Persistent mirror checking, preoccupation with perceived physical flaws, continuously asking for reassurance about appearance, comparing one’s own appearance to that of others, obsessions, social avoidance, excessive exercise, self-hatred…extreme body image disturbance.

A mental illness with one of the highest suicide rates…

Sounds familiar, especially when working with eating disorders.

But what if I told you that there was no fear of weight gain, no self-perception of being overweight, and no eating disturbance. Then what?

Consider perhaps the most severe form of body image disturbance: Body Dysmorphic Disorder (BDD).

BDD is defined in the DSM-IV-TR as a preoccupation in some imagined defect in personal appearance, or an excessive concern with a minor physical irregularity. The preoccupation causes significant distress or impairment and is not better accounted for by another mental disorder (i.e., an eating disorder). Individuals with BDD experience body image distortion in ways that may be similar to eating disorders patients, however, body image concerns in BDD do not focus on weight or weight gain as much as they focus on specific aspects of the body or bodily details. For example, the most frequent complaints made by BDD patients about their bodies have to do with:

skin (65%)
hair (50%)
nose (38%)
eyes (20%)
legs/knees (18%)
Other body parts may be of concern to a BDD patient, such as stomach, thighs, or buttocks, however, the concern tends not to be about weight or overall body shape. Common complaints may involved real or imagined “defects” such as acne, wrinkles, scarring, discoloration, asymmetry, or swelling. A patient may be simultaneously preoccupied with multiple body parts, or, in contrast, be excessively preoccupied with a singular body part or feature. When concerns about weight gain, “fatness”, or body shape are prevalent, the DSM-IV-TR states that both a diagnosis of BDD and the diagnosis of an eating disorder may be warranted.

BDD affects up to 2% of the U.S. population, males and females in equal number. Approximately 2/3 of cases begin before age 18 but may go undiagnosed for years. BDD tends to be chronic with a high rate of relapse.

We are not certain if BDD patients actually see body parts differently, or if they see their bodies accurately but think differently about what they see. In other words, it is not entirely clear if there is a sensory disturbance or a cognitive disturbance (or both?). We do know that individuals with BDD selectively over-attend to details (rather than the “whole”) and become fixated on them. Some studies reveal organizational and executive functioning deficits in BDD patients (Olivardia, 2004).

Myths about BDD
According to PsychCentral contributor Margarita Tartakovsky, M.S., several myths regarding body dysmorphic disorder continue to circulate, including:

It’s not a real disorder.
It’s rare.
It occurs only in the extreme.
It occurs only in women.
Facts about BDD

Many patients use terms such as “tormented”, “obsessed”, “driven”, and “tortured” to describe their lives with BDD. BDD patients may recognize that their concern is excessive, however this level of insight is not always the case. One study found that 53% of BDD patients were “not entirely convinced that their defects were real”, but nevertheless struggled with strong thoughts that their perceptions were real (Olivardia, 2004, p.545).

Patients may attempt to camouflage their appearance, avoid social situations due to intense self-criticism, shame, and fear of rejection/judgment. As many as 3/4 of BDD patients seek some form of dermatological or cosmetic procedure for their ailment, however, cosmetic surgery is counterproductive and contraindicated for BDD patients. The majority report that surgery, for example, left them dissatisfied or even feeling worse about their symptoms.

As far as etiology is concerned, like many mental illnesses, a combination of genetic, environmental, familial, psychological, and sociocultural risk factors have been postulated (Phillips, 2005). The most frequently diagnosed co-morbid illnesses are depression, OCD, social phobia, and eating disorders.

Assessment Instruments, such as the Body Image Disturbance Questionnaire, the Body Dysmorphic Disorder Questionnaire (see ** below), and the BDD-YBOCS are available. The latter two can be found in the resource entitled, The Broken Mirror, by Katherine Phillips.

Cognitive Behavioral Therapy, behavioral interventions, and pharmacotherapy appear to have the most promise for treating BDD. Exposure with response prevention, thought records, cognitive restructuring and retraining are examples of techniques that have been used with success. Motivational Interviewing and relapse prevention training are useful components as well. Specialized treatment programs are also available. To learn more about De-mystifying the treatment of BDD, click HERE

Resources that include assessment instruments and details about the above interventions and procedures include:

Phillips, K. A. (2005). The Broken Mirror: Understanding and treating body dysmorphic disorder. Oxford: Oxford University Press.
Wilhelm, S. (2006). Feeling Good about the Way You Look: A program for overcoming body image problems. New York: The Guilford Press.
Claiborn, J., Pedrick, C. (2002). The BDD Workbook: Overcome body dysmorphic disorder and end body image obsessions. Oakland, CA: New Harbinger Press.
Additional Sources: Olivardia, R. (2004). Body Dysmorphic Disorder. In Thompson, J.K. (Ed.) Handbook of eating disorders and obesity, pp.542-561. New Jersey: John Wiley & Sons.

Phillips, K.A. (2002). Body Image and Body Dysmorphic Disorder. In Fairburn, C.G. & Brownell, K.D. (Eds.) Eating disorders and obesity: A comprehensive handbook (Second edition), pp.113-117. New York: The Guilford Press.

**Phillips, KA.;Atala, KD.; Pope, HG. New Research Program and Abstracts, American Psychiatric Association 148th Annual Meeting, Miami. American Psychiatric Press; Washington, DC: 1995. 1995. Diagnostic instruments for body dysmorphic disorder.