Body dysmorphic disorder

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Introduction         
What is body dysmorphic disorder?
When does a concern with appearance become BDD? 
What are the most common areas of the body involved in BDD?
How common is BDD? 
When does BDD begin?
How severe a condition is BDD? 
What causes BDD?
Are people with BDD vain?
How is the condition likely to progress?
What treatments are available?
Cognitive behaviour therapy
Antidepressant medication
Finding help
Further reading 
Useful contacts

  
Introduction

This factsheet is for people living with body dysmorphic disorder (BDD), their families and friends, and for anyone else who is interested in BDD. We hope that it answers some of the most common questions about the nature and symptoms of BDD and the ways the condition may be treated.

What is body dysmorphic disorder?

Body dysmorphic disorder (BDD) is a body image problem. It is defined as an individual’s preoccupation with one or more perceived defects in his or her appearance. For the diagnosis to be BDD, the preoccupation must also cause significant distress.

The older term for BDD is “dysmorphophobia” which is sometimes still used in the UK. The media sometimes refer to BDD as "Imagined Ugliness Syndrome". This isn't particularly helpful, as the perceived ugliness is very real to the individual concerned. Some people with BDD will acknowledge that their distress may be an extreme response to the defect concerned. Others are so firmly convinced about their defect that they are regarded as having a delusion. Whatever the degree of insight into their condition, people with BDD usually realise that others believe their appearance to be "normal" and have been told so many times.

When does a concern with appearance become BDD?

Many people are concerned to a greater or lesser degree with some aspect of their appearance, but for a person to receive a diagnosis of BDD the preoccupation must cause significant distress or impairment in at least one area of their life. For example, someone living with BDD may avoid a range of social situations because of the anxiety and discomfort these situations create. Alternatively, a person may enter such situations but remain very self-conscious. He or she may camouflage themselves excessively to hide the perceived defect by using heavy make-up, brushing their hair in a particular way, changing their posture, or wearing heavy clothes. They may spend several hours a day thinking about their perceived defect and asking themselves questions that cannot be answered, such as “why was I born this way?”

People with BDD may feel compelled to repeat frequently certain time-consuming behaviours such as:

• checking their appearance in a mirror or reflective surface
• seeking reassurance about their appearance
• checking by feeling their skin with their fingers
• cutting or combing their hair to make it "just so"
• picking their skin to make it smooth
• comparing themselves against models in magazines or people in the street.
  

What are the most common areas of the body involved in BDD?

Most people living with BDD are preoccupied with some aspect of their face and many believe that they have multiple defects. The most common complaints (in descending order) concern the nose, the hair, the skin, the eyes, the chin, the lips or the overall body build. People living with BDD may complain of a lack of symmetry. They may feel that something is too big or too small or, that it is out of proportion to the rest of the body. Any part of the body may be involved in BDD, including the breasts or genitals.

How common is BDD?

It is not known what proportion of the population have experience of BDD. It is recognised to be a hidden disorder as many people with BDD are too ashamed to reveal their problem. One survey has estimated that it affects about one per cent of the population. Mild BDD is probably more common in women and in adolescents.

When does BDD begin?

BDD usually develops in adolescence, a time when people are most sensitive about their appearance. However, many people live with BDD for many years before seeking help. When they do seek help through mental health professionals, they often do so with other symptoms such as depression, social anxiety or obsessive compulsive disorder and do not reveal their real concerns.

How severe a condition is BDD?

As is the case for other mental health conditions, such as depression, BDD varies in the type and severity of its symptoms from person to person. Many people living with BDD experience difficulties in relationships with family members and friends due to the behaviours and feelings related to their condition. The symptoms of BDD can also be barriers to education, employment and leisure activities. As a result, people living with BDD are likely to experience social isolation. Many have reported feelings of shame, guilt and loneliness.

People living with BDD are usually demoralised. Many are clinically depressed or have social phobia. In extreme cases, they may be unable to leave their homes, and experience suicidal feelings. Some resort to cosmetic surgery (including dangerous and painful ‘DIY’ surgery) that can cause high levels of distress and is unlikely to improve their symptoms.

What causes BDD?

There has been very little research into BDD. In general terms, there are two different theories - one biological and the other psychological. A biological explanation would emphasise that some people’s genetic make-up may make it more likely for them to develop BDD. Certain stresses or life events such as teasing or abuse, especially during adolescence, may trigger the condition. Once the disorder has developed, there may be a chemical imbalance of serotonin or other chemicals in the brain.

A psychological explanation would emphasise a person’s low self-esteem and the way they judge themselves almost exclusively by their appearance. They may fear being alone and isolated all their life, or seen as worthless if they cannot correct their perceived defect [the aspect of their appearance that causes distress]. They demand perfection, or an impossible ideal, in their appearance. Once the disorder has developed, it is then maintained by excessive self-focused attention and behaviour such as checking the perceived defect, making comparisons with other people, avoiding social situations and seeking reassurance.

Are people with BDD vain?

No. People living with BDD believe themselves to be ugly or defective. They tend to be very secretive and reluctant to seek help because they are afraid that others will think them vain or self-obsessed.

How is the condition likely to progress?

Many individuals with experience of BDD have repeatedly sought treatment from dermatologists or cosmetic surgeons with little satisfaction before finally accepting psychiatric or psychological help. Treatment can improve the outcome of the condition for most people. 

Some people living with BDD may function reasonably well for a time and then relapse. Others may remain chronically unwell. Research on outcome without therapy is not known but it is thought that symptoms persist for many years.

What treatments are available?

There has been very little research on the treatment of BDD. However, from the evidence available, the National Institute for Clinical Excellence (NICE) has drawn up guidelines to help healthcare professionals to treat BDD.

The NICE guidelines state that in the first instance, adults and adolescents experiencing BDD should be offered cognitive behaviour therapy (CBT) and be given self-help materials. If this is not effective, they should be offered the choice of more intensive CBT or a course of antidepressants from the serotonin specific reuptake inhibitors (SSRI) group, or a combination of the two.

Although based on the best evidence available, the treatments recommended in the NICE guidelines are not appropriate for everyone. As is the case for all mental health problems, the person may be able to manage and recover from his or her condition with the help of other talking therapies, or by using the information available to develop their own solutions.

Cognitive behaviour therapy

Cognitive behaviour therapy (CBT) is a combination of psychotherapy and behaviour therapy. It is aimed at helping a person to challenge the thoughts, images, beliefs and attitudes (their cognitive processes) that have negative effects on their feelings and behaviour.

Through therapy, the person develops new ways of thinking and new ways of coping with emotional difficulties. Successful therapy results in a person choosing to give up old self-destructive forms of behaviour and experiencing improvements in mood and emotional wellbeing.

The focal points of CBT for people with body dysmorphic disorder are attitudes and beliefs about physical appearance in general, and the person’s perceived defect in particular.

During therapy, people learn alternative ways of thinking, including ways of directing their attention away from themselves. They learn to give up comparing their appearance with others and dwelling upon their perceived defect. They confront their fears without their camouflage and learn to stop rituals such as checking and excessive grooming. The adverse side effect of the treatment is the anxiety that occurs in the short term. However, facing up to the fear is likely to get easier over time and the anxiety gradually subsides.

If you would like more detailed information about CBT, Mind has produced booklets on this and related topics. See ‘Further reading’ for details.

Antidepressant medication

Serotonin specific reuptake inhibitors (SSRI) antidepressants have been available in the UK since 1989. The most commonly prescribed SSRIs are fluoxetine (brand name Prozac) and paroxetine (brand name Seroxat).

Depression is thought to be associated with lower levels of certain chemicals in the brain, including the neurotransmitter serotonin. SSRIs alleviate the symptoms depression by blocking the reuptake of the serotonin into the nerve cell that released it, thereby prolonging its action.

Since their availability in the UK, SSRIs have been prescribed for other mental health conditions and have had some success in treating people experiencing BDD. However, NICE points out that the evidence for SSRIs’ success in treating BDD is limited and less certain than for other mental health problems. Also, it is not known how SSRIs work on the brain to alleviate symptoms of BDD.

According to NICE guidelines, if a person is prescribed an SSRI, the drug may need to be taken daily for at least 12 weeks to determine its effectiveness. The guidelines state that if the drug is effective, then a person will need to remain on it for at least 12 months, to allow for further improvements and to prevent a relapse. When the treatment is complete, or the person chooses to stop taking the drug, the dose should be reduced gradually to minimise the possibility of withdrawal symptoms.

If you would like more detailed information about SSRIs, see the Mind booklet, Making sense of antidepressants.

Finding help

If you think you may be experiencing BDD and want to help yourself to cope with and recover from the condition, there are many resources available that can help you. Organisations, such as OCD Action, can give advice, information and support. See ‘Useful contacts’.

Having high quality, reliable information will help you to assess your situation and choose your next course of action. If you are living with BDD, it will help you feel more confident and less anxious as you learn that you are not alone and the condition is treatable.

Using a self-help book, you may be able to manage the condition yourself and gradually work towards recovery. Alternatively, you may find the self-help approach useful but need some guidance and support in putting it into practice. In that case, it is worth finding a counsellor or therapist who has the same approach as that of the self-help programme. This will probably mean looking for a private therapist through the British Association of Behavioural and Cognitive Psychotherapy (BABCP) (see ‘Useful contacts’). Some therapists offer sliding rates, depending on a person’s ability to pay.

Counselling may also be available at your GP’s practice or through voluntary organisations in your area. For contact details of voluntary organisations, call MindinfoLine or look in your phone directory.

Many people living with BDD find it useful to join self-help group. Meeting others with the condition can help overcome feelings of shame and isolation. Self-help groups can provide moral support and useful information, including practical tips on how to cope with BDD in daily life. To find out if there are any self-help groups in your area, contact MindinfoLine or any of the organisations listed in ‘Useful contacts’.

Another option favoured by many people is Internet-based self-help. The Internet permits anonymity and physical invisibility. For reliable, high quality electronic resources, including virtual self-help groups and discussion forums, see ‘Useful contacts’.

If you feel that you, or a friend or relative, may need medical help for BDD, the first step, is to make an appointment with your GP. He or she may suggest that you first try to treat your problem within the GP’s practice, at what is called ‘primary care’ level. This is likely to consist of talking through the issues with your GP and, if you choose to do so, taking antidepressant medication. If your GP’s practice provides counselling, you may be referred to this service, especially if the counselling is based on the CBT approach.

If your problems cannot be treated effectively within the GP’s practice, your GP can refer you to your local Community Mental Health Team (CMHT) for an assessment and further treatment. All NHS mental health services should be able to provide CBT, though the time you have to wait for treatment varies across health authorities in England and Wales.

If treatment within your local area has proved unsuccessful, your Community Mental Health Team can refer you to a specialist clinic for BDD. In the UK, there is only one NHS specialist clinic for BDD, based at the Maudsley Hospital in south London.

Many private hospitals run BDD specialist services and may accept NHS referrals. Due to the high national demand for this service, you will face long waiting lists from NHS referrals ? approximately 13 weeks for a first assessment and 9 to 12 months until the start of treatment.

During this waiting period, it is important to take advantage of all available resources that can help you to understand and manage your condition and provide support through difficult times. Your GP, other practice staff (such as counsellors and nurses) and your Community Mental Health Team can be valuable in supporting you during this time.

Further reading

Mind booklets
Making sense of antidepressants, Mind, 2006.
Making sense of cognitive behaviour therapy, Mind, 2004.
Making sense of counselling, Mind, 2004.
Mind rights guide 3: Consent to treatment, Mind, 2004.
Understanding anxiety, Mind, 2005.
Understanding depression, Mind, 2006.
Understanding obsessive compulsive disorder (OCD), Mind, 2004.
Understanding talking treatments, Mind, 2005.

Mind factsheets
A brief guide to who’s who in mental health, Mind Information Unit, 2005.

Other resources
National Institute for Clinical Excellence (NICE) November 2005, Obsessive compulsive disorder: core interventions in the treatment of obsessive compulsive disorder and body dysmorphic disorder, NICE.
Philips, K.A., 2005, The broken mirror: understanding and treating body dysmorphic disorder, Oxford University Press.

Useful contacts

BDD Central
website: www.bddcentral.com
A comprehensive website for BDD, including discussion forums and an online support group.

British Association of Behavioural and Cognitive psychotherapy (BABCP)
The Globe Centre
PO Box 9
Acccrington BB5 0XB
tel: 01254 875277
email: babcp@babcp.com
website: www.babcp.com
For help finding a therapist.

Centre for Anxiety Disorders and Trauma
South London and Maudsley Trust
99 Denmark Hill
London SE5 8AZ
tel: 020 7919 2101
email: anxietydisordersunit@slam.nhs.uk
A national specialist clinic and residential unit for BDD run by Dr David Veale.

First Steps to Freedom
24 Neville Road
Chichester
West Sussex PO19 3LX
tel: 0845 120 2916
email: first.steps@btconnect.com
website: www.first-steps.org
A charity that aims to give practical help to people with obsessions, compulsions and phobias. Services include a telephone helpline, telephone self-help groups and telephone counselling and befriending.

National Phobics Society
Zion Community Resource Centre
339 Stretford Road
Hulme
Manchester M15 4ZY
tel: 0870 122 2325
email: info@phobics-society.org.uk
website: www.phobics-society.org.uk
The leading UK charity dealing with anxiety and phobias. Services include email support.

National Institute of Clinical Excellence (NICE)
MidCity Place
71 High Holborn
London WC1V 6NA
tel: 020 7067 5800
email: nice@nice.org.uk
web: www.nice.org.uk
Independent organisation providing guidance on the promotion of good health and the treatment of ill health.

OCD Action
Aberdeen Studios
Aberdeen Centre
22-24 Highbury Grove
Highbury
London N5 2EA
tel: 020 7226 4000
email: info@ocdaction.org.uk
website: www.ocdaction.org.uk
The leading national charity focused on obsessive compulsive and related disorders including as BDD. Services include self-help groups and an online discussion forum.

This factsheet was written Dr David Veale MD, FRCPsych, August 2005, and updated by Rachael Twomey, Mind Information Unit, May 2006.