Health Tips

Most of us have something we don’t like about our appearance — perhaps it’s a flat nose, eyes that are too small,or the fact that you are not muscular enough to be masculine. Although we may fret about our physical imperfections – whatever ‘perfect’ means – these thoughts usually don’t get in the way of our normal lives.

Sadly, for individuals with body dysmorphic disorder (BDD), such thoughts may be what they hold onto in their minds for hours each day, to the point that they experience tremendous stress and interference in their daily lives. 

Understanding BDD

Patients with body dysmorphic disorder (BDD) believe they look ugly or deformed (thinking, for example, that they have an unattractive nose, or severely scarred skin), when in reality they look normal. They can't control their negative thoughts and don't believe people who tell them that they look fine.

Their thoughts may cause severe emotional distress and interfere with their daily functioning. People with BDD may miss work or school, avoid social situations and isolate themselves, even from family and friends, because they fear others will notice their flaws. As a result of their appearance concerns, they may stop working and socializing, become housebound, and even commit suicide. 

Unfortunately, BDD is very much underdiagnosed or misdiagnosed as another disorder, despite it affecting 2% of the general adult population, and the number is higher in cosmetic surgery settings. This is mainly because symptoms of BDD can overlap with symptoms of other psychiatric disorders, and some of these other disorders may happen alongside BDD. According to the Anxiety and Depression Association of America, if you suffer from BDD, you may also suffer from social anxiety disorder, depression and/or an eating disorder.

Identify BDD

Psychiatrists diagnose BDD according to the criteria in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).  The DSM-5 suggests that people with BDD usually have the following cues, which nudges the psychiatrist to think of the possibility of BDD:

1. Checking

   1. Looking in mirrors or any reflective surfaces (e.g. a window);

   2. Feeling the feature they are anxious about using their fingers;

   3. Taking photos of themselves to check their appearance.

2. Camouflage

   1. Wearing clothes (e.g. hats/scarves) to hide the features;

   2. Wearing excessive make-up;

   3. Posturing to hide the feature;

   4. Styling hair in certain ways (e.g. to minimise asymmetry of the face or hide the jawline).

3. Reassurance seeking

   1. Asking others for reassurance about appearance;

   2. Comparing with pictures taken in the past to check there has been no change.

4. Other compulsive/ritualistic/repetitive behaviours - BDD is very similar to obsessive-compulsive disorder (OCD), with a few distinctions.

   1. Hair removal;

   2. Skin picking;

   3. Grooming;

   4. Particular beauty routines.

In more severe cases, an individual may spend hours performing their grooming rituals, waiting until a time where they feel ‘OK’, or ‘just right’, or when they feel that the feature is hidden sufficiently to allow them to interact with others. Note: If you are a person who pays attention to detail, or likes having things tidy, it does not mean that you necessarily have OCD. OCD is a psychiatric order and only through a diagnosis done by a psychiatrist can you know if you have OCD or not.

5. Avoidance of:

   1. People;

   2. Reflective surfaces;

   3. Daylight/sunshine;

   4. Certain lighting;

   5. Specific groups of people (e.g. teenagers who may be more likely to ridicule them);

   6. Photographs;

   7. Wind (in case it ruffles carefully groomed hair).

Many individuals with BDD are housebound and find any social interaction almost impossible.

Some patients with BDD (usually males) have the obsessive beliefs that their body build is too small or should be more muscular. In such cases, they will be diagnosed with “BDD with muscle dysmorphia”. If BDD is accompanied by panic attacks, the person will be diagnosed with “BDD with panic attacks”.

Treatment of BDD

Cognitive behavioural therapy (CBT)

For milder cases of BDD, patients can undergo cognitive behavioural therapy (CBT). CBT is a structured treatment in which you meet a certified clinical psychologist and talk about your problems and get insights to cope with those problems in return. It can be offered individually or in a group. 

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The focus of CBT is to help patients manage their symptoms by changing the way they think and behave, such as providing them with ways to cope with self-focused attention, and to help them reduce avoidance and obsessive behaviours. If you’re wondering if seeing a therapist can really help, we wrote an article about it, read more here. Evidence has shown that CBT is effective at treating BDD.

Medications

On the other hand, people with moderate BDD should be offered either CBT or medications, whereas patients with severe BDD should be offered both. Studies suggest that a class of antidepressant called selective serotonin reuptake inhibitors (SSRIs) are effective in treating BDD. An example of SSRI is a medication called fluoxetine. 

Alternatively, if a patient's BDD does not improve with SSRIs, a tricyclic antidepressant called clomipramine can be offered as well. Sometimes, psychiatrist may add in a class of medication called second-generation antipsychotics (e.g. aripiprazole) to the treatment regimen if the patient with BDD also experiences prominent delusions, is very agitated, is moderately or severely depressed, or appears at risk for suicidal or violent behavior. Another medication called buspirone, which is commonly used to treat anxiety, can also be added to the treatment regimen for serious cases of BDD.

Is social media part of the problem?

It’s great that the rise of social media allows us to connect with people and share our moments in life with one another. However, for the most part, social media negatively affects people’s perception of their body image. Women who follow Victoria Secret’s models or K-pop girl group members on Instagram feel they need to have a smaller waistline to be qualified as pretty; men who see muscular model figures on social media feel they need to somehow bulk up and flex those biceps to look more masculine. As a result, these unrealistic and often distorted beauty standards have destroyed many people’s confidence and self-esteem. The problem is aggravated by the positive reinforcement cycle of posting attractive selfies: the better-looking the photo they posted, the more number of likes they receive, and the more validation they need to sustain their sense of self-worth.

Don’t get us wrong here. BDD is a multi-faceted issue and social media should not take all the blame. We also don’t think that making Instagram disappear is going to cure all patients with BDD. What we want to advocate here is a mindful usage of social media, which is beneficial for an individual’s mental health and well-being. 

If improving your physical appearance makes you happy, by all means go for it. But you should not base your self-worth entirely on how you look, and you certainly must not think that you need to look a certain way to be beautiful. We should all understand that beauty is subjective, and allow a broader definition for beauty: all sizes of women's waistlines are beautiful, and a man’s muscle mass should not correlate with his masculinity. 

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References

1. Anxiety & Depression Association of America - BDD (Symptoms & Related Disorders)

2. UpToDate - Body dysmorphic disorder: Clinical features

3. UpToDate - Body dysmorphic disorder: General principles of treatment

4. Anxiety & Depression Association of America - Does Media Induce Individuals with Body Dysmorphic Disorder (BDD) To Have Plastic Surgery?

5. The Pharmaceutical Journal - Recognising and managing body dysmorphic disorder

6. NICE guideline CG31 - 2019 surveillance of obsessive-compulsive disorder and body dysmorphic disorder: treatment 

7. Obsessive-Compulsive Spectrum Disorders, 2010. Body dysmorphic disorder. 12(2), pp.221-232.

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Written By

Ms Joyce Toh

Reviewed By

Doc2us Medical Board