Body dysmorphic disorder: symptoms, causes, and treatments

Body dysmorphic disorder is a preoccupation with one’s appearance, especially with a perceived flaw or defect that other people can’t see. Individuals with this disorder constantly worry about their appearance, which gives them a great deal of distress and anxiety. 

The exact causes of body dysmorphia are unknown. A combination of factors such as genetics, abnormal brain function, and negative experiences in childhood can contribute to the development of body dysmorphic disorder. 

The disorder can be managed successfully. The most common treatment approaches are cognitive-behavioral therapy and medications such as selective serotonin reuptake inhibitors (SSRIs). Healthcare professionals may prescribe other types of medications depending on a patient’s symptoms. Proper treatment of BDD requires strong adherence to the treatment protocol. The support system plays a huge role in the treatment of BDD. 

What are the symptoms of body dysmorphic disorder?

Symptoms of body dysmorphic disorder are listed below.

• Being preoccupied with a perceived flaw in appearance: focusing excessively on the supposed flaw and constantly talking about it, even when others see nothing wrong
• The strong belief of being deformed: a person with BDD is convinced their appearance is flawed and views themselves as being deformed or ugly
• Attempting to fix the “flaw”: an individual with BDD constantly engages in behaviors that focus on fixing or hiding the “flaw” in their appearance. These behaviors include checking oneself in the mirror constantly, skin picking, grooming, etc.
• Believing others notice the “flaw”: to a person with BDD, their appearance-related problem seems so big that they believe others see it too. Not just that, they also believe others stare at them, mock them, and notice their appearance in a negative manner
• Constant comparisons: people with BDD tends to compare themselves and their appearance to others
• Seeking reassurance: since a person with BDD is convinced their appearance is flawed in some way, they may constantly ask others about it. While doing so, they seek reassurance i.e., want other people to tell them nothing is wrong or that their problem isn’t obvious/visible
• Strong desire for plastic surgery: to someone with BDD, plastic surgery is oftentimes the only solution to fix their appearance. Even if they undergo a cosmetic procedure, individuals with body dysmorphic disorder don’t stop there. Instead, they’re convinced they need to do more or fix some other people. This leads to multiple cosmetic procedures, and to others, it may seem the person is obsessed with plastic surgery
• Social isolation: due to a strong belief in flawed appearance or that others see it too, a person with BDD will strive to avoid social activities as much as possible. When around people, they feel anxious.

What are the causes of body dysmorphic disorder?

The causes of body dysmorphic disorder are generally unknown. A combination of different issues can contribute to the development of BDD, like with many other mental health conditions. The most common causes of body dysmorphic disorder are listed below.

• Genetics: genetic predisposition or vulnerability could contribute to the development of body dysmorphia symptoms. At this point, specific genes or genetic mutations and pathways that play a role in body dysmorphic disorder are unknown. A study from JAMA Psychiatry found that some aspects of obsessive-compulsive disorders, including BDD, are strongly influenced by genes. The involvement of genes could explain phenomenologic similarities, comorbidity patterns, and familiarity. The same study also revealed some disorder-specific genetic influences are evident in BDD and some other OCDs. That means it is highly likely there is a set of disorder-specific genes that contribute to the development of BDD. 
• Abnormal brain function: impaired function in some parts of the brain and imbalances of certain neurotransmitters may contribute to body dysmorphic disorder. For example, Psychological Medicine published a study that found that people with BDD exhibited higher activity in brain areas that process detailed information. The greater activity they had in detail-processing areas such as the fusiform cortex, the less attractive they perceived the faces to be. Other pieces of evidence confirm people with BDD may have abnormalities in functional brain connectivity with the orbitofrontal cortex, a part of the frontal lobe. The orbitofrontal cortex is associated with OCD pathology and obsessive-compulsive symptoms in BDD. Body dysmorphia may implicate brain regions and symptoms involved in facial emotion perception, such as the right parietal cortex, inferior frontal cortex, amygdala, and others. Also, impaired serotonin balance may contribute to the development of BDD. More precisely, persons with BDD may have a decreased serotonin binding density. Serotonin helps regulate mood. At the same time, BDD is associated with higher serum oxytocin levels. Oxytocin is a hormone released by the brain that has multiple functions, including affecting social interaction. Elevated oxytocin levels are linked to higher severity of BDD symptoms.
• Negative experiences about body and self-image: a person’s environment plays a significant role in the development of body dysmorphic disorder. Negative experiences in childhood such as teasing, bullying, neglect, and abuse (physical and/or verbal) affect the way a person perceives their appearance. As a result, they adopt negative body image and unrealistic expectations that pave the way to body dysmorphic disorder. 

What are the risk factors for body dysmorphic disorder?

Risk factors for body dysmorphic disorder are listed below.

• Family history: a person is more likely to develop body dysmorphic disorder if their family members have it as well. It’s difficult to determine whether symptoms are inherited from genes or picked up from parents’ behaviors.
• Certain personality traits: people with introverted, insecure, sensitive, narcissistic, and perfectionist tend to be at a higher risk for body dysmorphic disorder. For example, perfectionists have a strong drive for perfection in everything they do, including their appearance. They may perceive some facial features or their bodies as flawed i.e. not perfect. 
• Other mental health problems: persons with other mental health conditions such as anxiety or depression are at a higher risk of developing body dysmorphic disorder as well. Mental health conditions make a person more vulnerable to negative thoughts, including those about their appearance. Also, sometimes it’s unclear whether BDD contributes to anxiety or depression or they cause body dysmorphic disorder.
• Societal/peer pressure: social pressures (from social media, TV, and society in general) and peer pressure at school nourishing unrealistic or unhealthy beauty standards put a person, especially an adolescent, at a higher risk for BDD. With continued exposure to unhealthy and negative beauty expectations and standards, a person becomes more inclined to think something is wrong with their appearance and that only plastic surgery can fix it. Societal pressure would lead to self-consciousness and strong dissatisfaction with one’s look, even if one accepted these supposed “flaws” in the past. 
• Traumatic events or emotional conflict: victims of bullying in school and children who were abused or neglected are more susceptible to developing BDD. Their body image has been greatly affected. Plus, their traumatic events have taken a major toll on how they perceive themselves compared to other people. An affected individual may believe something is wrong with them or they’re not worthy of respect or love unless they change their appearance. 

How is body dysmorphic disorder diagnosed?

Body dysmorphic disorder is diagnosed after taking a personal and family medical history and performing a physical exam. If a healthcare provider suspects a person has BDD, they may refer them to a psychiatrist or psychologist. 

The mental health professional evaluates a patient’s behavior, attitude, and symptoms they’re experiencing. They will diagnose BDD when a patient is preoccupied with a flaw (or more of them) in their appearance or when they can’t function at work/ home due to worries about their look and do repetitive actions due to concern for their appearance. These repetitive actions include checking oneself in the mirror constantly, and grooming, among others. 

Generally speaking, body dysmorphic disorder is difficult to diagnose because people feel ashamed and tend to be secretive about their symptoms. The embarrassment makes them reluctant to schedule an appointment to see a healthcare provider. For that reason, BDD can go unnoticed for many years, and many people never receive a diagnosis and treatment. 

How to prevent body dysmorphic disorder?

It is not clear how to prevent body dysmorphic disorder at this point. There is no known strategy to avoid it. However, it is possible to decrease its effects and reduce the risk of a serious problem by catching BDD early. Since body dysmorphic disorder starts in early adolescence, early diagnosis and timely treatment can be beneficial. Also, long-term maintenance treatment can prevent relapse of BDD symptoms.

When it comes to reducing the risk of BDD, society itself plays an important role. Unhealthy beauty standards presented by social media and the entertainment industry are major contributors to insecurities that may lead to BDD. For that reason, putting a strong focus on healthy and realistic attitudes about body image is necessary. As people, especially adolescents, learn to accept themselves and their bodies, they become less likely to experience symptoms of BDD. 

That being said, body dysmorphic disorder is more than that, which is why there is no specific strategy that would protect a person from developing it ever. Getting educated and informed about BDD and its symptoms helps people, particularly parents, recognize them and encourage an affected person to seek help before it becomes worse. 

What effects does BDD have on a person’s life?

Effects of BDD on a person’s life include piling medical bills, in cases when a person undergoes cosmetic surgery, as well as complications listed below.

• Anxiety
• Depression 
• Suicidal thoughts and behavior

1. Anxiety

Anxiety is an intense feeling of dread, unease, fear, and worry. While everyone can be anxious from time to time, anxiety as a mental health disorder can be debilitating. Since BDD is a type of anxiety disorder, it’s not surprising anxiety is a major effect or complication of this condition. For example, one study found that body dysmorphic disorder was relatively common among college students and was strongly associated with stress and anxiety. 

A paper from the Clinical Psychology Review found a link between BDD and social anxiety disorder, especially in Eastern cultures. Since a person with BDD is convinced something about their appearance is wrong, they may develop anxiety that affects their social functioning.

Generally speaking, anxiety may result from traumatic events and other negative experiences. As an anxiety disorder, BDD also has this component since negative experiences are risk factors for this disorder. 

The symptoms may vary, but a person tends to become nervous and restless. Other symptoms include hyperventilation, increased heart rate, sweating, trembling, and difficulty controlling worry. When left unmanaged, irrational thoughts associated with body dysmorphic disorder become more intense and lead to anxiety symptoms. 

2. Depression

Depression is a serious mental health disorder characterized by persistent feelings of sadness, hopelessness, and helplessness. It affects how a person thinks, feels, and behaves. Evidence shows body dysmorphic disorder and depression are strongly related. It’s highly unlikely BDD is only a symptom of depression, but it can contribute to it as well. Recognizing depression in patients with BDD can be difficult because its symptoms are often concealed due to shame and embarrassment. 

When left untreated, body dysmorphia can lead to severe depression. That may happen because a person’s perception of their appearance keeps getting worse, and so do the symptoms of BDD. In this situation, a person feels like there is no way out because even if they get plastic surgery, they are often still unsatisfied with the results. This leads to desperation and depression.

Plus depression is also caused by various factors, including low serotonin, which happens to be one of the causes of BDD. 

A person with depression is constantly sad, loses hope, thinks they’re worthless, loses interest in activities they used to enjoy, and becomes socially isolated. 

3. Suicidal thoughts and behavior 

Suicidal thoughts and behaviors are consequences of a serious underlying problem. The BDD Foundation reported that, according to one survey of BDD patients attending a specialist clinic, 25% of them have attempted suicide. The same report shows around 0.3% of patients with body dysmorphia commit suicide each year.

Living with body dysmorphic disorder can be very difficult. Some people experience high levels of distress and feel hopeless. They develop depression which keeps getting worse. For some patients with BDD, the only solution is suicide, which is why suicidal thoughts and tendencies are the scariest complications of this disorder.

A paper from Primary Psychiatry confirmed suicidal ideation is a common effect of BDD but emphasized a lot more research on this subject is necessary. Symptoms of suicidal thoughts and behaviors include talking about suicide a lot, social isolation, mood swings, feeling trapped or worthless, and engaging in self-destructive behaviors. 

What are the treatments available for body dysmorphic disorder?

Treatments available for body dysmorphic disorders are usually, a combination of the approaches listed below:

• Cognitive-behavioral therapy
• Selective serotonin reuptake inhibitors (SSRIs)
• Medication

1. Cognitive behavioral therapy

Cognitive-behavioral therapy (CBT) is a form of talk therapy that helps people change the way they think and behave in order to manage or treat a certain problem. During CBT sessions, therapists help patients identify negative or irrational thoughts and beliefs. The main premise of cognitive-behavioral therapy is that negative thoughts lead to negative emotions and behaviors. So by changing their thinking pattern, a person can also improve their emotional health and their behavior at the same time.

As the first-line treatment for BDD, cognitive-behavioral therapy helps patients challenge their negative thoughts and body image. As a result, they may start replacing irrational thoughts or beliefs with a more realistic outlook. In other words, this type of talk therapy enables patients to adopt more flexible ways of thinking. 

Patients also learn coping skills to handle symptoms of BDD, such as mirror checking, excessive use of medical services, and seeking reassurance. 

A study from Neuropsychiatric Disease and Treatment found that CBT reduced anxiety and depression in BDD patients as well as OCD symptoms related to body dysmorphia. Additionally, Clinical Psychology Review published a paper confirming that CBT is an effective treatment for BDD. The therapy reduced depressive symptoms, delusions, and improved insight. 

Since many people with BDD develop anxiety, especially social anxiety disorder, the therapist may also work with the patient on improving social skills and interpersonal interactions. 

2. Selective serotonin reuptake inhibitors (SSRIs)

Selective serotonin reuptake inhibitors (SSRIs) are antidepressants. In fact, they’re the most commonly prescribed medications for the treatment of depression. These drugs work by increasing serotonin levels in the brain, hence the term “selective” – they don’t act on other neurotransmitters. More precisely, SSRIs inhibit the absorption of serotonin into neurons. As a result, more serotonin is available for better transmission of messages between neurons. 

Doctors may prescribe SSRIs to patients with body dysmorphia because decreased levels of serotonin play a significant role in the development of this condition. Plus, in some cases, body dysmorphia and depression overlap, meaning SSRIs could help patients manage their symptoms. The role of SSRIs is to help patients control their thoughts and behaviors more effectively. 

3. Medication

Healthcare professionals may prescribe other medications to manage BDD. The specific medications depend on the symptoms, but the abovementioned SSRIs are the most common pharmaceutical treatments for this condition. Besides SSRIs, some patients may need clomipramine, a tricyclic antidepressant with strong serotonergic action. The main objective of medications is to reduce the intensity of symptoms and improve a patient’s quality of life.