors to prevent seeing defects when passing by.

When people with BDD engage in compulsions there is no pleasure involved, but rather a reduction of distress. Individuals with BDD do not want to be doing compulsions, but their fears and anxiety about the consequences of not performing them are so great that the temporary relief offered feels worthy of the problems the compulsions cause.

How is BDD Diagnosed?

Proper diagnosis of BDD by a specialized professional is crucial. It’s not uncommon for BDD to be misdiagnosed as an eating disorder, OCD, social anxiety, or even a psychotic disorder. When a patient isn’t correctly diagnosed, they will be treated for the wrong issue, and therefore the true problem will not improve.

In the United States, diagnosing BDD is based on criteria set forth by the Diagnostic and Statistical Manual of Mental Disorders (DSM). Its current edition, the DSM 5-TR, sets forth three primary criteria for the diagnosis of BDD – preoccupation with at least one perceived physical flaw that is minimal or non-observable to others, compulsions related to the preoccupation with perceived physical defects, and that the preoccupation causes clinically significant distress or impairment in various areas of functioning, including work, school, or social life.

Who Gets BDD?

2.4% of adults in the United States struggle with BDD, almost equally between men and women (DSM-5-TR)
11-13% of dermatology patients, 13-15% of cosmetic surgery patients, 20% of rhinoplasty surgery patients, 11% of adult jaw correction surgery patients, and 5-10% of adult orthodontia/cosmetic dentistry patients have BDD (DSM-5-TR)
BDD rates about adolescents and college students is higher among females than males (DSM-5-TR)
Mean age of the onset of BDD is 16-17 years old (DSM-5-TR)
Two-thirds of people with BDD have an onset before age 18 (DSM-5-TR)

How is BDD Treated?

One of the major complicating factors to treating BDD is the lack of insight. If a person is intent on convincing the therapist (among others) that their perceived flaw is real, and others engage in the argument, they are, in fact, engaging with the BDD. This is one of the reasons why therapy from a mental health clinician who specializes in BDD must be involved in treatment.

Enhancing motivation is key to starting therapy. Without engagement in the therapeutic process, no progress can be made. Motivational Interviewing can be extremely helpful in this process, as well as recognizing the ambivalence and resistance that’s often present with people with BDD. This work also can aid with keeping a person in treatment when they have setbacks in progress.

Cognitive behavioral therapy (CBT) is the core of treatment for BDD, with specific protocols for the disorder. This includes psychoeducation, cognitive work on self-defeating thoughts, exposure and response prevention, and mirror retraining. Acceptance and Commitment Therapy (ACT) can also be extremely beneficial to treating people with BDD, specifically values-based work.