What is Body Dysmorphic Disorder?
Body Dysmorphic Disorder (BDD) is an anxiety disorder that is closely linked with body image and self esteem. Previously known as dysmorphophobia, BDD causes an intense preoccupation with perceived aesthetic flaws or physical defects, which are often associated with the face, skin, hair, or weight. Individuals with BDD become intensely focused on these perceived flaws, which are often minimal or non-existent. Many people with BDD will view their bodies in a “distorted” manner, where they view features or perceive size differently from reality.
This preoccupation causes significant distress and difficulty with daily functioning. BDD can vary in severity from person to person and from day to day, but for many people it has a profound impact on their daily life. Concerns with physical appearance can make it difficult to go out in public or see the people you care about, increase isolation and loneliness, and worsen mental wellbeing. The pervasive effects of BDD can have an impact on your work life, interests, education, and relationships.
Many people with BDD don’t realize that there are treatments that can help, and they may keep their symptoms hidden due to embarrassment or guilt. It is, therefore, difficult to know how many people experience the disorder. While estimates vary, it is thought that up to 10 million Americans, or around around 2.5% of the population, are affected by BDD, making its lifetime prevalence higher than anorexia and perhaps even OCD. Because Body Dysmorphic Disorder remains a strikingly under-discussed and overlooked issue, many people are unaware of the wide range of treatments available. Here, we will explore the effects of BDD and the evidence-based treatments that can alleviate them.
Key features and characteristics of Body Dysmorphic Disorder include:
Obsessive Self-Examination: People with BDD often engage in excessive grooming, by checking their appearance in mirrors, seeking reassurance from others, and comparing themselves to others. They may spend hours each day scrutinizing their perceived flaws.
Avoidance and Social Isolation: Due to their concerns about their appearance, individuals with BDD may avoid social situations, public places, or events where they feel their appearance will be scrutinized. This can lead to isolation and difficulties in relationships.
Negative Self-Image: BDD can lead to low self-esteem and a negative self-image. Individuals may believe that their perceived flaws make them unattractive or deformed, even if others do not see these flaws.
Repetitive Behaviors: Common behaviors associated with BDD include excessive grooming, skin picking, hair pulling, and seeking frequent cosmetic procedures or surgeries, often with little satisfaction or relief. People may also frequently perceive that others are staring at or judging their appearance.
Causes and Risk Factors for BDD
The development of BDD can be influenced by various factors. The diathesis-stress models for BDD suggest that a combination of biological predisposition and environmental stressors contributes to the development of the disorder. Research from twin studies shows that genetic factors play a role in around 42% to 44% of the variation in BDD-like symptoms. The rest of the variation is attributed to unique environmental influences that differ among individuals.
Common risk factors for BDD include:
Genetics: There is evidence to suggest a genetic predisposition for BDD. Individuals with a family history of the disorder or related conditions like Obsessive-Compulsive Disorder (OCD) may be at a higher risk.
Brain Chemistry: Imbalances in certain neurotransmitters, particularly serotonin, have been associated with BDD. These chemical imbalances can affect mood, perception, and obsessive thinking.
Psychological Factors: Certain personality traits or psychological characteristics may increase the risk of BDD. These can include perfectionism, low self-esteem, high levels of self-criticism, and a tendency to focus excessively on appearance. Co-occurring conditions are a significant risk factor, as BDD is often accompanied by other mental health conditions such as depression, anxiety disorders, and Obsessive-Compulsive Disorder (OCD).
Negative Life Experiences: Traumatic events, bullying, neglect, or critical comments about one’s appearance during childhood or adolescence can contribute to the development of BDD. Such experiences may lead to distorted body image and heightened self-consciousness. Pressure from peers or family members to conform to certain beauty standards or undergo cosmetic procedures can also be a risk factor.
Media and Societal Influences: The portrayal of idealized and unrealistic beauty standards in media and social platforms can contribute to feelings of inadequacy and dissatisfaction with one’s appearance, potentially increasing the risk of BDD.
Treatments for BDD
For a number of years, traditional treatments for BDD have consisted of some combination of selective serotonin reuptake inhibitors (SSRIs) and cognitive behavioral therapy (CBT). However, alternative approaches are gaining popularity.
Traditional CBT
Cognitive behavioral therapy is often the first option considered for BDD.
CBT for BDD typically involves 12 to 22 weekly sessions and focuses on techniques like Exposure and Response Prevention (ERP). Other strategies used in CBT for BDD encompass psychoeducation, motivation enhancement, cognitive restructuring, mirror retraining, and attention training.
ERP gradually exposes individuals to anxiety-inducing situations (like bright lights or mirrors) while discouraging safety behaviors (such as camouflaging or excessive makeup) to reduce distress and achieve anxiety reduction. In adults, randomized, controlled trials have shown that CBT effectively reduces the severity of BDD compared to various control conditions. However, a substantial percentage of those with BDD (46% to 60%) do not respond well to CBT, and remission rates are low. Few studies have addressed the long-term effects of CBT, so further investigation is needed. A 12-month follow-up study of adolescents who received CBT for BDD indicated that while overall improvements were maintained, a significant proportion still experienced symptoms and remained vulnerable to various risks and negative outcomes (such as cosmetic surgery or suicidal behavior).3
Acceptance and Commitment Therapy (ACT)
Acceptance and commitment therapy is an alternative form of behavior therapy that has gained recognition and popularity in recent years. ACT centers on accepting thoughts and symptoms rather than attempting to change or dispute them. It incorporates mindfulness, acceptance, and value-based living.
ACT suggests that individuals label their emotions as distressing and use ineffective methods to change them. In BDD, where appearance dominates attention, people are encouraged to identify and commit to other meaningful values in life. Some studies show that ACT can reduce body dissatisfaction, fear of judgment, and other related symptoms, which improves overall well-being.
Medications
Various serotonin reuptake inhibitors (SRIs) have been used to treat BDD, including fluoxetine, fluvoxamine, citalopram, escitalopram, and clomipramine. Most evidence supporting the effectiveness of these medications comes from open trials, which report response rates ranging from 53% to 70%. There is positive evidence for the effective combination of SRIs and therapy. In a recent study, people who continued to receive escitalopram for 6 additional months had a lower relapse rate (18%) compared to those who switched to a placebo (40%). This suggests that extended SRI treatment may be highly effective or even necessary to prevent relapse in BDD.
In Summary
While there are other potential treatments for BDD, reliable research into these is lacking. Though traditional treatments involving CBT with a focus on ERP and SSRIs are effective for many, a substantial proportion of people do not respond well, which highlights the need for alternative approaches, such as acceptance and commitment therapy. More research is needed to increase both medical and public knowledge of the effective forms of treatment for BDD.
Sources:
[1] Hong K, Nezgovorova V, Hollander E. New perspectives in the treatment of body dysmorphic disorder. F1000Res. 2018 Mar 23;7:361. doi: 10.12688/f1000research.13700.1. PMID: 29636904; PMCID: PMC5871801.rnal%20Injury%20Prevention.
