Body dysmorphia

Body dysmorphic disorder (BDD), or body dysmorphia, is an anxiety disorder that causes sufferers to spend a lot of time worrying about their appearance and to have a distorted view of how they look.

For example, they may be convinced that a barely visible scar is a major flaw that everyone is staring at, or that their nose looks abnormal. 

Having BDD does not mean the person is vain or self-obsessed.

When does low confidence turn into BDD?

Almost everyone feels unhappy about the way they look at some point in their life, but these thoughts usually come and go and can be forgotten.

However, for someone with BDD, the thought of a flaw is very distressing and does not go away.

The person believes they are ugly or defective and that others perceive them in this way, despite reassurances from others about their appearance.

BDD can lead to depression and even thoughts of suicide.

Who is affected?

It is estimated that up to 1% of the UK population have BDD, although this number may be an underestimate as people with BDD often hide it from others. It affects more females than males.

BDD can affect all age groups, but usually starts in adolescence, when people are most sensitive about their appearance.

It is more common in people with a history of depression or social phobia. It often occurs alongside OCD or generalised anxiety disorder, and may also exist alongside an eating disorder such as anorexia or bulimia.

What are typical behaviours of someone with BDD?

People with BDD may:

• constantly compare their looks with other people's
• spend a long time in front of a mirror, and at other times avoid mirrors altogether 
• spend a long time concealing what they believe is a defect 
• become distressed by a particular area of their body (commonly their face)
• feel anxious when around other people 
• are very secretive and reluctant to seek help, because they believe others will see them as vain or self-obsessed
• seek medical treatment for the perceived defect – for example, they may have cosmetic surgery, which is unlikely to relieve their distress
• excessively diet and exercise

Although BDD is not the same as obsessive compulsive disorder (OCD), there are similarities. For instance, the person may have to repeat certain acts, such as combing their hair, applying make-up, or picking their skin to make it 'smooth'.

It can seriously affect daily life, often affecting work, social life and relationships.

What are the causes?

The cause of BDD is not clear, but it may be genetic or caused by a chemical imbalance in the brain.

Past life experiences may play a role too – for example, BDD may be associated with teasing or bullying during childhood. 

Getting help

If you feel you may be suffering from BDD, see your GP.

They will consider how distressing the condition is for you and how much your life is affected, to work out whether you have:

• mild BDD, where symptoms are distressing but manageable and you are able to carry on with everyday life
• more severe BDD, where symptoms are very distressing and seriously restrict your everyday life

This will also help your GP to identify the most suitable treatment.

How is it treated?

Step 1: CBT and self-help

Your GP should initially offer you cognitive behavioural therapy (CBT) and recommend a self-help book or computer programme.

CBT is a talking therapy that can help you manage your problems by changing the way you think and behave. You'll work with the therapist to agree some goals – for example, one aim may be to stop obsessively checking your appearance.

Some people may find it helpful to join a self-help group to get moral support from other sufferers and practical tips on how to cope with BDD in daily life. To find out if there are any self-help groups in your area, ask your doctor or contact the Mind charity infoline (call 0300 123 3393 or email info@mind.org.uk).

Step 2: antidepressants

If CBT and self-help are not effective, you should be offered the choice of more intensive CBT, a course of an SSRI antidepressant (probably fluoxetine), or a combination of the two.

The SSRI should be taken daily and it may take 12 weeks before it has an effect. If it is effective, this treatment should continue for at least 12 months, to allow for further improvements and prevent a relapse. 

When the treatment is complete and your symptoms are under control, the SSRI dose should be reduced gradually to minimise the possibility of withdrawal symptoms.

Adults younger than 30 will need to be carefully monitored when taking SSRIs because of the potential increased risk of suicidal thoughts and self-harm associated with the early stages of treatment. 

Your community mental health team may refer you to a specialist clinic for BDD, although the only NHS specialist clinic for BDD is based at the Maudsley Hospital in South London.

Step 3: clomipramine or an antipsychotic

If you don't respond to two or more SSRI antidepressants, you may be prescribed a different type of antidepressant such as clomipramine, or a low-dose antipsychotic medication. Speak to your doctor about the possible side effects of these medicines.