Most people have had an experience in which they were unhappy with their body or physical appearance. Skin care and weight loss industries are multi-billion-dollar businesses for a reason. The proliferation of thin bodies in the media contributes to a negative self-image for many individuals.
For some people, concerns about their bodies escalate to a level of clinical severity meriting diagnosis and treatment for a mental health condition. People with body dysmorphic disorder focus on their perceived flaws in an excessive, distorted way that causes them to engage in self-defeating behavior and to experience difficulties in their daily lives. People with this disorder frequently suffer from comorbid anxiety and depression and require medication and treatment.
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What Is Body Dysmorphic Disorder?
Body dysmorphic disorder (BDD), also known as body dysmorphia, body dysmorphia disorder and BDD disorder, is a mental health condition in which people suffer acute distress in response to perceived physical flaws.
In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), body dysmorphic disorder is classified as an obsessive-compulsive type of disorder. This is a change from the previous edition of the diagnostic manual (DSM-IV-TR), where it was classified as a somatoform disorder.
This change reflects the fact that BDD has both obsessive and somatic, or physical, components. For a person to be diagnosed with body dysmorphic disorder, the DSM-5 definition requires a person to meet all four of the following criteria:
- Preoccupation with perceived physical defects that are not apparent to others
- At least one episode of repetitive behaviors, such as skin picking, mirror checking or repetitive cognitions like comparing specific features to those of others
- Clinically significant distress or functional impairment caused by this preoccupation
- Symptoms not explained by weight-related obsessions of an eating disorder
Symptoms of BDD can be purely cognitive or include compulsive body-focused actions. These behaviors may or may not reflect an attempt to modify a person’s appearance.
A diagnosis of body dysmorphic disorder will typically include one of the following specifiers:
- Good or fair insight
- Poor insight
- Absent insight or delusional beliefs
In other words, a person with BDD may recognize that their obsessive thoughts are somewhat distorted or may fully believe that their perceptions are accurate. What separates BDD-related cognition from normal thoughts related to body image or fitness goals are the disproportionate nature of the thoughts and the distress they cause.
Body dysmorphic disorder also includes a muscle dysphoria subtype in which people fixate on the belief that their bodies are too small or lacking in muscle. This is not simply a matter of wanting to improve their physical condition—in this case, gain muscle mass. Rather, it is characterized by a distorted self-image that causes significant distress and affects their ability to function.
Symptoms of Body Dysmorphic Disorder
Symptoms of body dysmorphic disorder include a number of thought patterns that people with the disorder may or may not express verbally to others. The anxiety that typically accompanies the condition can cause people to avoid saying anything that would invite scrutiny or judgment. In other cases, this anxiety can drive people to obsessively verbalize their fears and seek frequent reassurance about their appearance. Cognitive BDD symptoms can include these thought patterns:
- Repeatedly thinking about one particular flaw and how to fix it
- Having thoughts about being unworthy, monstrous or unlovable
- Wondering if other people are noticing one or more physical flaws
- Fearing that other people are talking about or mocking these flaws
- Feeling ashamed or embarrassed even after neutral or positive interactions
- Having perfectionistic tendencies and a limited sense of acceptable aesthetics
Body dysmorphic disorder symptoms also include behaviors that are much easier to detect:
- Camouflaging appearance with baggy clothing, excessive makeup or body position
- Pursuing cosmetic surgery, especially multiple surgeries on the same feature
- Checking appearance in a mirror and making frequent minor adjustments
- Avoiding mirrors, other reflective surfaces, recordings or photographs
- Picking at skin or engaging in any other repetitive grooming behavior
- Withdrawing socially or significantly limiting social activities
Symptoms including food restriction and excessive exercise may also be signs of BDD, though they frequently indicate a comorbid eating disorder.
Causes of Body Dysmorphic Disorder
What causes body dysmorphic disorder? The results of multiple research studies show a strong biological component to the condition, with nearly half of BDD symptoms being accounted for by genetic factors. These may include a family history of mental illness, temperamental factors like sensitivity to physical sensations, and a tendency toward obsessive rumination.
Environmental causes of body dysmorphic disorder include negative life experiences that instill fear of judgment or rejection because of physical imperfections. In one study, Didie, Tortolani and Pope found that nearly 80 percent of people with BDD had a history of being neglected or abused as children. Severe bullying is also linked with the development of body dysmorphia. Body dysmorphic disorder causes can be less traumatic in origin, including teasing from peers and having acne or another skin condition, even if it is successfully treated.
How Is Body Dysmorphic Disorder Diagnosed?
Like most mental health conditions, BDD is diagnosed through clinical interviews performed by mental health professionals. Targeted questions help clinicians determine if a person meets the DSM-5 diagnostic criteria for the disorder. Clinical instruments, including the Body Dysmorphic Disorder Examination (BDDE), have been developed to help clinicians rule out similar conditions and precisely diagnose BDD as a specific condition.
In some cases, observations about behavior may spur a clinician who is treating a person for other mental health conditions to examine them for secondary BDD. Body dysmorphia often emerges as a comorbid condition, commonly appearing with depression and anxiety. For example, if a therapist notices a client sitting or dressing in an incongruous way that seems intended to hide one or more physical features, that therapist might ask questions to determine if these behaviors are related to depression or anxiety or if they indicate a secondary diagnosis of BDD.
Who is at Risk for Body Dysmorphic Disorder?
Risk factors for body dysmorphic disorder can include:
- A family history of mental illness -especially of obsessive-compulsive or body dysmorphic disorders
- Personality traits or temperament, including sensitivity, perfectionism and shame-proneness
- Lifetime experiences of body shaming, including childhood teasing, bullying or abuse
- A history of medical or dermatological conditions that affect the appearance
- Other mental health conditions, including anxiety and depression
Any combination of these risk factors, especially having a sensitive or perfectionistic temperament, a genetic pre-disposition to BDD and a history of being teased for physical differences, significantly increases the likelihood someone will develop the disorder.
Body Dysmorphic Disorder Statistics
Body dysmorphia disorder statistics show that there is increased risk of suicide for people with the disorder: people with BDD report a 16 to 26 percent higher rate of suicidal ideation and a 6 to 20 percent higher rate of suicide attempts compared to people without the disorder.
One study found that nearly 80 percent of people with BDD had experienced suicidal ideation and about 28 percent had made a suicide attempt. The risk is even higher in people with comorbid bipolar, major depressive, eating, personality or substance use disorders.
About 7 percent of people with an anxiety disorder have comorbid body dysmorphia. Social anxiety disorder (SAD) has the highest rate of comorbid BDD of any anxiety disorder. People with both SAD and BDD nearly always develop SAD prior to developing BDD.
Body dysmorphic disorder has a prevalence of about 3 percent in the entire United States population.
If you or someone you know is struggling with a substance use disorder that could be associated with BDD or another co-occurring disorder, help is available. At The Recovery Village, a staff of professionals provides a continuum of care for addiction and co-occurring disorder treatments. Call and speak to a representative to learn more about which treatment program can work for you.