Body dysmorphic disorder (BDD) is characterised by an excessive preoccupation with a real or imagined defect in one's own physical appearance.

People with BDD have a distorted or exaggerated view of how they look and are obsessed with actual physical characteristics or perceived flaws, such as a certain facial feature or imperfections of the skin. They often think of themselves as ugly or disfigured. People with the disorder often have problems controlling negative thoughts about their appearance, even when reassured by others that they look fine and that the minor or perceived flaws aren't noticeable or excessive.

BDD is a type of somatoform disorder. Somatoform disorders are characterised by physical symptoms that suggest a medical condition. However, a thorough medical evaluation doesn't reveal any underlying medical cause for the physical symptoms.

Body dysmorphic disorder causes people excessive anxiety and distress, often impairing their social life and performance at school or work. People with BDD may find it difficult to meet new people or make friends because of intense fear that their appearance might be judged in a negative way. In severe cases of BDD, a person may severely limit contact with other people in an attempt to avoid having others see the perceived physical flaw.

Treatment for BDD may involve a combined approach involving medication and talk therapy (psychotherapy). Antidepressant medications used along with cognitive behavior therapy can help people with BDD manage the obsession and anxiety about their appearance, increase confidence in how they look, and obtain normalcy in their social and work lives.

Signs and symptoms

The signs and symptoms of body dysmorphic disorder include:

• Frequently comparing the flaw in appearance with that of others
• Repeatedly checking the appearance of the specific body part in mirrors or other reflective surfaces
• Refusing to have pictures taken
• Wearing excessive clothing, makeup and hats to camouflage the perceived flaw
• Using hands or posture to hide the imagined defect
• Frequently touching the perceived flaw
• Picking at one's skin
• Frequently measuring the imagined or exaggerated defect
• Elaborate grooming rituals
• Excessively researching about the perceived defective body part
• Seeking surgery or other medical treatment despite personal opinions of others and recommendations of doctors that the flaw is minimal or doesn't exist or that treatment is unnecessary
• Seeking reassurance about the perceived defect or trying to convince others that it's abnormal or excessive
• Avoiding social situations in which the perceived flaw might be noticed
• Feeling anxious and self-conscious around others (social phobia) because of the imagined defect

People with severe BDD may drop out of school, quit their jobs or avoid leaving their homes. In the most severe cases, people with BDD may consider or attempt suicide.

Certain physical obsessions are common in a person with BDD. These include:

• Overall size, shape or symmetry of a certain facial feature, such as size or shape of nose
• Moles or freckles perceived as too large or noticeable
• Acne and blemishes
• Minor scars or skin abrasions
• Too much facial or body hair
• Baldness
• Breast size
• Muscles perceived as too small
• Size or shape of genitalia

Causes

The cause of body dysmorphic disorder is unclear. However, researchers believe that a number of factors may be involved and that they can occur in combination, including:

• A chemical imbalance in the brain. An insufficient level of serotonin, one of your brain's chemical messengers involved in mood and pain, may contribute to BDD. Although such an imbalance in the brain is unexplained, it may be hereditary.
• Obsessive-compulsive disorder. BDD often occurs with obsessive-compulsive disorder, in which a person uncontrollably practices ritual behaviors that may literally take over his or her life. A history of or genetic predisposition to obsessive-compulsive disorder may make you more susceptible to BDD.
• An eating disorder. BDD also may be present with an eating disorder, such as anorexia nervosa or bulimia nervosa, especially if it involves a weight-related part of the body, such as the waist, hips or thighs.
• Generalised anxiety disorder. BDD may accompany generalised anxiety disorder. This condition involves excessive worrying that disrupts your daily life, often causing exaggerated or unrealistic anxiety about life circumstances, such as a perceived flaw or defect in appearance, as in BDD. A history of or genetic predisposition to generalised anxiety disorder may make you more susceptible to BDD.
• Psychological, behavioral or cultural factors. People from families of higher socio-economic status or strict cultural standards may experience BDD more often. Someone who feels that he or she must live up to unobtainable or unrealistically high expectations for personal appearance and success may be more prone to BDD.

When to seek medical advice

Shame and embarrassment may keep you from seeking treatment for body dysmorphic disorder. But even if your anxiety and rituals are deeply ingrained, treatments can help. If you suspect you have BDD, see your doctor or a mental health professional.

Screening and diagnosis

According to the American Psychiatric Association, a questionnaire called the Body Dysmorphic Disorder Questionnaire (BDDQ) is used by a psychiatrist or a psychologist to help determine if a person has BDD. The questionnaire is conducted during an office visit with your doctor and as part of an interview focusing on your concerns about your physical appearance. Another tool used to help diagnose BDD, the Body Dysmorphic Disorder Examination (BDDE), consists of a series of questions to evaluate these key tendencies of the disorder:

• Preoccupation with and evaluation of appearance
• Degree of self-consciousness and feelings of discomfort in public
• Tendency to overvalue appearance in determining overall self-worth
• Avoidance of social situations and physical contact with others
• Excessive altering of one's appearance through grooming, cosmetics or dress
• Tendency to frequently check one's appearance, perform repetitive grooming and seek reassurance from others

To diagnose the disorder, your doctor will ask questions about your obsessions, compulsions and disappointments regarding your appearance, and about your emotional well-being in general. He or she may also talk to your friends and relatives about your behavior.

Complications

Body dysmorphic disorder tends to be chronic and can bring about other health problems and complications in your life:

• Depression. Chronic BDD often causes depression, a disorder that affects your thoughts, moods, feelings, behavior and physical health. It's a serious illness that can take a terrible toll on individuals and families. Untreated depression can lead to a downward spiral of disability, dependency and suicide.
• Social isolation. BDD is commonly associated with social isolation, social phobia and other negative impacts, such as dropping out of school, quitting a job or becoming completely homebound.
• Unnecessary medical procedures. Some people with body dysmorphic disorder tend to aggressively seek unnecessary and excessive medical care and procedures, such as cosmetic surgery, in an attempt to correct or significantly improve an actual or perceived physical flaw. Such attempts sometimes end up producing additional medical problems and even worsening the flaw. In general, any medical or surgical procedure carries certain risks of complications, such as serious infection and even death. A person with the disorder may make multiple desperate attempts to get rid of a perceived defect in appearance without weighing the possibility of increased risk of health complications.

Treatment

Doctors often use a combination of medications and talk therapy (psychotherapy) to help people cope with and overcome body dysmorphic disorder:

• Antidepressants. These medications are used to treat mental health conditions. There are several types of antidepressants, grouped by how they affect brain chemistry. A specific type of antidepressants called selective serotonin reuptake inhibitors (SSRIs) may help lessen or alleviate the signs and symptoms of BDD.
• Cognitive behavior therapy. This type of talk therapy identifies unhealthy, negative beliefs and behaviors and replaces them with healthy, positive ones. It's based on the idea that your own thoughts — not other people or situations — determine how you behave. The premise is that even if an unwanted situation hasn't changed, you can change the way you think and thus behave in a positive way. Cognitive behavior therapy can be effective in learning to manage the effects of BDD. Careful attention to your thoughts may be coupled with certain behavioral assignments, such as reducing the amount of time you check how you look in the mirror, or increased exposure, such as going out in public more often.

BDD can be a challenging condition to treat. Clinical studies continue and have shown promise for more effective treatment using SSRIs and other serotoninergic agents.

Self-care

Certain steps may help you get the most from your medical care and overcome body dysmorphic disorder:

• Follow the schedule for your medication. To get the full benefit of your medicines, it's important to follow instructions exactly. This means taking the right medicine and dose, at correct time intervals, for the length of time prescribed. Bad effects can result from taking too much or too little of a medicine, or taking it too often or not often enough.
• Don't skip therapy sessions. The therapeutic process can be daunting and uncomfortable, especially in the beginning. But within a few weeks, you should begin to see an improvement in your symptoms, including relief from distress, better decision-making abilities, improved relationships and new coping skills.
• Involve your family. Provide them with materials that explain BDD and encourage them to join support groups with you. You may find support groups in your community or through the Internet.

Coping skills

Try these tips to help reduce the anxiety associated with BDD:

• Break the cycle. When you feel anxious about your appearance, concentrate on something else. Take a brisk walk or delve into a hobby to refocus.
• Take care of yourself. Get enough rest, eat a balanced diet, exercise, and take time to relax. Avoid caffeine and nicotine, which can worsen anxiety. Don't turn to alcohol or over-the-counter drugs for relief.
• Talk to someone. Share your problems with a friend or professional counselor who can help you gain perspective. Initiate and follow a routine for regular social support.