What is body dysmorphia? Symptoms, causes, treatments and misconceptions

Body dysmorphic disorder (BDD), or body dysmorphia, is a serious mental health condition that can have devastating impacts on people's lives.

The good news is that there are effective treatments.

Here, we consult the top experts to understand exactly what BDD is, the common misconceptions around the condition (it's not just women who suffer from it), and what to do if you suspect you or someone you know might have body dysmorphia

What is BDD?

Professor David Veale, consultant psychiatrist, trustee of the BDD Foundation and co-author of Overcoming Body Image Problems, explains,"BDD is a body image problem. It is defined as a preoccupation with one or more perceived flaws in one's appearance, which other people can hardly notice or do not believe to be important. The symptoms must also either cause significant distress or debilitation.

"Some people will acknowledge that they may be 'blowing things out of all proportion'. Others are very firmly convinced about their 'defect' that they do not believe a family member or friend. Whatever the degree of insight into their condition, sufferers have often been told that they look 'normal' many times."

"BDD is a mental health condition," says Kitty Wallace, head of operations at BDD Foundation. "The most common concerns are usually around facial features e.g. skin, hair, nose, eyes, chin, and teeth. However, any part of the body can become a focus of concern."

It is estimated around 2% of the population have BDD, however, the condition is under-diagnosed due to a lack of awareness.

"Similarly to OCD, those suffering will have intrusive and all-consuming thoughts about their perceived flaw, how they view themselves and how they feel they are perceived by other people," adds Wallace. "The intrusive thoughts can become extremely debilitating and individuals may become totally housebound, unable to engage in day-to-day activities, relationships, education or work.

"Sadly, the rate of suicide in BDD is high, with approximately 80% of people with the condition experiencing suicidal thoughts, and about one in four attempting suicide."

But effective help is out there.

Who does BDD affect?

"BDD predominantly affects young people," says Professor Veale, who points out that while the age of onset is usually in adolescence, it may take years to present.

Wallace adds, "BDD can affect all genders. Studies show that it affects men and women almost equally. However, men seem to be more reluctant to come forward and seek the help and support they need.

"BDD usually begins in late adolescence (16-18 years). However milder symptoms of BDD often precede this from about the age of 12-14. However, there is an average 10 year delay between onset of symptoms and seeking help."

BDD symptoms

Professor Veale explains, "Many people are concerned to a greater or lesser degree with some aspect of their appearance but for a diagnosis of BDD, the preoccupation must cause significant distress or hindrance in at least one area of someone's life. For example, someone with BDD might avoid certain social and public situations to prevent themselves from feeling uncomfortable and worrying that people are rating them negatively.

"Alternatively, a person may enter such situations but remain very self conscious. He or she may camouflage themselves excessively to hide their 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 (for example, 'Why was I born this way?', 'If only my nose was straighter and smaller'. They may feel compelled to repeat frequently certain time consuming behaviours."

These include:

• Checking their appearance in a mirror or reflective surface (or avoiding them altogether)

• Seeking reassurance about their appearance

• Constantly comparing their appearance to others

• Checking by feeling their skin with their fingers

• Cutting or combing their hair to make it 'just so'

• Going to a lot of effort to conceal perceived flaw/s (e.g. with make-up, clothes, postures or other means)

• Picking their skin to make it smooth

• Taking many selfies (or avoiding pictures or only posting ones of yourself using a filter)

• Avoiding social situations

• A lot of time spent researching cosmetic/dermatological treatments online

• Obsessively worrying about one or more features for more than an hour a day (usually far more)

"We have a quiz on our website that will give people a % likelihood that they have BDD. It uses the same diagnostic criteria that a clinical psychologist would use. It is not a formal diagnosis but it will give a good indication. You can find it here," says Wallace.

BDD causes and triggers

"There has been very little research into BDD, and we urgently need funding so that we can understand it fully and develop better treatments. However, it is believed that BDD can develop due to a combination of genetic predisposition (nature) and environmental factors such as traumatic life experiences (nurture)," says Wallace.

"Many people with BDD will refer to having been teased, bullied or abused in childhood. There could also be perfectionism at play for some with BDD. Recent brain imaging studies have also shown that individuals with BDD have abnormalities in how they process what they see. This means that they are misperceiving that parts of their appearance are flawed or unattractive."

BDD misconceptions

Wallace believes the two biggest misconceptions about BDD are:

1. 'It's vanity or narcissism'

"It is really important that we reduce the shame and stigma around having this condition so that people feel able to reach out for the right help and support. If we consider that the definition of vanity is 'excessive pride or admiration of one's own appearance', this is the exact opposite of what individuals with BDD experience. Those with BDD feel excessive levels of shame around their appearance and most just want to look 'normal', whilst perceiving themselves as being hideous."

2. 'It's the same as an eating disorder'

"BDD is a different diagnosis to having an eating disorder but due to the term 'body' in the name, people often assume that it is just connected with weight and shape. BDD is most commonly focussed on aspects of the face such as skin, nose, hair, eyes, jaw or chin.

"Although there can be an overlap between the two conditions, and someone can be diagnosed with both, they are different. BDD usually doesn’t involve worries about being fat or weighing too much, it tends to be focussed on specific areas of concern so, restricted or 'clean' eating might be used to try and clear the skin, or improve the jaw line, or improve another specific aspect of the body."

What to do if you suspect you or someone you know has BDD

If you think you might have BDD, Wallace recommends reaching out for support. "BDD is very treatable, and there is help available. The first port of call is usually your GP. Sadly, some GPs still don't know enough about BDD but we have a GP card on our website that you can take with you. This has all the information your GP needs, following the NHS Nice guidelines for treatment.

You can also use the charity's quiz as mentioned to get a better idea of whether you have BDD, and their resources for more information and support.

For others, the expert adds, "We would suggest gently introducing the topic to see whether they resonate with the distress and behaviours associated with BDD. Most people with BDD believe that they have a physical problem with their appearance, rather than a psychological problem. This can lead to resistance in accepting that they may have BDD. However, by focussing on the distress or associated behaviours they may be better able to accept that they may have BDD.

"Encourage your loved one to seek professional help with therapy or medication. We know that BDD can impact the whole family and can wreak havoc with relationships. Many loved ones will describe endlessly trying to reason and reassure someone with BDD that they look fine but unfortunately this does not help, and can fuel distress or further debates around their appearance.

"Support them to seek the right help, which could involve attending initial appointments with health care professionals, being their cheerleader through treatment and praising improvement, however small. Patience is key."

BDD treatments

"There are effective treatments available for BDD," Wallace emphasises. "The most effective and evidence-based forms are specialised cognitive behaviour therapy (CBT) and/ or SSRI medication.

"Specialised CBT for BDD would include something called exposure response prevention (ERP), where you learn to slowly challenge some of your fears around your appearance."

Can you cure BDD?

What does Professor Veale think? "Some people can be cured, others need a longer treatment."

And Wallace? "Certainly, there are many people who refer to themselves as fully recovered from BDD but recovery looks different for everyone and some people may learn to manage their symptoms, even if they wouldn’t refer to themselves as 'cured'. What we can say is, no one should struggle alone with BDD, and that it is possible to get better.

"Most people with BDD can’t imagine feeling better when they first seek treatment but we know that with the right help and support, they can regain control of their life, free from the distress that BDD causes."

BDD foundation has an email helpline, which you can contact for more information or support: support@bddfoundation.org. There are also lots more resources on its website as well as support groups you can join. You can also call Samaritans any time, day or night on 116 123.

To find out more about what BDD is like in reality, read Danny Gray's story here:

Living with body dysmorphia: 'I convinced myself I needed a hair transplant' (Yahoo Life UK, 8-min read)

Watch: Craig David believes he suffered from body dysmorphia during his time in Miami