Body dysmorphic disorder (BDD)

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

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 thoughts are very distressing, do not go away and have a significant impact on daily life.

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

Who is affected

It's estimated that up to one in every 100 people in the UK may have BDD, although this may be an underestimate as people with the condition often hide it from others. BDD has been found to affect similar numbers of males and females.

The condition can affect all age groups, but usually starts when a person is a teenager or a young adult, when people are generally most sensitive about their appearance.

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

Typical behaviours of someone with BDD

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

A person with BDD may:

• constantly compare their looks to other people's
• spend a long time in front of a mirror, but 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 (most commonly their face)
• feel anxious when around other people and avoid social situations
• be 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 OCD, there are some 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".

BDD can also lead to depression, self-harm and even thoughts of suicide.

What causes BDD?

The cause of BDD is not clear. 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 more common in people who were teased, bullied or abused when they were children.

Getting help

People with BDD are often reluctant to seek help because they feel ashamed or embarrassed.

However, if you have BDD, there is nothing to feel ashamed or embarrassed about. It is a long-term health condition, just like many physical conditions, and it's not your fault.

Seeking help is important because it's unlikely that your symptoms will improve if left untreated, and they may get worse.

You should visit your GP if you think you may have BDD. Initially, they will probably ask a number of questions about your symptoms and how they affect you, such as:

• Do you worry a lot about the way you look and wish you could think about it less?
• What specific concerns do you have about your appearance?
• On a typical day, how many hours is your appearance on your mind?
• What effect does it have on your life?
• Does it make it hard to do your work or be with friends?

If your GP suspects BDD, they can refer you to a mental health specialist for further assessment and any appropriate treatment.

Treating BDD

With treatment, many people with BDD will experience an improvement in their symptoms.

The specific treatments recommended for you will depend on how severely BDD affects your daily life.

If you have relatively mild BDD, you will usually be referred for a talking treatment called cognitive behavioural therapy (CBT). More severe cases may be treated with a type of medication called a selective serotonin reuptake inhibitor (SSRI) and/or more intensive CBT.

Cognitive behavioural therapy (CBT)

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

An important element of CBT for treating BDD is known as graded exposure and response prevention (ERP). This involves facing situations where you would normally think obsessively about your appearance, so you are able to gradually cope better with these situations over time.

As part of your therapy, you may also be given some self-help materials to use at home and you may be invited to participate in some group work.

Selective serotonin reuptake inhibitors (SSRIs)

SSRIs are a type of antidepressant that increase the levels of a chemical called serotonin in your brain. Serotonin is a chemical that the brain uses to transmit information from one brain cell to another.

A number of different SSRIs are available, but most people with BDD will be prescribed a course of fluoxetine.

Your medication should be taken daily and it may take 12 weeks before it has an effect. If it's 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.

Common side effects of SSRIs include headaches, feeling agitated or shaky, and feeling sick. However, these will often pass within a few weeks.

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.

Further treatment

If SSRIs aren't effective in improving your symptoms, you may be prescribed a different type of antidepressant called clomipramine.

In some cases of BDD that are particularly difficult to treat, you may be referred to The National OCD/BDD service in London.

This service offers assessment and treatment to people with BDD who have not responded to treatments that are available from their local and regional specialist services.