How Body Dysmorphic Disorder Works

By: Jessika Toothman  | 
People with body dysmorphic disorder don't see their true reflection. Instead, they see major flaws and defects, despite other people's reassurances.
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Key Takeaways

  • Body dysmorphic disorder (BDD) is a mental health condition characterized by obsessive preoccupation with perceived flaws in physical appearance.
  • Psychological and emotional impacts include anxiety, depression and impaired social functioning.
  • Treatment options such as therapy and medication aim at managing symptoms and improving quality of life.

Many of us have those moments when we take a look in the mirror and wish for things to be a little different -- perhaps a firmer body, clearer skin or straighter teeth. But what if those moments lasted for months or even years?

Some people are so preoccupied with what they perceive as defects that they spend hours obsessing in the mirror every day. They analyze themselves and see hideous monsters staring back. These people compare themselves to others and constantly ask for reassurance about their appearances. They mask or camouflage their features so people can't see their flaws. If they feel particularly revolting, they might skip classes or work, or they may permanently remain within their homes to avoid anyone's glance. Someone may resort to a permanent option, like cosmetic surgery or suicide, to escape self-destructive thoughts.


Someone exhibiting these behaviors may have a psychiatric disorder known as body dysmorphic disorder (BDD), sometimes referred to as dysmorphophobia. Characterized by a preoccupation with a physical flaw -- whether imaginary or exaggerated -- BDD frequently occurs along with other psychiatric disorders, such as obsessive-compulsive disorder, anorexia nervosa and clinical depression. These disorders, along with other factors discussed later in this article, frequently cause BDD to be misdiagnosed or undiagnosed.

BDD, like many medical conditions, runs from mild to severe. Some people can accept that even though they may see their defects as obvious and unattractive, they know that they probably look "normal". However, others with BDD really believe that they appear to others as they do to themselves, that the defects they see in the mirror truly exist. Experts refer to this condition as delusional BDD, when people are certain that their perceptions of themselves are correct, despite evidence to the contrary.

BDD does not discriminate between class, race, ethnicity or gender [source: Butler Hospital]. People with the disorder often abhor more than one physical feature, most commonly the skin, hair, nose and other body parts.

So what are the behaviors of someone dealing with body dysmorphic disorder? BDD exhibits many obsessive-compulsive traits, and the next page will discuss the disorder in more detail.


Symptoms of Body Dysmorphic Disorder

Rubberball/Rubberball Productions/ Getty Images Someone with BDD may obsessively check the mirror to view his or her "flaws."
Rubberball/Rubberball Productions/Getty Images

First, let's go over some typical behaviors of a person living with BDD and some of the actions they might take before seeking treatment. Keep in mind, these behaviors are usually compulsive, meaning that even though the person may want to stop, he or she simply must repeat the behaviors. Also, while the person may at first perform these behaviors or rituals in order to feel better, the urge to continue can intensify and become a source of even greater anxiety and unhappiness.

Common symptoms and signs of BDD may include:


  • Excessively checking appearance in mirrors or other reflective surfaces
  • Constantly comparing appearance to other people
  • Picking at or otherwise attempting to fix the imagined flaw, such as through excessive grooming
  • Measuring, touching or checking the supposed defect
  • Changing clothes frequently
  • Refusing to be photographed and destroying existing photographs
  • Constantly asking loved ones for reassurance
  • Camouflaging, masking or disguising the perceived flaw with heavy make-up, bulky clothing, hats or posture
  • Excessively dieting and exercising
  • Feeling anxiety and fear when around other people
  • Avoiding mirrors or reflective surfaces
  • Experiencing suicidal thoughts

As part of the condition, people with BDD might:

  • Seek medical advice and treatment from doctors, cosmetic surgeons and dentists in an effort to fix the supposed physical defect
  • Perform surgeries on themselves
  • Avoid social situations
  • Isolate themselves from other people
  • Harm themselves
  • Attempt suicide

BDD can lead people to drop out of school or quit their jobs and become housebound. Some may even isolate themselves in a room and allow others to see them only when they are completely masked or veiled. Many people with BDD -- around 80 percent -- have considered suicide, and about 25 percent of people with the disorder have attempted suicide [source: Butler Hospital].

The disorder typically begins in adolescence. However, some people start to exhibit symptoms in childhood, and others may not develop the disorder until reaching adulthood. Researchers are exploring different avenues as they search for a direct cause of BDD, examining possible biological, psychological and environmental factors. So far, those efforts have not established a direct cause, and many in the field believe BDD's onset to be complex, with a number of possible contributing factors. Let's take a look at some of the possible factors in the next two pages.


Biological Causes of Body Dysmorphic Disorder

One of the possible factors involved with BDD is an imbalance of serotonin levels in the brain. This imbalance resembles the serotonin levels of someone with depression.
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In the arena of biological causes, researchers have begun looking for differences between the brains of healthy people and people with BDD. One study conducted by researchers at the University of California, Los Angeles shows that people with BDD may process visual information differently than people without the disorder.

Researchers showed 25 people, half with BDD and half without the disorder, three different images of faces in high, regular and low resolutions. MRI results showed that participants with BDD used the left sides of their brains -- the analytical side -- to process all three images. The other participants used their brains' left hemispheres for only the high-resolution images. This could mean the minds of people with BDD strive to acutely process visual details, even when there aren't any to process. This might be why they can see flaws in themselves, even when those flaws might not exist [source: Feusner].


Another biological factor under consideration is that people with BDD seem to have a chemical imbalance of the neurotransmitter serotonin, because they often respond well to the SSRI (selective serotonin reuptake inhibitors) class of antidepressants. Serotonin is one of the chemicals in the brain that transmits signals between the billions of neurons that constantly communicate with each other, allowing the body to think and act. Serotonin (produced in each individual neuron from an amino acid called tryptophan) is typically active in the regions of the brain responsible for emotions, sleeping and sensory perception.

During interactions between neurons, serotonin is released from the end of the first (presynaptic) neuron and picked up by the second (postsynaptic) neuron. Not all of the serotonin will be taken into the second neuron. The remainder, along with what's released from the postsynaptic neuron after use, floats within the space between the two -- called the synaptic cleft -- until enzymes destroy it. Some of the released serotonin is also reabsorbed by the first neuron.

SSRIs decrease the rate at which the serotonin is taken back into the presynaptic neuron. This causes more serotonin to linger in the synaptic cleft, also increasing the message's strength as it passes to the postsynaptic neuron. This leads to a more ideal chemical balance and seems to have a positive effect on mood. SSRI drugs include Prozac, Paxil, Zoloft and Celexa. For a more detailed explanation about serotonin and antidepressants, read How Antidepressants Work.

While doctors know that differences in brain and neurotransmitter functions exist, they don't know whether BDD causes the differences or if the differences cause BDD. However, as researchers continue to study those discrepancies, they learn valuable information about specific areas of the brain that might be targeted in BDD treatment.

But researchers are looking beyond biological links, as many cultural and psychological factors appear to influence BDD. The next section will examine how culture and personal life-events can determine the way we view ourselves.


Cultural and Psychological Causes of Body Dysmorphic Disorder

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Cultural factors, such as a societal premium on image and beauty, may contribute to BDD. Muscle dysmorphia is an example of this theory. Proponents believe perceived social pressures on men to be big and buff -- through means such as advertising and the media -- could cause a man to develop BDD. He might obsess about his size and begin to exercise excessively to emulate the so-called perfect bodies of some models and celebrities.

Researchers are discussing the possible links between pop culture and the prevalence of people with BDD resorting to cosmetic surgeries and treatments for relief. This theory is easy to spot; one only need glance at the local grocery store's magazine rack and view which tabloids feature the latest celebrities to go under the knife. Many people with BDD aren't even seeking to look as glamorous as those celebrities; they just want to resemble what they deem as normal.


However, procedures like plastic surgery do not address the root of the problem. Patients with BDD rarely report being satisfied with the results and may become obsessed, depressed or suicidal after procedures, or they may simply shift their obsession to another part of their body. Some may become violent or threaten legal action against their physicians and surgeons. In some instances, obsession turns into anxiety that the perceived defect will return.

Critics of these socio-cultural theories point out that BDD was documented long before mass media reached such pervasive levels and say researchers should look to other causes of BDD development. Dr. Katharine Phillips, one of the leading experts of the disorder, told The New York Times that researchers have documented patients with BDD as far back as the late 1800s [source: Wartik].

Other possible inducements of BDD could be childhood trauma, abuse or neglect. Researchers are attempting to determine whether frequent instances of abuse or neglect as children -- especially emotional neglect -- could be linked to the development of BDD. In one study, 78 percent of participants reported some type of maltreatment during their childhoods (although the study didn't determine whether the maltreatment occurred prior to the onset of BDD). Forty percent of respondents said the maltreatment was severe [source: Didie].

In some personal accounts, people who have reached a level of recovery in their battles against BDD believe that childhood traumas damaged their self-confidence and personal identities, contributing to their development of BDD. These traumas might include feelings of abandonment, victimization or depression over the death of a loved one.

Now that we know what it is like to have BDD and the factors that influence the disorder's development, let's look at the ways it can be treated.


Treatments for Body Dysmorphic Disorder

Researchers believe BDD affects about 1 to 2 percent of the general population [source: Butler Hospital]. However, they say more studies are needed to determine a more accurate estimate as they suspect the percentage may be higher.

BDD is often misdiagnosed or undiagnosed because of patients' reluctance to reveal their problem due to a number of causes:


  • They worry that they will be viewed as superficial or vain for being so concerned with their appearance.
  • They are so ashamed of the flaws they believe they have that they are reluctant to discuss them with a therapist.
  • They believe their problems can be addressed only through physical treatments and may not realize the disorder's psychological roots.
  • They often have another psychiatric disorder that they're more willing to discuss during therapy; this other disorder then becomes the primary diagnosis.

However, once BDD has been discussed, it's a relatively easy disorder to diagnose, usually with a simple questionnaire. Currently, there are two main treatments patients typically take, which can be used independently or as a combination.

The most common treatment method is to prescribe an SSRI which, as described earlier, increases the amount of serotonin in the brain, improving mood and decreasing BDD symptoms. SSRIs are also helpful because they treat a number of other disorders people might have in conjunction with BDD.

Another way to treat BDD is cognitive-behavioral therapy (CBT), a general method of psychotherapy first developed in the 1950s, which encompasses several approaches. CBT focuses on the concept that a person's thoughts are at the root of his or her feelings and behaviors (as opposed to outside influences). CBT also helps people learn new ways to think and react to those outside influences through an educational approach [source: The National Association of Cognitive-Behavioral Therapists].

CBT can give patients a series of goals so they begin to learn more appropriate behaviors and develop mechanisms to cope in difficult situations. This method of BDD therapy is preferred for its effectiveness and relative brevity. When patients adhere to homework assignments, CBT can help them achieve relief within months.

For more information about body dysmorphic disorder, take a look at the links on the next page.


Frequently Asked Questions

Can body dysmorphic disorder (BDD) coexist with other mental health conditions?
Yes, individuals with BDD may also experience co-occurring mental health conditions such as depression, anxiety disorders, obsessive-compulsive disorder (OCD) or eating disorders, highlighting the importance of comprehensive assessment and integrated treatment approaches for addressing complex psychological needs.
How does body dysmorphic disorder (BDD) affect daily functioning and quality of life?
Body dysmorphic disorder (BDD) can significantly impair daily functioning and quality of life by causing distress, preoccupation with perceived flaws, and avoidance of social interactions or activities that exacerbate body image concerns.

Lots More Information

Related HowStuffWorks Articles

More Great Links


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