“You are not a helpless victim of your own thoughts, but rather a master of your own mind.”  –
Louise L. Hay

A reader of my weekly column recently wrote requesting I explore the issue of body dysmorphic disorder noting, “We have a family member suffering from this and it is destroying the person’s life and greatly impacting relatives.”  Sadly, this is all too often the case with this heartbreaking disease.

Body dysmorphic disorder (BDD) is a chronic mental illness in which the afflicted individual is unable to stop thinking, an actual obsession, about a flaw in their physical appearance, whether that flaw is real or imagined.  The person continually complains about their imperfection, and their preoccupation can develop to such a level as to cause considerable distress ultimately leading to impairment in both their social and occupational/school functioning.  They are unable to control their negative thoughts and are unwilling, or unable, to believe it when family and friends tell them they look fine.  They may become reticent to seek help as they fear that doing so will force them to confront their insecurity.  Sufferers feel too embarrassed and are often unwilling to accept that health professionals will tell them they are suffering from a mental illness.  They wholeheartedly believe that fixing the “defect” is the only resolution to their suffering.  In the extreme, patients may actually choose to suffer from their symptoms rather than accept the belief they have no deformity.

The self-imposed shame as a result of their “flaw” can escalate to the point of causing significant depression, anxiety, and social isolation.  Sufferers will often seek multiple cosmetic procedures in an attempt to “correct” their perceived physical defect, but sadly such procedures never end up satisfying the victim of this tragic disorder.  The first recorded case dates back over 125 years, was not recognized by the American Psychiatric Association until some one-hundred years later, and was originally termed dysmorphophobia, the fear of having a deformity, but more recently changed to body dysmorphic disorder.

Because people with BDD may often compulsively look at themselves in a mirror, it is often misconstrued as a vanity-driven obsession when in fact it is actually just the opposite.  Individuals afflicted with BDD do not perceive, or believe, themselves to be better looking than others; rather they possess the sense of being “flawed” and irreversibly hideous or inadequate.

There are several symptoms and behaviors commonly associated with body dysmorphic disorder.  Some of the symptoms include:

• Strong preoccupation with physical appearance.
• Obsessive thoughts and associated compulsive behaviors related to perceived defect(s) in appearance.
• Strong feelings of being self-conscious in any sort of social situation as a result of believing others are noticing, and possibly even mocking, the perceived defect(s).
• Need to seek reassurance from others about their appearance.
• The unyielding belief that the perceived defect(s) make you unsightly.
• Strong feelings of shame.
• Persistent low self-esteem.
• Excessive grooming.
• Excessive exercise.
• Avoidance of social situations.
• Frequently comparing one’s own appearance with that of others.
• Anxiety.
• Difficulty working or focusing on school work due to the preoccupation with their appearance.
• Delusional thoughts related to the perceived defect(s) in appearance.

Some of the more common compulsive behaviors associated with BDD include:

• Excessive grooming behaviors (hair combing, eyebrow plucking, skin-picking, etc.).
• Persistently seeking reassurance regarding their appearance from family and friends.
• Compulsive mirror checking (including continual looking in reflective surfaces such as car windows, glass doors, etc.) alternating with a staunch unwillingness to look at their reflection, and actually going as far as removing mirrors from the home.
• Wearing of gaudy clothing and/or excessive jewelry in an attempt distract and divert attention to the flaw.
• Compulsive data gathering (via books, magazine articles, websites) relating to the perceived defect.
• Numerous dermatologic procedures and/or plastic surgeries, most often with little or no gratification.
• Compulsive skin touching.
• Attempting to conceal the imagined defect by use of cosmetics, wearing baggy clothes, or wearing hats.

The most common locations of perceived defects are:

• Skin

• Hair
• Nose
• Complexion (acne and other blemishes on the face)
• Stomach
• Breasts/Nipples
• Eyes
• Thighs
• Teeth

The body feature focused on may change over time.

The specific cause of body dysmorphic disorder is unknown.  As with many mental disorders it appears to be a combination of neurobiological, genetic, psychological and environmental factors.  BDD most often develops in adolescence or early adulthood, periods in development of heightened concern and self-criticism about personal appearance.  Although for quite some time considered a diagnosis most often applied to women, BDD has been shown to affect women and men in almost equal numbers.  Approximately 1-2% of the world’s population meets the diagnostic criteria for body dysmorphic disorder.  Sadly, many suffer terribly for years before finally seeking treatment.   In fact, a 2006 study found the completed-suicide rate in patients with BDD to be 45 times greater than that of the general population within the United States.  This rate is more than twice that of people suffering from clinical depression, and three times higher than those with bipolar disorder.  Approximately 80% of those with BDD have been found to have experienced suicidal ideations, and there has been a suggested link between undiagnosed BDD and an increased suicide rate in people who have undergone cosmetic surgery.

There are several mental health diagnoses often found in association with body dysmorphic disorder which can complicate an accurate diagnosis by health professionals.  Recent research indicated that over three-quarters of those suffering from BDD will experience major depression at some point in their lives which is a significantly higher rate than the 10-20% seen in the general population.  Nearly a third of patients with BDD will also present with obsessive-compulsive disorder as well as agoraphobia.

Studies have demonstrated that body dysmorphic disorder can be effectively treated with either psychotherapy or psychiatric medications.  More specifically cognitive behavioral therapy (CBT) and selective serotonin reuptake inhibitors (SSRI’s).  A 2007 study demonstrated that symptoms of BDD were significantly diminished in over 80% of subjects receiving CBT.  Based on the current theory that BDD may neuro-chemically be the result of decreased levels of serotonin in the brain, a 2002 study showed that the use of an SSRI versus a placebo-controlled group achieved over a 50% therapeutic response.  It further appears that the dose of any given SSRI used in treating BDD is more effective when used in doses higher than typically prescribed to treat major depression.  As with similar disorders, a combined treatment approach of CBT and SSRI’s is more effective than either alone.  There are a number of highly qualified and capable cognitive-behavioral therapists and psychiatrists within the Tri-Counties with vast experience who can effectively assist in treating body dysmorphic disorder.