Body Dysmorphic Disorder
J. is a 15-yo teen who believes his hair is "all wrong" despite the beliefs of his friends and family who see none of these 'defects'. But now it's to the point where he refuses to go to school unless he combs his hair for hours.
M. is a 45-yo woman. Her ability to focus on details makes her a gifted and accomplished musician and music teacher. Unfortunately, she has been increasingly obsessed with signs of ageing which she thinks make her nose now appear much bigger. Despite the reassurance of family members, she is so concerned about her appearance that she has been reducing her social contacts to a greater and greater extent. "I can't go out - people will see how ugly I am."
Ask yourself the following questions (from the Body Dysmorphic Disorder Clinic at the Massachusetts General Hospital):
- Do you worry a lot about your appearance?
- Do you consider any part or parts of your body especially unattractive?
- Do you spend a lot of time thinking about your defect(s)? At least one hour per day?
- Do your appearance concerns interfere with your work or social life?
- Do you repetitively check your appearance in mirrors or go to great lengths to avoid mirrors?
- Do you often ask people for reassurance about how you look?
- Do you spend a lot of money on make-up, cosmetics, etc., to camouflage your flaws?
- Do you often compare your appearance to that of others?
- Do you pick at your skin?
- Have you had repeated cosmetic surgeries?
Have you answered “yes” to several of these?
- If so, then read on to learn more about body dysmorphic disorder.
Imagine what life would be like if you didn't have to be controlled by worries about your appearance. There is hope. There are services and support to help you with BDD thoughts and concerns.
It is normal for people to have concerns about their appearance from time to time, and some may obsess more than others. Humans are a social species, and indeed, humans judge each other based on appearance and grooming. It makes sense that one would want to keep one’s appearance within a certain range, in order to fit in with others.
However, in some people, these concerns are so severe that it becomes a disorder.
Body dysmorphic disorder (BDD), also known as dysmorphophobia (fear of something being wrong with one’s body), is a condition where individuals are obsessed with perceived flaws in their appearance to the point that it causes problems in their life (APA, 2013).
Typical symptoms are:
- Thinking and worrying constantly about the defects or flaws that they think they have, or comparing themselves with others.
- Worries that other people notice, judge or talk about their perceived defect (when in all likelihood, people are not noticing anything at all).
Behaviours such as
- Attempting to conceal their perceived defects with make-up, clothing.
- Excessive grooming to try to remove perceived imperfections such as combing one's hair repeatedly.
- Picking their skin.
- Asking for constant reassurance from others.;
Other symptoms may include:
- Worries about being photographed or filmed.
- Being critical about not only their own appearance, but that of others.
People with BDD may have concerns about any part of the body. However, most concerns are about the face (e.g. nose being too big, or eyes being too small), hair or skin. Males may be prone to have worries about their muscular build (i.e. worries about being small, weak and not muscular enough).
Friends and relatives would say the concerns are imaginary because there is no obvious defect. Even if there is an imperfection, most others would regard these as "normal" imperfections and the worries to be excessive and unreasonable.
These behaviors and thoughts are distressing, not pleasurable and are hard to control/resist.
Negative Impact of Having BDD
BDD can cause a significant negative impact on a person’s life. As a result of their BDD, they may:
- Reduce or avoid close relationships.
- Reduce or avoid school, work or social activities.
- In some cases, people can even become housebound.
People with BDD may also be at risk of other conditions and problems such as:
- Depression, social anxiety, obsessive-compulsive disorder (OCD), substance use problems. The severe stress caused by having BDD can even lead to thoughts that life is no longer worth living.
In the USA, about 2.2% of men, and 2.5% of women suffer from BDD.
Body dysmorphic disorder usually starts in adolescence, but is usually not diagnosed until individuals are older (20's to 30's).
Despite all the pain and suffering that BDD can cause, it is under-recognized, for many reasons:
- Most people with BDD are convinced that they really do have serious flaws and imperfections, as opposed to recognizing it is a misperception.
- People with BDD may feel ashamed, guilty, embarrassed for having their symptoms.
- People with BDD may worry that they will be judged negatively by others for their symptoms.
People with BDD may end up seeing health professionals for other problems (e.g. anxiety, depression, eating disorders, OCD, hair pulling, social anxiety), without it being realized that the BDD may actually be the main issue.
People with BDD may also seek out dermatologists or plastic surgeons with the attempt of removing their imperfections, thus subjecting themselves to the risks of a medical procedure. Even if the treatment is performed, it typically does not help people feel better -- it does not deal with the underlying worries.
Like most many conditions, body dysmorphic disorder is likely due to a combination of factors such as:
- Genetics and family history.
- The person has experienced stressful life experiences. Most people with BDD report they have had significant stressful and/or traumatic life experiences.
- Societal pressures from society and mass media to look a certain way, with its emphasis on “beauty” and “perfection”.
The person with BDD notices a detail about their appearance…
In person with BDD, the brain hyperfocuses on details (as opposed to the ‘big picture’) (Feusner, 2010; Toh, 2017; Jefferies, 2012).
The brain perceives that there is something wrong, and as a result, the person’s alarm system (“fight or flight”) activates, leading to feelings of anxiety and distress.
Under stress, the visual system narrows its focus (“tunnel vision”) even further to focus on the perceived threat (Rogers, 2003).
With body dysmorphic disorder, this results in a vicious circle -- the more anxiety, the more narrowed vision, the more anxiety.
The good news is that there are many strategies and exercises to turn off the false alarm.
Strategies to Counter the Narrow Visual Focus
1. Vision Exercises to Promote Peripheral Vision
Good peripheral vision is felt to be helpful in many endeavours (such as sports, reading and driving). Interestingly enough, vision exercises have been proposed for help with calming the nervous system (Bowan, 2008).
There appears to be promising anecdotal evidence that peripheral vision exercises may be a helpful strategy to help with body dysmorphic disorder (Launay, 2020), though note that more research is required in this area.
Consider doing the following:
- Do try to deliberately focus on the big picture, and be aware of your surroundings, as opposed to hyperfocusing with central vision on details, such as individual flaws.
Are you sitting or standing up?
Hold your hands at different points at the limits of your peripheral vision
- Move your fingers, while looking at a point in the middle distance and being aware of the movements of your hands.
- Hold your hands at different points at the limits of your peripheral vision
- Are you walking outside? Be aware of your surroundings on your left and right side.
Are you on the train or bus? It may be easier to do this on a train or bus, because normally you can’t see much forward anyways. Notice the landscape streaming by on both sides of your vision.
- Are you outside in nature? Try to enjoy the beautiful landscape. Look at a large painting or poster on your wall. Put a nature screensaver / background on your computer screen.
- Are you using a computer? Try to remember the 20/20/20 rule -- every 20 minutes, look at least 20 feet away, for at least seconds, at something panoramic rather than narrow.
After a short while of doing any of the above exercises, you will hopefully feel more relaxed and calm (i.e. demonstrating your parasympathetic system has been activated).
2. General Strategies to Calming the Nervous System
Strategies that help calm the nervous system (not specific to BDD) include:
Lifestyle strategies such as
- Ensuring enough sleep.
Ensuring healthy nutrition, which includes limiting stimulants such as caffeine and processed foods.
- More about Nutrition and Brain (Mental) Health
Ensuring sufficient time outside, as nature is calming for the nervous system.
- More about Nature and Brain (Mental) Health
Spending quality, face-to-face time with people and activities that bring purpose, hope and meaning to your life. Social engagement calms our nervous systems as human beings are wired to be social.
Breathing exercises, yoga, breathwork.
- Many practices focus on the importance of breathing. Having a longer exhale than inhale helps with parasympathetic stimulation.
- More about breathing strategies
- Many practices focus on the importance of breathing. Having a longer exhale than inhale helps with parasympathetic stimulation.
It can sometimes be challenging supporting a loved one with body dysmorphic disorder. You may hear them talking about their concerns about their body, and most likely, you will have tried to reassure them that everything is alright. Yet despite their reassurance, they continue to be obsessed and distressed with perceived imperfections.
- Try to see things from their perspective, and understand how stressful it must be to feel that there is something seriously wrong with your body.
- Validate how stressed they are to be worried that something is wrong. “Thank you for letting me know about your worries. I can see this is really tough for you.”
- Ask how you might support them: “How can I support you?”
- Stay calm. No matter how frustrated you get, it really doesn’t help to get angry or upset at them. It is not their fault -- they have these worries because of the illness, which itself is due to something with the way their brain is wired.
- Ask them if they might be open to seeing a health care professional to help them deal with the incredible stress that they are having. You do not need to mention that they have BDD.
Have you (or your loved one) tried various strategies but is still struggling with body dysmorphic disorder?
- If so, then see a health professional, such as your primary care provider. Your provider can ensure that there aren’t other conditions that might be contributing.
- Your family physician can recommend services and supports that might be helpful in your area, such as a mental health clinic, or a psychologist, social worker, or other health professional.
Cognitive Behavioural Therapy (CBT)
Cognitive behavioural therapy (CBT) is a type of talking therapy given by a trained professional, such as a psychotherapist, psychologist or psychiatrist.
Body dysmorphic disorder tricks people into having negative thoughts (e.g. "I'm so ugly") and behaviours (e.g. avoiding going out). CBT helps by changing people's thoughts and behaviours to deal with body dysmorphic disorder (NICE, 2005).
Education about BDD
Learning all about BDD, e.g. what is it? What can be done about it?
Practicing positive, “coping thoughts”
i) Monitoring and learning to be aware of one's 'automatic' thoughts.
E.g. "Aha! I'm getting worried about my nose again! That's the BDD tricking me into having those thoughts, its not me. I'm not going to let the BDD get in the way of my life."
ii) Evaluating both the usefulness and validity of thoughts, by asking questions such as:
E.g. "Is this a helpful thought?"
E.g. "What's the evidence to support this thought?"
iii) Challenging unhelpful thoughts and replacing them with more helpful thoughts, by asking oneself questions such as:
E.g. "What is a more valid or realistic thought?"
E.g. "What is a more helpful or useful thought to have?"
For example, a person with BDD might change his/her negative thoughts (e.g. "I'm so ugly") into more realistic thoughts (e.g. "Sure, my nose isn't perfect, but hey, I'm definitely not ugly! Even if I was, my friends and family would still love me.")
Practicing positive, “coping behaviours
c) Learning helpful behaviours to overcome the BDD:
i) Exposure: BDD typically tricks people into avoiding social situations, or stressful situations such as mirrors. Exposure is about helping the person to gradually face more and more of these situations, at a comfortable, gradual step-by-step fashion.
ii) Response prevention: BDD typically tricks people into having compulsive behaviours such as skin picking, comparing oneself to others, looking in the mirror. Response prevention is about preventing these behaviours from happening, once again, in a gradual, step-by-step fashion.
Advantages of psychotherapy: CBT teaches skills that can be long lasting. Compared to medications, CBT does not have the same risk of physical side effects.
Disadvantage of psychotherapy: CBT requires the person to have enough capacity and ability to do CBT. When one’s symptoms are too severe, CBT may simply not be possible.
Still struggling despite psychotherapy?
If so, then medications may be helpful such as:
Specific serotonin reuptake inhibitors (SSRIs), which work by increasing the function of serotonin in the brain. Treatments usually need to be given for long periods (i.e. 12-16 weeks).
Examples of SSRIs include Fluoxetine (Prozac), Citalopram (Celexa), Sertraline (Zoloft), Fluvoxamine (Luvox), Escitalopram (Cipralex), Paroxetine (Paxil). Other similar medications include Venlafaxine (Effexor).
Advantages of medications: When one is feeling overwhelmed, a person may not have the ability to see a therapist, whereas it may be possible to take a medication to help with the symptoms. After the medications have helped, this can then make it possible for the person to see a therapist, do visual exercises, etc.
Disadvantages / disadvantages of medications: Medications can sometimes cause side effects. On the other hand, this is why medications are monitored by a prescribing physician, in order to manage any side effects that might arise, e.g. reducing the dosage of the medication, stopping the medication, or changing a medication.
Musicians who have written about specific exercises to calm the autonomic nervous system via parasympathetic exercises.
Florence Launay, a vocal coach who writes about the link between tunnel vision and BDD, recommends peripheral vision exercises for both music performance and in body dysmorphic disorder. She writes a blog “Finding a way out of Body Dysmorphic Disorder: the parasympathetic path”
- Karen Bulmer, tuba player and Professor of Low Brass at Memorial University of Newfoundland, who writes about “broadening your vision” in general for music performance and in life. https://musicmindandmovement.com/blog/broaden-your-vision
Looking for more information on visual exercises?
Soften the Gaze, Emma McAdam
Chrissy Zwmijewski, The Daily Habits That Are Unknowingly Increasing Your Stress
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.
"About Body Dysmorphic Disorder" (from the Body Dysmorphic Disorder Clinic at Massachusetts General Hospital), retrieved Dec 29, 2008 from http://www2.massgeneral.org/bdd/info.htm.
Body Image Program at the Butler Hospital, a specialty program for BDD directed by Dr. Katharine Phillips. Retrieved Dec 29, 2008 from http://www.butler.org/body.cfm?id=123.
Chu, C., Rosenfield, M., Portello, J.K., et al. (2011). A comparison of symptoms after viewing text on a computer screen and hard copy. Ophthalmic Physiology, 31(1),29-32.
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Godnig, E.C. (2003). Tunnel vision: Its causes and treatment strategies. Journal of Behavioral Optometry, 14(4), 95-99. Available from https://pdfs.semanticscholar.org/17fa/1596044fbfbe0aaf4123432e0f23df76dce0.pdf
Jamie D. Feusner; Teena Moody; Emily Hembacher; Jennifer Townsend; Malin McKinley; Hayley Moller; Susan Bookheimer. Abnormalities of Visual Processing and Frontostriatal Systems in Body Dysmorphic Disorder. Arch Gen Psychiatry, 2010; 67 (2): 197-205.
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Phillips, Katharine. The Broken Mirror, 2005.
Porges, S. W. (2018). Polyvagal theory: A primer. In S. W. Porges, & D. Dana (Eds.), Clinical applications of the polyvagal theory: The emergence of polyvagal‐informed therapies (pp. 50–69). New York, NY: W.W. Norton & Company.
Rogers, T. J., & Landers, D. M. (2005). Mediating effects of peripheral vision in the life event stress/athletic injury relationship. Journal of Sport and Exercise Psychology, 27(3), 271-288.
Rogers TJ, Alderman BL, Landers DM. Effects of life-event stress and hardiness on peripheral vision in a real-life stress situation. Behav Med 2003;29(1):21-6. http://bit.ly/2qEKhd4
Toh WL, Castle DJ, Rossell SL. Face and object perception in body dysmorphic disorder versus obsessive-compulsive disorder: the Mooney Faces Task. J Int Neuropsychol Soc. 2017;23:471–80. https://doi.org/10.1017/S13556... Health Organisation. ICD-11 International Classification of Diseases for Mortality and Morbidity Statistics. Eleventh Revision. World Health Organisation. 2018. Available from: https://icd.who.int/browse11/l-m/en.
National Institute for Health and Clinical Excellence. Obsessive-Compulsive Disorder: Core Interventions in the Treatment of Obsessive-Compulsive Disorder and Body Dysmorphic Disorder: CG31. National Institute for Health and Clinical Excellence. 2005. [Accessed 2020 Aug 20]. Available from: http://www.nice.org.uk/guidance/cg31
Written by the health professionals at CHEO and the Department of Psychiatry at the University of Ottawa.
Special thanks to Florence Launay, a French music historian and vocal coach, with lived experience with BDD.
Icons courtesy of Freepik.
Conflicts of interest: None declared.
Information in this pamphlet is offered 'as is' and is meant only to provide general information that supplements, but does not replace the information from your health provider. Always contact a qualified health professional for further information in your specific situation or circumstance.
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Date of Last Revision: Dec 23, 2020