More Information about Body Dysmorphic Disorder

People with body dysmorphic disorder (BDD) worry about how they look. They’re obsessed with the belief that there’s something wrong with their physical appearance. People with BDD may worry, for example, that their skin is scarred, their hair is thinning, their nose is too big, or something else is wrong with how they look. They may describe themselves as looking unattractive, ugly, deformed, abnormal, disfigured, or hideous. Some people even believe they look like a monster.  To other people, however, people with BDD look normal. But when others tell the BDD sufferer that they look fine or that the flaw they perceive is minimal or not visible, people with BDD find it hard to believe this reassurance. Most people with BDD are convinced or fairly certain that they truly look abnormal, which is why trying to talk them out of their appearance concerns usually doesn’t help.

BDD Preoccupations and Disliked Body Areas
People with BDD can dislike any body area. Some people are concerned with just one body part, although most dislike many parts of their body. Here is a list of the most commonly disliked areas, collected from more than 500 people who have participated in our research studies.

BDD thoughts are often referred to as preoccupations, or as “obsessions,” meaning that they are time-consuming (they usually occur for many hours a day), difficult to resist, and hard to control. Some people with BDD realize that the flaws they perceive really don’t look that bad, but most don’t realize this: they think they probably – or truly – look abnormal or ugly in some way. People who are absolutely convinced that their appearance beliefs are accurate are sometimes said to have “delusional” BDD.

Common BDD Behaviors
Virtually everyone with BDD engages in one or more BDD-related behaviors. These behaviors are generally intended to check the perceived defect, obtain reassurance about how it looks, fix it, or hide it from other people. Many of these behaviors are done over and over again, many times a day. There’s usually a strong urge to do them, and they’re typically hard to resist or control. For these reasons, the behaviors are often called “compulsive.”

Here is a list of the most common BDD behaviors and the percentage of people who perform each behavior excessively. These percentages are based on more than 500 people who have participated in our research studies.  This list isn’t comprehensive, however, and some people engage in BDD behaviors that aren’t listed here.)

BDD Causes Substantial Suffering
People with BDD spend a lot of time thinking about their perceived appearance flaws -- on average, for 3-8 hours a day. Most find that these thoughts about their body are difficult to resist or control. They’d like to stop thinking them but can’t. This is one of the things that makes BDD a psychiatric disorder and differentiates BDD from the more "normal" appearance concerns that many people experience.

In addition, the appearance concerns cause significant emotional distress (for example, anxiety or depression) or significant problems in social functioning and/or work or school functioning. Typically BDD causes both emotional distress and problems in functioning.  

Although some people with BDD manage to function well despite their distress, most find that their appearance concerns cause problems for them. They may find it hard to concentrate on their job or school work, which may suffer. Relationship problems are common. People with BDD generally have very poor quality of life. They may have few friends, avoid dating, miss school or work, and feel very self-conscious in social situations because of their worries about how they look.

It’s often hard for other people to realize how much suffering BDD can cause. After all, to them the BDD sufferer looks fine. But BDD is an unusually distressing disorder. People with BDD are very upset by their thoughts that they look abnormal. Most people with BDD feel depressed and anxious. They also typically feel very isolated from other people and think that other people are making fun of them because of how they look. Some people abuse alcohol or drugs in an attempt to diminish the distress their BDD causes. Many feel that life isn’t worth living. Some even commit suicide.

How BDD Can Affect People’s Lives
In our research, we have found that, on average, people with BDD have poor functioning and report that their quality of life is very poor – in other words, it’s hard for them to enjoy things or get satisfaction out of life. The more severe a person’s BDD symptoms are, the poorer their functioning and quality of life tend to be. Some people are able to compensate reasonably well, doing well enough that others can’t tell that anything is wrong. Even when functioning is severely impaired, others may know that something is wrong but may not realize that BDD is the cause. Others, however, function very poorly because of their BDD symptoms.

BDD almost always causes some problems with relationships and social activities. People with BDD are often reluctant to participate in activities with other people. They typically feel embarrassed to be seen, so they feel anxious and self-conscious in social situations. BDD can interfere with friendships, dating and other relationships, which may be strained or avoided altogether, and intimacy is often forgone. Many people with BDD are very isolated from other people.

People with BDD may find it harder to do their job, schoolwork, or household duties. They often miss days of work or school because of their body image concerns, or even avoid work or school entirely. Many withdraw from the world to at least some extent.

Here are some of the more common areas in which BDD causes problems for people with this disorder:

• Spending time with friends
• Dating
• Intimate relationships
• Attending social functions and events
• Doing things with one’s family
• Going to school or work each day, or functioning as a homemaker
• Being on time for school, work, or other activities
• Missing school or work
• Productivity at school, work, or with housework
• Doing homework or maintaining grades
• Maintaining a household, doing errands, going shopping
• Other daily activities

In addition, depression and anxiety are common. Accidents and even violent behavior can occur. Occasionally, people do surgery on themselves, with disastrous results. Some people contemplate - and attempt - suicide.

BDD Severity
The severity of BDD varies, ranging from relatively mild to life-threatening. Some people experience manageable distress and are able to function well, although not up to their potential. Others find that this disorder ruins their life. Some are completely housebound, sometimes for many years, because they feel too ugly to be seen and are so depressed over how they look.  Some people with BDD are so distressed over their appearance that they kill themselves.

In this way, BDD is like other medical and psychiatric problems. For example, severe diabetes can lead to hospitalization and serious medical complications such as blindness, whereas people with a milder form can remain active and productive. BDD is similar. When it’s milder, it’s more manageable and even shades into normality. When it’s severe, it’s as crippling as any serious psychiatric or medical illness.

Some people who’ve heard or read about a particularly severe case of BDD may think they don’t have the disorder because their symptoms “aren’t that bad.” Others, with severe BDD, may think they don’t have BDD because their symptoms are so severe they think there couldn’t possibly be other people who have the same problem, who suffer as much as they do. But although no one with BDD has exactly the same experience as anyone else with BDD, all people with BDD have important things in common. The severity may differ, the body areas may differ, the behaviors may differ somewhat from person to person, but everyone with BDD is distressed or doesn’t function as well as they might because of their preoccupation with some aspect of how they look.

Suicidal Thinking and Behavior in People with BDD
While much more research is needed to determine how common suicidal thinking and behavior are in people with BDD, what we currently know is very concerning. About 80% of people with BDD report that they’ve had suicidal thinking at some point in their lives – thinking that life isn’t worth living or that they’d rather be dead, or having thoughts of killing themselves. Many people attribute this thinking primarily to the suffering that their BDD causes. About 24% to 28% of people with BDD have attempted suicide.

Most concerning, people with BDD appear to have a very high rate of completed suicide. While research on this critically important issue is still very limited, the suicide rate among people with BDD appears markedly high: about 45 times higher than in the general population. This sobering finding underscores the need for better diagnosis and treatment of BDD, and the need for more research on BDD.

We are currently doing a study, funded by the American Foundation for Suicide Prevention, to better understand the risk and predictors of suicidal thinking and behavior in people with BDD. We hope that this research will ultimately lead to better identification, treatment, and even prevention of suicide in people with BDD. The good news is that with the right treatment (see below), suicidality in people with BDD often diminishes.

Melissa's and Craig’s Experiences with BDD

Melissa’s Experience: Melissa is 17 years old. At around the age of 12, she started worrying about her appearance. This worry got worse and worse until she was preoccupied with how she looked, thinking about this for hours a day. She was obsessed with what she considered her excessively broad and long nose, overly round face, low jaw line, wrong eye color, acne, small breasts, unshapely calves, and large waist and thighs. Everyone else thought that Melissa was attractive, but she didn’t believe this. In fact, she misinterpreted glances from other people as confirmation that she was ugly. She’d always been an excellent student who was active in school activities and had many friends, but because of her appearance concerns she became increasingly withdrawn from others, stopped dating, and didn’t go to school on days she thought she looked especially ugly.

Craig’s Experience: Craig is a 35-year-old divorced man. He is intensely preoccupied with freckles and very slight facial acne that he thinks are “hideously ugly” and “visible to the whole world, as if a neon sign was pointing at them.” In his words, he “obsesses” about his acne and freckles for “24 hours a day.” Craig also spends hours each day checking mirrors and compulsively picking his skin in the hope that he “won’t look so bad.” However, these behaviors usually make him feel worse. He suffers intense distress and shame over the physical flaws that he perceives.

As a result of his appearance concerns, Craig became very depressed and drank alcohol excessively. He also did a poor job at work, because he was so distracted by his appearance obsessions and compulsive mirror checking, and because he didn’t want other people to see him and avoided them. He then started spending entire weekends in bed and didn’t even leave his house because he felt too ugly to be seen. Craig had thoughts about suicide and felt so tormented that he would recklessly run across streets in the hope that a car would hit him.

BDD Affects People of All Ages
BDD can affect people at any age. It can occur in adolescents and even young children. Many adults with BDD have surprisingly vivid memories of their early symptoms. We aren’t certain how common BDD is in children and adolescents (because so little research has been done); however, most people with BDD appear to develop it before age 18, usually during the early teenage years.

BDD’s characteristics in adolescents appear very similar to those in adults. Like adults, children and adolescents have distressing, time-consuming preoccupations that can focus on any body area.

BDD in children and adolescents can cause problems in functioning. This can include: poor grades, dropping out of school, withdrawing from family and friends, becoming housebound, and even suicide attempts. It’s important to recognize BDD in this age group, as normal development can be derailed by these symptoms. Long-term academic, occupational, and social problems can develop if BDD isn’t treated early.

It’s important to realize that not all appearance concerns in adolescents are normal or simply a passing “phase” – sometimes they’re BDD. Please see Medication Study for Children and Adolescents for information about a treatment study that we are currently doing, in which we’re evaluating a promising treatment for children and adolescents with BDD.

 

BDD Affects Both Males and Females
BDD appears to affect about an equal number of females and males, or perhaps somewhat more females than males (more research is needed to determine this with certainty). It’s clear, however, that BDD affects both women and men. Males and females with BDD appear to have more similarities than differences in terms of demographic factors (such as age), characteristics of BDD, and co-occurring disorders (such as depression).

However, there also appear to be some interesting differences between men and women with BDD. Males are more likely than females to be unmarried and to be preoccupied with their genitals or thinning hair. They’re also more likely to think that their body build is too small, skinny, or not muscular enough. In addition, males are more likely to have a problem with alcohol or drugs. Females appear more likely to be preoccupied with excessive body hair and with their hips, breasts, legs, or weight (thinking they’re too large and fat). They’re also more likely than males to pick their skin, check mirrors, and use camouflaging (e.g., with makeup), and they’re more likely to have a coexisting eating disorder.

 

BDD Affects People from A Variety of Races, Cultures, Walks of Life
BDD can affect people of any race or ethnicity, and it occurs around the world— both Western and non-Western cultures. Indeed, BDD is well known and recognized in certain countries—Japan, for example—but has escaped adequate recognition in many others, including, until recently, the United States. People with BDD have been described in virtually all the European countries, Australia, the former Soviet Union, the Middle East, Canada, many South American countries, China, Japan, and Africa. People with BDD come from a variety of backgrounds, different socioeconomic groups, and with varying levels of education. In other words, BDD can affect anyone.
 

How BDD Differs from Normal Appearance Concerns
BDD is different in some ways from normal appearance concerns. It differs in several ways (also see descriptions above):
 

• The person with BDD is preoccupied with their perceived appearance flaw. They worry about their appearance for at least an hour a day. The average time spent per day is 3 to 8 hours.
• The appearance concerns cause significant emotional distress – for example, feelings of depression, anxiety, or even thoughts of suicide.
• The appearance concerns interfere with normal functioning (for example, at work, school, with friends, other social situations, or other activities).

BDD Isn’t Vanity
BDD is a serious and treatable mental illness. BDD isn’t vanity. Most people with BDD just want to look normal.

People with BDD often suffer because they feel selfish and vain – even though they aren’t. Rather than a problem of excessive vanity, BDD is an illness -- like depression or anorexia nervosa or heart disease. It has a life of its own and doesn’t reflect moral weakness. Sometimes people with BDD are told to just stop worrying about how they look. If only it were this simple! This approach usually doesn’t help. Instead, it’s important to recognize that BDD is a disorder that often gets better with the right treatment.
 

BDD Is Relatively Common
Researchers have found that about 1% to 2% of people in the general population have BDD. This translates into many millions of people in the United States alone. Some research studies, however, have reported much higher rates of BDD. BDD is also fairly common in people who receive dermatologic treatment or cosmetic surgery. Still, we need much larger and more scientifically rigorous studies to more precisely determine how common BDD is, in both the United States and in other countries. But in the meantime, these study results indicate that BDD is probably as common as many other well-known psychiatric disorders, such as schizophrenia, bipolar disorder, panic disorder, and anorexia nervosa.
 

BDD Is Often Under-recognized, Under-diagnosed, and Misdiagnosed
Even though BDD appears relatively common, it usually goes unrecognized and undiagnosed.

BDD often goes unrecognized because of …

• Secrecy and shame: Many people with BDD don't reveal their symptoms to people because they’re too embarrassed and don’t want to be considered vain– or because they don’t want to draw more attention to the flaws they perceive by discussing them with other people.
• Lack of familiarity with BDD: Many people, including health professionals, aren’t aware that BDD is a known mental illness that often responds to the right psychiatric treatment.
• Trivialization: BDD is easily trivialized because it can be confused with vanity, even though it is a serious, distressing, and sometimes life-threatening condition.
• Pursuit of cosmetic treatment: Many people with BDD see dermatologists, plastic surgeons, and other physicians rather than mental health professionals. BDD often goes undiagnosed in these settings. These treatments usually aren’t helpful and may even make the appearance concerns worse.
• Misdiagnosis: People with BDD may also have depression, social anxiety, low self-esteem, or other symptoms that may be less embarrassing to discuss. Thus, if they don’t mention their appearance concerns specifically, BDD can be misdiagnosed as another psychiatric disorder. The table below lists some of the disorders that are commonly confused with BDD. Although people with BDD often have depression, social phobia, or OCD in addition to BDD, it’s important that both those disorders and BDD be diagnosed and targeted in treatment. As best we know, effective treatment for BDD differs in some ways from treatments for other psychiatric disorders. If BDD isn’t identified and targeted separately in treatment, treatment may be ineffective.

Screening Questions for BDD
How do you know whether you or someone you know has BDD? For the time being, psychiatric diagnoses are made primarily by asking questions that ascertain that the disorder's symptoms are present. Dr. Phillips has developed several “diagnostic instruments” (also known as scales or questionnaires) for such purposes. We have included a self-report form, the BDDQ, which can serve as a screening instrument for BDD. For the adolescent version, please click BDDQ Adolescent.
The BDDQ screens for the presence of BDD, meaning that it can suggest that BDD is present, but it can't necessarily give a definitive diagnosis. The diagnosis is ideally determined by a trained clinician in a face-to-face interview. The BDDQ and other diagnostic instruments are also included in Dr. Phillips' book: “The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder.”  

Clues to BDD's Presence
Here are some additional clues that you or a loved one may have BDD. Not everyone with BDD does all of the things in this list, and they aren’t required for the diagnosis. However, many people do one of more of the following, which may be a clue that BDD may be present:

• Frequently comparing your appearance with that of others; scrutinizing the appearance of others
• Often checking your appearance in mirrors or other reflecting surfaces
• Camouflaging the perceived defect with clothing, makeup, a hat, your hand, your posture, or in some other way
• Seeking surgery, dermatological treatment, or other non-psychiatric medical treatment for appearance concerns when doctors or other people have said your flaws are minimal or such treatment isn't necessary
• Questioning: seeking reassurance about the flaw or attempting to convince others of its ugliness
• Excessive grooming (for example, combing hair, shaving, removing or cutting hair, applying makeup)
• Avoiding mirrors
• Frequently touching the perceived defect to check its shape, size, or some other characteristic
• Picking your skin to try to improve its appearance
• Measuring the disliked body part
• Excessively reading about the defective body part and how to make it look better
• Exercising or dieting excessively
• Using drugs (for example, anabolic steroids) to become more muscular or lose fat
• Changing your clothes a lot to try to find something that makes you look better
• Avoiding social situations in which the perceived defect might be exposed
• Feeling very anxious and self-conscious around other people because of the perceived defect

What Causes BDD?
We don’t really know the answer to this question, but it’s likely that BDD results from a combination of factors: genetic makeup and neurobiological factors as well as environmental factors, such as life events and our society’s focus on appearance. The figure below illustrates this theory and shows a possible pathway to the development of BDD. With enough of these risk factors, the disorder may develop. The factors that contribute to BDD’s development may differ somewhat for different people.

Click the following to view the figure on the development of BDD.

At this time, theories about what causes BDD are largely speculative, although recent research findings do give us some important clues. We need much more scientific research on this important question, because understanding what causes BDD will help us develop even more effective treatments and perhaps even prevent this serious mental illness from occurring.