Body Dysmorphic Disorder

Body Dysmorphic Disorder (BDD) is a very painful psychological condition where a person is obsessed over perceived flaws in their physical appearance.  This obsession leads to significant emotional distress and avoidance of many situations, sometimes leading to suicidal depression or inability to leave their home.

The person’s perceived flaws, however, are actually typically minimal or non-existent. In fact, around half of people with BDD have delusional beliefs about their appearance and other people’s reactions to their appearance (e.g. believing people are laughing at their acne when their skin is normal). Any part of the body can be the target of BDD.

Many people with BDD undergo painful and expensive cosmetic surgeries to try to cure their body image concerns. However, this typically results in more feelings of hopelessness as the surgical procedures fail to improve their internal misrepresentations of their physical appearance.

Here is a model of what happens with people who have BDD:

  • To begin with, the person has beliefs about appearance that are rigid and extreme; for example, “only attractive people can marry and have a good life.” This may have been instilled by an upbringing which pushed and over-valued an attractive physical appearance. There may have been a perfection-emphasis.
  • People with BDD have been shown to have a very detail-oriented focus. In general, they look at things in small details, focusing on parts of the body rather than the complete picture. In other words, they cannot see the forest because the trees get in the way. To get a better understanding of the ramifications of this, go to a mirror and stare at a part of your face two inches away and try to find something unattractive about a particular feature. Better yet, use one of those magnifying mirrors. You might find body image dissatisfaction creeping up on you, too.
  • In addition to a detail-oriented focus, persons with BDD tend to interpret neutral scenarios as threatening more often than those without BDD, and they tend to over-estimate the attractiveness of other’s faces.
  • All of this leads the person with BDD to feel shame, depression, anxiety, and under negative scrutiny.
  • As a result, they engage in significant safety behaviors and avoidances. They might spend hours picking out their clothes in order to maximally camouflage (cover-up) or draw attention away from their perceived flaws. Grooming and mirror-checking behaviors can take many hours a day. They take desperate measures in order to avoid what they think as “subjecting the world” to their “hideousness”. All of that hard work on their appearance does not improve their body image and so they struggle to avoid situations that might trigger their concerns (dating, stores, parties, and so on).
  • All of these avoidances and safety behaviors may, in the moment, ease their suffering a bit. They feel that because they hid themselves or their flaws away that they have narrowly escaped humiliation and scorn. This further reinforces both the avoidance and safety behaviors and their belief that had they not engaged in these cover-up and avoidance behaviors, they would have had dire social consequences. They do not then have the opportunity to learn that they are ok just as they are. If a bald guy always wears a baseball cap, he does not get to learn that most people will not reject him just for being bald. The more he wears the cap, the more he believes that he must to wear it…or else.

Currently, the two main treatments for BDD are serotonin reuptake inhibitors (SRIs) and Cognitive-behavioral therapy (CBT). Combining those treatments, in some cases, may increase the likelihood of a successful therapeutic outcome.

CBT treatment includes:

  1. Learning about BDD and what maintains it
  2. Challenging maladaptive appearance thoughts and beliefs
  3. Exposure to previously avoided situations without camouflage or other BDD “compulsions” (safety behaviors)
  4. Perceptual retraining (learning to look at entirety of appearance without judgment)
  5. Relapse prevention

Eric Goodman, Ph.D.

www.216.194.169.74/~anxiet14

References:

  • Wilhelm, S., Buhlmann, U., Hayward, L., Greenberg, J., & Dimaite, R. (2010). A cognitive-behavioral treatment approach for body Dysmorphic Disorder. Cognitive and Behavioral Practice, 17, 241-247.
  • Phillips, K.A. (2004). Psychosis in body dysmorphic disorder. Journal of Psychiatric Research, 38, 63-72.