BODY DYSMORPHIC DISORDER - FAQ

Dr David Veale, The Priory Hospital, North London

The aim of this site is to answer common questions about the nature and treatment of Body Dysmorphic
Disorder. It is designed for the lay public.
Body Dysmorphic Disorder (BDD) is a mental disorder defined as a preoccupation with a perceived defect in
one's appearance. If a slight defect is present, which others hardly notice, then the concern is regarded as
markedly excessive. In order to receive the diagnosis, the preoccupation must cause significant distress or
impairment in one's occupational or social functioning.
An Italian doctor, Morselli, first coined the term dysmorphophobia in 1886 from "dysmorph" a Greek word
meaning misshapen. It was subsequently renamed Body Dysmorphic Disorder by the American psychiatric
classification. Freud described a patient whom he called the "Wolf man" who had classical symptoms of
BDD. The patient believed that his nose was so ugly that he avoided all public life and work. The media
sometimes refer to BDD as "Imagined Ugliness Syndrome". This probably isn't particularly helpful, as the
ugliness is very real to the individual concerned.
The degree of handicap varies so that some people will acknowledge that they may be blowing things out of
all proportion. Others are so firmly convinced about their defect that they are regarded as having a delusion.
Whatever the degree of insight into their condition, sufferers often realise that others think their appearance
to be "normal" and have been told so many times. They usually distort these comments to fit in with their
views (for example, "They only say I'm normal to be nice to me" or "They say it to stop me being upset").
Alternatively they may firmly remember one critical comment about their appearance and dismiss 100 other
comments that are neutral or complimentary.

What are the most common complaints in BDD?

Most sufferers are preoccupied with some aspect of their face and often focus on several body parts. The
most common complaints concern the face, namely the nose, the hair, the skin, the eyes, the chin, or the
lips. Typical concerns are perceived or slight flaws on the face or head, such as hair thinning, acne, wrinkles,
scars, vascular markings, paleness or redness of the complexion or excessive hair. Sufferers may be
concerned about a lack of symmetry, or feel that something is too big or swollen or too small, or that it is out
of proportion to the rest of the body. Any part of the body may however be involved in BDD including the
breasts, genitals, buttocks, tummy, hands, feet, legs, hips, overall body size, body build or muscle bulk.
Although the complaint is sometimes specific "My nose is too red and crooked"; it may also be very vague or
just refer to ugliness.

When does a concern with one's appearance become BDD?

Many people are concerned to a greater or lesser degree with some aspect of their appearance but to obtain
a diagnosis of BDD, the preoccupation must cause significant distress or handicap in one's social, school or
occupational life. Most sufferers are extremely distressed by their condition. The preoccupation is difficult to
control and they spend several hours a day thinking about it. They often avoid a range of social and public
situations in order to prevent themselves feeling uncomfortable. Alternatively they may enter such situations
but remain very anxious and self-conscious. They may monitor and camouflage themselves excessively to
hide their perceived defect by using heavy make-up, brushing their hair in a particular way, growing a beard,
changing their posture, or wearing particular clothes or for example a hat. Sufferers feel compelled to repeat
certain time consuming rituals such as:

Checking their appearance either directly or in a reflective surface (for example mirrors, CDs, shop
windows)
Excessive grooming, by removing or cutting hair or combing
Picking their skin to make it smooth
Comparing themselves against models in magazines or television
Dieting and excessive exercise or weight lifting

Such behaviours usually make the preoccupation worse and exacerbate depression and self-disgust. This
can often lead to periods of avoidance such as covering mirrors or removing them altogether.

How common is BDD?

BDD is a hidden disorder and its incidence is unknown. The studies that have been done so far have been
either too small or unreliable. The best estimate might be 1% of the population. It may be more common in
women than in men in the community although clinic samples tend to have an equal proportion of men and
women.

When does BDD begin?

BDD usually begins in adolescence - a time when people are generally most sensitive about their
appearance. However many sufferers leave it for years before seeking help. When they do seek help
through mental health professionals, they often present with other symptoms such as depression or social
phobia and do not reveal their real concerns.

How disabling is BDD?

It varies from a bit to a lot. Many sufferers are single or divorced, which suggests that they find it difficult to
form relationships. Some are housebound or unable to go to school. It can make regular employment or
family life impossible. Those who are in regular employment or who have family responsibilities would almost
certainly find life more productive and satisfying if they did not have the symptoms. The partners or families
of sufferers of BDD may also become involved and suffer.

What causes BDD?

There has been very little research into BDD. In general terms, there are two different levels of explanation one biological and the other psychological, both of which may be correct. A biological explanation would
emphasise that an individual has a genetic predisposition to a mental disorder, which may make him or her
more likely to develop BDD. Certain stresses or life events especially during adolescence may precipitate the
onset. Sometimes use of drugs such as ecstasy may be associated with the onset. 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 demand perfection and an impossible ideal.
By paying excessive attention to their appearance, they develop a heightened perception of it and become
increasingly accurate about every imperfection or slight abnormality. In the end there is a big disparity
between what they believe they should ideally look like and how they see themselves. What a sufferer
therefore "sees" in a mirror is what they construct in their head and this depends upon a number of factors
such as mood and their expectations. The way a sufferer avoids certain situations or uses certain safety
behaviours perpetuates the fear of others rating them and maintains their excessive attention on themselves.

What are the other symptoms of BDD?

Sufferers are usually demoralised and many are clinically depressed. There are many similarities and
overlaps between BDD and Obsessive Compulsive Disorder (OCD) such as intrusive thoughts, frequent
checking and reassurance seeking. The main difference is that BDD patients have less insight into the
senselessness of their thoughts than OCD sufferers do. Many BDD patients have also suffered from OCD at
some time in their life. Sometimes the diagnosis of BDD is confused with anorexia nervosa. However in
anorexia, individuals are more preoccupied by self-control of weight and shape. Occasionally, an individual
may have an additional diagnosis of BDD when she is also preoccupied by the appearance of her face.
Other conditions that frequently exist in combination with BDD or are confused with BDD include:
- Apotemnophilia. This is desire to have a disabled identity in which sufferers with healthy limbs request one
or two limb amputations. Some individuals are driven to DIY amputation such as putting their limb on a
railway line. Very little is known about this bizarre and rare condition. However there are significant
differences between apotemnophilia and BDD as cosmetic surgery is rarely successful in BDD.

- Social phobia. This is a fear of being rated negatively by others leading to avoidance of social situations or
marked anxiety. This usually stems from the sufferers belief that he or she is revealing themselves to be
inadequate or inept. If the concern is only about appearance then the BDD is the main diagnosis and the
social phobia is secondary.
- Skin-picking and trichotillomania This consists of an urge to pluck ones hair or eyebrows repeatedly). If
the skin-picking or hair-plucking is out of concern with ones appearance then BDD is the main diagnosis.
- Obsessive Compulsive Disorder (OCD). Obsessions are recurrent intrusive thoughts or urges, which the
sufferer usually recognises to be senseless. Compulsions are acts, which have to be repeated until a sufferer
feels comfortable or "sure". A separate diagnosis of OCD should only be made if the obsessions and
compulsions are not restricted to concerns about appearance.
- Hypochondriasis. This is a doubt or conviction of suffering from a serious illness which leads a person to
avoid certain situations and to check their body repeatedly. The International Classification of Diseases (ICD10) classifies BDD as part of hypochondriasis whereas the American classification regards it as a separate
disorder.

Are people with BDD vain or narcissistic?

No. BDD sufferers may be spending hours in front of a mirror but believes themselves to be hideous or ugly.
They are often aware of the senselessness of their behaviour, but none the less have difficulty controlling it.
They tend to be very secretive and reluctant to seek help because they are afraid that others will think them
vain.

How is the illness likely to progress?

Many sufferers have repeatedly sought treatment with dermatologists or cosmetic surgeons with little
satisfaction before finally accepting psychiatric or psychological help. Treatment can improve the outcome of
the illness for most sufferers. Others may function reasonably well for a time and then relapse. Others may
remain chronically ill. BDD is dangerous and there is a high rate of suicide.

What treatments are available?

As yet, there have been no controlled trials to compare different types of treatment to determine which is the
best. There have been a number of case reports or small trials that have shown benefit with two types of
treatment, namely cognitive behaviour therapy and anti-obsessional medication. There is no evidence that
psychodynamic or psychoanalytical therapy is of any benefit in BDD, in which a lot of time is spent looking
for unconscious conflicts that stem from childhood.

Cognitive Behaviour therapy

Cognitive Behaviour Therapy (CBT) is based on a structured programme of self-help so that a person learns
to change the way he thinks and acts. A persons attitude to his appearance is crucial as we can all think of
people who have a defect in their appearance such as a port wine stain on their face and yet are well
adjusted because they believe that their appearance is just one aspect of themselves. It is therefore crucial
to learn during therapy alternative ways of thinking about ones appearance. BDD sufferers need to learn to
confront their fears without camouflage (a process called "exposure") and to stop all "safety behaviours"
such as excessive camouflage or avoiding showing ones profile. This means repeatedly learning to tolerate
the resulting discomfort. Facing up to the fear becomes easier and easier and the anxiety gradually
subsides. Sufferers begin by confronting simple situations and then gradually work up to more difficult ones.
Cognitive Behaviour Therapy has not yet been compared to other forms of psychotherapy or medication so
we don't yet know which is the most effective treatment. However there is definitely no harm combining CBT
with medication and this may be the best option.
Cognitive behaviour therapists come from a variety of professional backgrounds but are usually
psychologists, nurses or psychiatrists.

Anti-Obsessional Medication
The second type of treatment is anti-obsessional medication - these are anti-depressants which are
strongly "serotonergic" (or "SSRIs"), which have some success in the treatment of OCD. These drugs may
be used either alone or in combination with a psychological treatment.
There are a number of SSRIs including:

Fluoxetine(UK trade name "Prozac"),

Fluvoxamine( "Faverin"),
Sertraline("Lustral")
Paroxetine("Seroxat")
Citalopram ("Cipramil").

A minority of people may experience nausea, diarrhoea, headache, difficulty sleeping, restlessness,
difficulties reaching orgasm or reduction in libido
The side effects can usually be minimised by taking the drug with food or reducing the dose. Most people
find the side effects are minor irritations and usually decrease after a few weeks. The exception to this is the
sexual side-effects which may persist. The drugs are not addictive and may be stopped at any time without
experiencing withdrawal symptoms. If and when medication is stopped, it is sensible to reduce it slowly.
Another older alternative is a potent serotonin drug, clomipramine (UK trade name "Anafranil"). The dose
required may be quite high (250mg or more) and this can lead to a number of side-effects including drymouth, blurred vision, constipation, drowsiness, dizziness on standing, inability to reach orgasm
A doctor will be able to discuss how these side effects can be minimised.
In order to know whether a sufferer might be helped, it will be necessary to take a high dose of the drug for at
least 3 months (for example up to 80mg fluoxetine). Those people who do get some benefit may find that
they still have some symptoms and that there is a high risk of relapse when they stop taking it.
The risk of relapse can probably be minimised by combining the medication with cognitive behaviour therapy.
Medication is especially helpful when a person is depressed as it may help in improving their motivation. A
family doctor can prescribe you these drugs but he or she will probably refer a sufferer to a psychiatrist who
will be more aware of the condition and the doses of medication required. An anti-psychotic drug may also
be prescribed, such as:

Pimozide (trade name in UK "Orap").

Haloperidol ("Haldol")
Sulpiride ("Dolmatil")
Chlorpromazine ("Largactil").

These drugs are probably only useful in a low dose in a few patients as an additional treatment to antiobsessional drugs and after anti-obsessional drugs have been fully tried. They are not thought to be helpful if
used alone. They have different side effects such as stiffness in the limbs or slurred speech that can be
countered by medication such as procyclidine. In low doses the drugs may just help reduce anxiety. There
has been no controlled trials that compares one of these anti- psychotic drugs with an anti-obsessional drug.
Researchers have reported that even "deluded" patients will respond to anti-obsessional drugs. Therefore if
medication is used, these are the treatment of first choice.