Body Dysmorphic Disorder: Condition & Treatment

Author: Elizabeth Milburn, CRNP

What is Body Dysmorphic Disorder (BDD)?

It seems that most people critique their own bodies, or parts of them (“Ugh my arms are flabby.” “My hair is thinning.”) However, BDD is a specific set of symptoms that are more time consuming and debilitating than just having a critical opinion about a part of one’s body. This disorder is very much like obsessive-compulsive disorder, but with a specific focus on one’s appearance.

People with Body Dysmorphic Disorder (BDD) have a preoccupation with one or more parts of the body that they perceive to have something very wrong. The preoccupations are unwanted and feel intrusive. The perceived defects are typically either not noticeable to others or appear very slight. People with BDD also perform repetitive behaviors or mental acts in response to the concern with their appearance. As with all mental disorders, the symptoms must cause significant distress or difficulty functioning in an area of life. The symptoms are typically quite time consuming, taking up 3 to 8 of 24 hours in a day. Individuals find the symptoms difficult to control, and the behaviors or mental acts are difficult to resist doing.

The level of insight into this issue can vary widely. Some people fully believe the distorted thought to be true. Some recognize the thought is not true or might not be true.

Elizabeth Milburn, CRNP treats students & adults (18+) w/ Body Dysmorphic Disorder (BDD).

Two Examples of Cases of Body Dysmorphic Disorder:

Patient A is extremely preoccupied with the appearance of their face. They had a dermatological treatment a few years ago that they are 100% convinced left scars on their cheeks that are highly visible and ugly. Others, including the clinician, do not see the scars. Patient A compulsively checks in the mirror or checks their phone camera many times a day to assess how the scars appear. The set of symptoms causes distress and anxiety when interacting with others, because Patient A feels that everyone is always looking at the scars on their face. Sometimes the anxiety is so great related to this that Patient A calls out of work.

Patient B is extremely worried that their thighs are “huge and deformed.” To others, Patient B’s thighs look much like everyone else’s and there is nothing to be concerned about. Patient B spends several hours before leaving the house trying on different pants and shirt combinations to see which option their thighs look the least “huge and deformed” in. They carefully check each choice in the mirror to compare and choose the right outfit. Patient B will send photos to their friends to ask if their thighs look OK in certain clothes. They ask many friends about the same outfit to make sure to get enough opinions. Sometimes Patient B does not feel comfortable in any of the choices and will cancel plans because of this. When patient B does go out, they usually wear a very long shirt that hides their thighs, and they are often preoccupied regarding what everyone else is thinking of their thighs

during an outing. Sometimes they check how their thighs look in a bathroom mirror while out with friends. They refuse to go swimming and have not been swimming in 10 years, since the disorder started to be severe.

Who Gets Body Dysmorphic Disorder (BDD)?

In the United States, it is estimated that 2.5% of females and 2.2% of males have this disorder. Two-thirds of people with BDD had symptoms begin prior to the age of 18. Individuals with a first degree relative with obsessive-compulsive disorder have a higher risk of developing BDD.

Why Treat Body Dysmorphic Disorder (BDD)?

There is a significant impairment in functioning socially in this population. There is a wide range of impairment, with some patients avoiding some situations, to some patients being unable to leave their home. About 20% of young people with BDD report dropping out of school due to their BDD symptoms. As with many mental disorders, there is a higher risk of suicidal thoughts and attempts with this illness versus the general population.

How is BDD Treated?

Although there are no medications formally approved by the FDA for BDD, some medications are very helpful for this illness. In our experience, it is treated quite similarly to obsessive compulsive disorder. Thus, typically SSRIs, SNRIs, and/or TCAs are used. Occasionally an SGA can be added on, especially when there is little to no insight about the perception not being accurate or true or if there is only a partial response the SSRI, SNRI, or TCA medications. In addition, major depressive episodes are common in patients with BDD. Depression co-occurring with BDD may interfere with a patient’s ability to participate fully in therapy. Therefore, depression medications are often utilized, many of which overlap with the previously mentioned medications.

Medication treatment can and should be combined with therapy for Body Dysmorphic Disorder (BDD). Different methods may be necessary depending on the individual and severity of their symptoms. Some of the methods are described next: Some patients need motivational interviewing to assess and assist with readiness to begin to change thoughts and behaviors. Psychoeducation about BDD should be provided. Cognitive strategies are often used (identifying distorted thoughts, evaluating them, and generating alternative thoughts). There is also a method called perceptual retraining (learning how to have a healthier relationship with reflective surfaces, learning to more objectively and kindly describe features). Finally, exposure and ritual prevention can be used. This type of therapy is a gold standard for obsessive compulsive disorder as well.