Everything You Should Know About Body Dysmorphic Disorder

The following article contains material about a body image disorder, eating disorders, substance abuse, and suicidal ideation.

It is normal to focus on a blemish or a bad haircut for a few days, and it is perfectly natural to have days where you change your shirt a few times because nothing feels quite right. But imagine if this was every day, and if you never stopped thinking about the flaws in your appearance: This is the situation faced by people with body dysmorphic disorder, or BDD (via Mayo Clinic). For people with this disorder, a flaw most of us can ignore for the most part becomes a preoccupation that can affect every aspect of daily life. They might feel so full of shame about these perceived defects that they have trouble leaving the house for work or school, or even to see their loved ones. They might spend disproportionate amounts of time working out, staring in the mirror, or perusing information about plastic surgery and cosmetics. Close relationships can take a hit — a 2010 research review published in Dialogues in Clinical Neuroscience noted that individuals with BDD are more likely to be both divorced and unemployed.

Not only is body dysmorphic disorder a difficult condition to have to deal with, it's increasingly common. According to the Anxiety and Depression Association of America (ADAA), BDD affects 1.7 to 2.4% of the general public, or about one in 50 people. The condition affects men and women fairly evenly. 

If you or someone you know is struggling with mental health, please contact the Crisis Text Line by texting HOME to 741741, call the National Alliance on Mental Illness helpline at 1-800-950-NAMI (6264), or visit the National Institute of Mental Health website.

The Body Dysmorphic Disorder Foundation calls attention to the commonality of misdiagnosis among those with BDD. Specifically, sufferers have often been misdiagnosed with such conditions as depression, social anxiety, or an eating disorder. Part of the difficulty in diagnosing BDD may stem from the likelihood of comorbidities with other conditions: Research shows that the prevalence of BDD is "8 to 37% in individuals with OCD [obsessive-compulsive disorder], 11 to 13% in social phobia, 26% in trichotillomania [pulling out hair, eyelashes, and eyebrows], and 14 to 42% in atypical major depressive disorder" (via Dialogues in Clinical Neuroscience). Approximately 40% of individuals with anorexia nervosa also have BDD, according to the American Family Physician. And in a study of 208 admitted inpatients at a youth psychiatric facility, those who expressed concerns with body shape or weight were much more likely to also convey symptoms of post-traumatic stress disorder, disassociation, and sexual preoccupation or distress (via Child Psychiatry and Human Development). 

Additionally, sometimes patients with BDD may also be misdiagnosed because they don't want to admit how deeply they're preoccupied by their appearance (via Oxford Medicine Online). 

Body dysmorphic disorder appears to have a genetic component, and you are more likely to wrestle with this problem if you have blood relatives who either have BDD themselves or who have been diagnosed with obsessive-compulsive disorder (via Mayo Clinic). Individuals who've gone through traumatic life experiences such as bullying, abuse, or neglect are also more likely to develop BDD, as are those individuals with perfectionistic tendencies, anxiety, or depression. And it's important to note that while perfectionism might sound like a positive trait — what's better than striving for perfection?! — when taken to an extreme it can become a hinderance. Noted researcher on the subject of shame and vulnerability, Brené Brown wrote in her book "The Gifts of Imperfection" that "The need to be or appear to be perfect or even to believe that it's possible to achieve perfection ... Perfectionism is not the same thing as striving to be your best, and it is not about healthy achievement and growth" (via Habits for Wellbeing). 

It's never been easy to be an adolescent or teenager, but "snapchat dysmorphia" is something that many of us never had to deal with. This is when patients seek out surgery to make them look more like their filtered selves, and a 2020 study published in the Journal of Family Medicine and Primary Care indicates it is becoming more common. 

Indeed, time spent on social media has been correlated with women feeling of dissatisfied about their bodies (via Body Image). But boys and young men are also contending with BDD at higher rates than ever before (via The Conversation). This has been attributed to social media and the changing representation of men in popular culture. Male models have become more muscular over time, and even male action figures have bulked up in recent years. Some researchers cite our changing social and economic landscape for the increasing rates of male BDD, stating that fewer opportunities for manual and industrial labor have left men without traditional outlets for expressing masculinity. Additionally, one study published in Body Image also found that gay men are especially susceptible to media influence on their body image. They are more likely than straight men to deal with a desire to be thinner, and to have anxiety about the perceived discrepancy between their appearance and the media ideal (via NCBI).

Muscle dysmorphia, also commonly referred to as "bigorexia" or "reverse anorexia," often manifests in excessive exercising, calorie counting and obsession with macronutrients, social isolation, a regimented meal schedule, excessive mirror-checking or total avoidance of mirrors, and reliance on anabolic steroids or other performance-enhancing drugs (via the International OCD Foundation). People with muscle dysmorphia are also more likely to develop orthorexia nervosa, an obsession with eating healthy food (via Scientific Reports). In contrast with anorexia nervosa, the focus for those with orthorexia nervosa is on the quality of food rather than the quantity.

The average age at which muscle dysmorphia develops is 19, and it tends to be particularly prevalent among weightlifters, bodybuilders, and military members (via The Conversation). In fact, one 2016 study of U.S. military personnel found that 4.2% of the women and 12.7% of the men suffered from muscle dysmorphia (via Military Medicine). Eating disorders also plague military personnel at an alarming rate — the National Guard Association of the United States reported in 2017 that the diagnosis of eating disorders rose by more than a quarter over the previous five years (via the Toledo Center for Eating Disorders).

If you are struggling with an eating disorder, or know someone who is, help is available. Visit the National Eating Disorders Association website or contact NEDA's Live Helpline at 1-800-931-2237. You can also receive 24/7 Crisis Support via text (send NEDA to 741-741).

According to Medscape, antidepressants (both selective serotonin uptake inhibitors and tricyclic depressants) may be employed to treat body dysmorphic disorder, although SSRIs are the preferred treatment. Drugs.com clarifies that although Trazadone is technically a serotonin receptor antagonist and reuptake inhibitor (SARI), it is very similar to SSRIs in its mechanism of action — it, too, is frequently used for treating major depressive disorder.

Neuroleptics, lithium, and benzodiazepines are used more rarely (per Medscape). Neuroleptics are antipsychotic medications that target and block the dopamine receptors present in the nervous system, and they are also used in the treatment of schizophrenia, bipolar disorder, and psychosis (via Osmosis). Lithium is a mood stabilizer most commonly used for the treatment of bipolar disorder (via National Alliance on Mental Illness). Benzodiazepines are tranquilizers; you may have heard of Xanax or Valium, which both fall into this class of medications (via WebMD). Occasionally, monoamine oxidase inhibitors (MAOIs) might be used if other treatment options haven't been successful (per Medscape). With any medication, it is important to follow dosage instructions and to consult your doctor or pharmacist with any concerns.

Other than getting professional help, there are some things that people with body dysmorphic disorder can do to improve their chances of recovery (via Banyan Mental Health). Although their instinct might be to self-isolate, loneliness is a trigger for mental illness. As difficult as it is, people with BDD sometimes have to force themselves to socialize. Meditation can help to improve the stress and anxiety that triggers BDD symptoms. By focusing on the present moment, someone with BDD can gain an understanding of the temporary nature of their thoughts and feelings, which decreases their chances of ruminating or obsessing about something happening right now. They can also begin to realize that they are not defined by their thoughts, and that it's possible to let go of thoughts that aren't serving their wellbeing (via Headspace).

Journaling can help individuals learn to "express their thoughts and emotions without acting on them" (via Banyan Mental Health). Insider further explains that journaling increases self-awareness and can serve as a useful distraction from preoccupation with physical appearance.

The unfortunate truth is that BDD is notoriously difficult to treat (via GoodTherapy). Rather than seeking a cure, people with BDD might want to think of treatment as leading to the "remission" of the disorder. But this process will be long-term, and have ups and downs. According to a recent study published in U.S. Pharmacist, "roughly 20% of patients will adequately recover from BDD, but 40% will subsequently relapse, typically related to an earlier age of onset and severity of BDD symptoms at presentation." Indeed, one prospective study found that the chances of remission are lower among those with more severe BDD, a longer course of BDD, and comorbid personality disorders (via The Journal of Nervous and Mental Disease). Surprisingly, the presence of major depression, a substance use disorder, social phobia, obsessive-compulsive disorder, or an eating disorder did not have a significant impact on the chances of partial or full remission. Still, with an appropriate support system, medical help, and a positive mindset, it is possible for people with BDD to live a normal life and to fight against the obsessive thoughts that haunt them. 

If you or someone you know is struggling with mental health, please contact the Crisis Text Line by texting HOME to 741741, call the National Alliance on Mental Illness helpline at 1-800-950-NAMI (6264), or visit the National Institute of Mental Health website.