What is Body Dysmorphic Disorder?

Imagine if every day, when you wake up, the first thing you think about before anything else is how you look, how it doesn’t feel right, and how you can fix it. And for most of the day, that feeling doesn't go away.

Groundhog Day. A feeling of dread. Trying to fix that ‘flaw’ you can see, even though no one else can. They tell you look fine – that they can’t see it. But you don’t believe them. Trying everything it takes to get rid of it. Lotions, picking and scraping, styling, products, or even saving up for cosmetic surgery.

This is the reality for people with Body Dysmorphic Disorder. A severe mental health condition that distorts a person’s self-image and leads to severe emotional distress.

Sadly, it’s hugely misunderstood. Seen as vain, teenage behaviour, or trivialised as ‘Body Dysmorphia’ – something you’ll *grow out of*.

In this blog, I delve into what Body Dysmorphic Disorder is, the signs and symptoms, and some of the support strategies you can start to put in place as a parent or carer of a child with this debilitating mental health condition.

Remember: The fact you’re here means you’re exploring and taking those first steps of knowledge and understanding. It can be very scary, and often lonely, watching someone with Body Dysmorphic Disorder slowly disappear in front of your eyes. At Beyond BDD, we’re here to offer a helping hand and shoulder to lean on with resources and more.

Okay – let’s get stuck in!

What is Body Dysmorphic Disorder (BDD)?

Body Dysmorphic Disorder (BDD) is a mental health condition – a type of Obsessive Compulsive Disorder (OCD). It’s a complex condition, but if I were to sum it up, it’s where someone becomes obsessively preoccupied with an element of their appearance. They see a flaw (often more than one) or defect others can’t see (or the perceived flaw is hardly noticeable).

For those suffering from BDD, these perceived flaws become a source of significant distress and impact day-to-day life.

People with BDD often spend hours obsessing over their appearance. Repetitive behaviours are common where they will spend lots of time (hours) in front of the mirror, constantly checking themselves.

They might skin-pick (or find another way to camouflage) to reduce the appearance of the perceived flaw or repetitively seek reassurance from others. This relentless checking and focus severely impacts relationships and normal daily life, such as attending school, work, or hobbies and activities they used to enjoy.

BDD is classified under Obsessive-Compulsive and Related Disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). It affects all genders and can develop at any age, although it typically begins in adolescence with one study reporting that more than 70% of cases are characterized by onset before 18 years.

Diagnosis can be complicated due to other coexisting conditions or conditions it’s mistaken for, like agoraphobia, depression and anxiety. Often, the person suffering can hide it for many years so it gets missed.

Understanding BDD starts with recognising it as a serious condition that goes beyond vanity. The person experiencing BDD can’t help what’s happening to them. And it can take a while before they reach out for support, as, of course, in their eyes, if the flaw were fixed, everything would be okay. We know from extensive research that this is not the case, and any interventions (like cosmetic surgery) don’t tend to fix BDD - in a lot of cases, they can make it worse.  

The severity of BDD can vary. In extreme cases, people with BDD might seek out cosmetic surgery. They might go on to have several surgeries, digging deeper into the black hole of BDD with no end in sight.

But there is hope. Lots of it. When diagnosed early and given the proper support and treatment, BDD can be lessened and, in some cases, disappear entirely. Through evidence-based therapy that is recommended and proven to work (CBT, ERP and sometimes SSRIs), people with BDD can learn how to manage their symptoms and return to normal life.

Common Signs and Symptoms of Body Dysmorphic Disorder

The signs and symptoms of Body Dysmorphic Disorder consist of symptoms that focus on the person’s perception of themselves. To the extent that it has a significant impact on their life (and can’t be better described by an eating disorder). Habits, rituals and checking behaviours are just some of the things we see in BDD.

1. Preoccupation with a perceived flaw or flaws

This preoccupation might be apparent with signs like mirror checking, or it could be internalised, so it’s very hard to see. But essentially, to meet the criteria for BDD, the person needs to be preoccupied (thinking about) their perceived flaw for at least an hour a day.

The perceived flaw must also be unnoticeable to others (or barely noticeable). If there is part of someone’s appearance that is clearly different, then BDD is not diagnosed (instead, they could be diagnosed with ‘Other Specified Obsessive-Compulsive and Related Disorder’)

2. Repetitive Behaviours

This can cover a wide range of things and might look very different from one person to another. It might be things they need to do every day like:

• Reassurance Seeking

Some people with BDD will constantly ask for reassurance. ‘Is it more noticeable today? Has it gotten bigger? Can you see it?’  These are very hard questions to combat, as the answer is always no. But it doesn’t matter how many times you continue to say this, it will either reassure them and provide relief for a very short period of time or provide no reassurance at all. They might reply with things like:

·       You would say that you’re my mum

·       You’re just saying that to make me feel better

They may spend a long amount of time comparing themselves with others.

On the other hand, some people with BDD don’t ask for reassurance. And instead will maintain that it’s how *they* see themselves that matters.

(grab a copy of our reassurance-seeking scripts for some ideas of how to compassionately handle reassurance seeking)

• Skin picking

Some people with BDD might pick their skin repeatedly to try and remove the perceived flaw. This can cause infections and intense bleeding and other problems.

• Excessive Grooming

This might include washing hair several times a day, shaving, brushing, or excessive use of lotions.

• Camouflaging

People with BDD might spend a lot of time trying to fix the perceived flaw, and depending on what part/s of the body they dislike, it can involve several different things like:

·       applying heavy makeup

·       wearing certain clothing to cover up perceived defects (caps pulled down or face masks for example)

·       or even undergoing cosmetic procedures. (Children will often beg their parents to pay for surgery).

Despite going through all these strategies, people with BDD rarely feel satisfied with their appearance. They might also engage in hair pulling, or other repetitive behaviours to *fix* the flaw, which can, of course, cause harm and more distress in the long term.

3. Withdrawal, Anxiety and Exhaustion

For BDD to be diagnosed, it must be causing a significant amount of stress and impact on normal functioning. You’ll see this as withdrawing from activities and exhausation because it can be so time-consuming and exhausting getting ready to leave the house.

While out in social situations, people with BDD may be constantly experiencing thoughts around their appearance. Constantly checking or touching. Popping to the toilet to re-check and touch up their appearance. Their sleep patterns might be affected, spending a lot of time in bed sleeping during the day.

Being isolated from friends, family and activities they used to enjoy often sends them into a spiral.  This is why it’s so important to recognise BDD and not the resulting issues like anxiety and depression, which can be mistaken for. BDD, as the root cause that needs addressing.

4. Not better explained by an eating disorder

When diagnosing BDD a psychiatrist will go through the clinical criteria in the DSM-5 which covers the above factors, but they’ll also check to see if it can be better explained by an eating disorder. If someone is concerned about their weight and is restricting food in some way, this would point to an eating disorder. There is still dissatisfaction around body image and appearance, but it requires very specific treatment. As with most disorders, they can also co-exist. Which is why that initial assessment with an expert is crucial.

5. The flaw is not noticeable to others (or hardly noticeable)

In BDD, the flaw is not noticeable to others, or it’s so small and insignificant that attention isn’t normally drawn to it or you’d need to be very close up to notice anything at all.

BDD Diagnostic Checklist

◼️ The person is preoccupied with a perceived flaw, one that is not noticeable to others, or very small and must be seen very close up to observe.

◼️ Those preoccupations must take up at least an hour of their day

◼️ They must be performing repetitive behaviours that stem from those preoccupations, for example, excessive grooming, camouflaging and mirror checking.

◼️ It is not better explained by an eating disorder.

◼️ It significantly impacts the person’s normal day-to-day function at work/school/social situations.

The Psychological Impact of Body Dysmorphic Disorder

The psychological impact of Body Dysmorphic Disorder is profound. People with BDD can feel shame, guilt and low self-esteem. The constant worry about their appearance can lead to chronic anxiety and depression. These negative emotions create a vicious cycle, where the more someone fixates on their perceived flaws, the worse their emotional state becomes. You can being to see how his has a significant impact on someone’s overall quality of life. It’s hardly surprising that recent research shows that BDD has the highest suicide rate out of all mental health disorders.

Work, school or other responsibilities can be impossible to attend, which exacerbates the BDD through the shame cycle, creating even more anxiety.

Suicidal thoughts and behaviours in BDD we think are higher than in any other mental health condition. It’s crucial for friends, family, and healthcare providers to be aware of these risks (which is why correctly diagnosing BDD is essential) and to provide the necessary support and intervention to prevent such tragic outcomes.

What causes Body Dysmorphic Disorder?

The exact causes of Body Dysmorphic Disorder are not fully understood, but it is believed to result from a combination of genetic, biological, environmental, and psychological factors. Research suggests that individuals with a family history of BDD or other mental health disorders may be at a higher risk of developing the condition. This genetic predisposition, together with environmental triggers, can contribute to the onset of BDD.

Biological factors, like differences in brain structure and function, have also been implicated in the development of BDD. Studies using neuroimaging techniques have found differences in the brain regions responsible for processing visual information and regulating emotions in individuals with BDD. These findings seem to show that people with BDD may have a heightened sensitivity to visual imperfections and so they have a distorted perception of their own appearance.

Environmental and psychological factors can play a role in the development of BDD. Traumatic experiences, such as bullying or abuse. Sociocultural influences, such as societal pressure to conform to certain beauty standards, can also contribute to BDD.

The most important thing to remember is that it’s not just one thing that causes it. Giving your child access to a phone when they were young did not cause their BDD. Undergoing your own aesthetic treatments did not cause your child’s BDD. It’s likely a very complex mix of ingredients. So, from one parent to another, please do not beat yourself up.

Now you know about BDD, there are things you can do to help stop feeding it and exacerbating it, which I will talk about in another article.

How to Diagnose Body Dysmorphic Disorder

Having read this blog you’ll probably have a good idea as to whether or not your chid is displaying signs of BDD. Diagnosing Body Dysmorphic Disorder can be challenging due to its overlap with other mental health conditions and the secretive nature of the disorder. Many people with BDD may feel ashamed or embarrassed about their concerns and not ready to talk about their symptoms with you – not least a healthcare provider. I’d urge you to make a note of all the things your child does that correlate with the symptoms of BDD and take them to your GP. They should then make a referral to CAMHS for an assessment. Make it clear how significantly this is impacting your child’s life - especially if you have any concerns about their safety or wellbeing.

When you go for the assessment, the clinician will ask about your child’s preoccupations with their appearance, the behaviours they engage in to address those concerns, and the impact it’s having on their daily life.

The clinician will be looking to rule out other conditions that may present with similar symptoms, such as obsessive-compulsive disorder (OCD), eating disorders, or major depressive disorder and will likely carry out a thorough assessment of mental health history, family history, and any co-occurring conditions. From this information, it’s likely they will tell you immediately their prognosis.

Treatment Options for Body Dysmorphic Disorder

Effective treatment for Body Dysmorphic Disorder involves a combination of therapy and medication. The NICE guidelines in the UK recommended (based on evidence) cognitive-behavioural therapy (CBT) combined with Exposure and response prevention (ERP). This helps people to identify and challenge the distorted thoughts and beliefs they have about their appearance, develop healthier coping strategies, and reduce any compulsions. (The compulsive behaviours that are happening because of their BDD).

Exposure and response prevention (ERP) where the person with BDD will slowly challenge BDD at their own pace by taking part in agreed-upon exercises that trigger BDD. This is a specialist therapy and needs to be undertaken with care and by experienced specialists.

In addition to these therapies, medication plays a pivitol role in managing the symptoms of BDD. Selective serotonin reuptake inhibitors (SSRIs) are often prescribed to help reduce the obsessive thoughts and compulsive behaviours. These medications can also help alleviate co-occurring symptoms of anxiety and depression. Healthcare providers will work closely with the person to make sure they’re on the right medication and dose.

The goal of treatment is to help people develop a healthier self-image and improve their overall quality of life.

Other ways to cope and/or reduce the impact of BDD

People with BDD tend to experience a lot of behaviours that feed their BDD. There are a number of things you can help them to do, to reduce their BDD:

Reassurance seeking – as we talked about earlier, some people with BDD will ask constantly for reassurance that they look okay or acceptable. This might alleviate their anxiety for a short period of time, but they soon go back to obsessing over their appearance and asking for reassurance again. Giving reassurance feeds the BDD and validates that there’s something wrong. It’s hard not to give reassurance, so I created a reassurance-seeking download for body dysmorphic disorder to provide you with some guidance on how to approach it with your child.

Checking behaviours are another thing that exacerbates BDD. This includes things like mirror checking, repeatedly touching, or touching up with makeup, etc. Gradually reducing these behaviours can help individuals break the cycle of obsession and compulsion and is something that’s usually undertaken through CBT and ERP. Challenging these behaviours doesn’t necessarily need to happen in the therapy session, and often children will be carrying out these challenging exercises at home with you.

Engaging in activities that promote self-care and self-compassion, such as mindfulness meditation, yoga, and creative hobbies and exercise - these can also help people to shift their focus away from appearance and cultivate a more positive and accepting relationship with their bodies.

Building a strong support network is vital. Connecting with others who understand and can provide emotional support can make a significant difference. Friends and family or other trusted adults. If your child’s BDD is focussed on their hair, can you find Barber who understands BDD and can take haircuts at their own pace.

Talk to those who are in your child’s immediate circle. Explain that this is not a trival condition, but a serious mental health problem. Ask them to be mindful about how they talk about themselves and their own appearance. Explain why they should listen to you child’s concerns if they open up, without judgment.

If your child needs encouragement and support to attend therapy, will they listen to other trusted adults to encourage them?

Seeking professional help from therapists and counsellors who specialise in BDD is often easier said than done. Try looking for experts in OCD, as the treatment path is very similar. However, BDD is more specific in its focus, so having a BDD expert on board is invaluable.

Resources and Support Groups for BDD

In the UK the BDD Foundation offer several resources for adults, children and families of those with BDD. There is also the IOCDF who cover lots of aspects of BDD on their website. Our website Beyond BDD is specifically for family, carers and other professionals in the lives of or supporting children with BDD.

Beyond BDD also have a free Facebook Support Group for parents and carers of children with BDD.

There are also emergency support helplines if you are concerned about your child’s safety.

EMERGENCY NUMBERS IN THE UK
If at any time your child is in crisis or you're deeply concerned about their safety, please programme these into their phone - and yours:

• Samaritans (available 24/7): 116 123 (free from any phone), or email jo@samaritans.org

• NHS 111 (for urgent but non‑emergency physical or mental health needs): call 111 free, 24/7

If prompted during the call, select the mental health support option to speak directly to trained clinicians

Education in Body Dysmorphic Disorder is key

Educating yourself about the realities of BDD can help dispel misconceptions and encourage a compassionate approach towards anyone affected by this terrible condition. Together, we can foster greater awareness and support within our communities.

Supporting individuals with Body Dysmorphic Disorder requires a collective effort from healthcare providers, family, friends, and society as a whole. If we can foster a culture of understanding, compassion, and acceptance, we can help individuals with BDD feel less isolated and more empowered to seek the help and support they need.