Introduction

Many of us spend a lot of time and effort on our appearance. We wear makeup, work out at the gym, buy flattering clothes and style our hair, all done in hope of looking more attractive. Individuals with Body Dysmorphic Disorder (BDD) are beset by a more extreme version of these normal appearance concerns. BDD is characterized by a time-consuming and potentially disabling preoccupation with imagined or slight defects in one's appearance or excessive concern about a slight physical anomaly. To meet the criteria for this diagnosis, the preoccupation must cause significant distress or impair school, personal or social functioning. Although virtually any body part can become the source of preoccupation, BDD most commonly involves the eyes, ears, nose, skin, chin, jaw or other facial features. Although we don't know what causes BDD, most likely there are multiple sources including biological, psychological and sociocultural factors. Both medication and cognitive/behavioral therapy have been helpful in moderating the symptoms.

Real Life Stories

For 17–year–old James, the simple act of looking in a mirror is torture. Ever since a friend made a casual comment about his appearance, James has been obsessed with the size and shape of his nose. "It's just not right... it just doesn't fit my face" he will state. James is unable to be reassured that there is nothing objectively wrong with his nose and will spend at least an hour per day checking himself in various reflections. He has begun to consult with cosmetic surgeons about the possibility of rhinoplasty.

"I wish I could convince my parents to take me to a plastic surgeon" said 15–year–old Kristin. She is preoccupied with her "large" jaw, "small" breasts and "uneven" skin and will ask her mother whether she looks okay at least a dozen times per day. She has begun to use heavy makeup and has also started wearing long sleeves and pants at all times in order to cover her skin. Kristin's appearance concerns are so time-consuming and distressing that she has ceased to spend time with her friends and has dropped her extracurricular activities.

Both James and Kristin have Body Dysmorphic Disorder.

What are the symptoms?

The defining features of Body Dysmorphic Disorder are a distressing and time-consuming preoccupation with an imaginary defect in one's appearance, or excessive concern about a slight physical anomaly. This preoccupation causes significant distress or impairs school or work, personal or social functioning. Although virtually any body part can become the source of preoccupation, BDD most commonly involves the eyes, ears, nose, skin, chin, jaw or other facial features. Other areas of concern include hands, feet, breasts and genitals. People with Body Dysmorphic Disorder are ashamed of their "defect" and invent elaborate means to hide their deformity from the world. Camouflaging behaviors include excessive hair combing and hair removal, ritualized application of makeup and avoidance of situations that might expose the perceived defect. Anxiety, shame and secondary depression are frequent consequences of this disorder. In one case series of individuals with BDD, 30% were so impaired as to remain housebound.

The most frequent co-occurring psychiatric disorders are obsessive-compulsive disorder, social anxiety disorder and depression. Suicidal thinking and gestures are, unfortunately, not uncommon consequences of BDD.

Who is likely to have it?

Body Dysmorphic Disorder often begins as early as adolescence and may remain undiagnosed for years. It is rare for children under 12 to be diagnosed with BDD. Although there have been no formal studies of the frequency of BDD in the general population, it is estimated to affect 1-2% of the United States population. If BDD were simply an extreme form of normal attention to appearance, it would probably be much more common in females because women show more obvious outward signs of appearance concerns. However, BDD appears to affect roughly equal numbers of males and females. Research to date suggests that although the symptoms echo normal appearance concerns, BDD is far more complex and serious a disorder.

Why does it happen?

At this time, theories about the cause(s) of BDD are speculative. Most likely there are multiple factors, including biological, psychological and sociocultural, that contribute to its etiology. Neurochemical factors, such as abnormalities in the brain chemical serotonin, may make some people more likely to express the symptoms of BDD. However, psychological factors such as teasing about one's appearance during childhood, family's or peers' emphasis on appearance or trauma or sexual abuse might also be risk factors for the expression of symptoms. Finally, media messages about appearance might worsen the condition in some vulnerable individuals with BDD.

How is it treated?

Psychopharmacology

The antidepressants known as SSRIs (selective serotonin reuptake inhibitors) are the cornerstone of medication treatment for Body Dysmorphic Disorder. Examples of SSRIs include Prozac, Zoloft and Paxil. The SSRIs are a type of antidepressant used successfully in the treatment of both depression and obsessive-compulsive disorder. People who respond to an SSRI generally experience improvement in several ways. They spend less time thinking about the defect and the thoughts are less intrusive and painful. Compulsive behaviors, such as checking or camouflaging, often diminish. Patients often report that associated anxiety and depression have lessened. Ultimately, self-confidence and self-esteem are enhanced.

Psychotherapy

Although research is still in the early stages, cognitive-behavioral therapy (CBT) appears to be another good treatment for Body Dysmorphic Disorder. A particular type of CBT known as Exposure and Response Prevention has been shown, thus far, to be the most useful type of therapy for BDD. Exposure consists of having the individual expose the physical defect in feared and/or avoided situations (i.e. school or social situations) while response prevention involves helping the individual refrain from performing compulsive behaviors related to the defect. The goal is that, over time, anxiety associated with the feared defect and situation will decrease and the associated behaviors will lessen in frequency. This type of therapy is often recommended in addition to medication.

Questions & answers

How do I know if my adolescent has Body Dysmorphic Disorder?

Body dysmorphic disorder can be a secretive condition and may not be immediately recognizable, even to parents or other family members. Adolescents with BDD may spend a lot of time alone in the bathroom; they may appear to be distant and self-preoccupied. Be concerned if your adolescent engages in excessive grooming rituals or asks repeatedly for assurance about appearance yet is unable to be reassured.

How do I respond to my teenager's requests for reassurance about his/her appearance?

Surprisingly, responding with reassurance will only heighten the concerns. Although it may be difficult, it is best to refrain from providing reassurance. Try to avoid commenting directly about the supposed defect; do not encourage visits to the dermatologist or plastic surgeon but instead support psychiatric treatment.

Will an adolescent with Body Dysmorphic Disorder get over it?

BDD appears to be a chronic condition and we don't yet have a good idea of the long-term course of the illness. We don't yet know if adolescents diagnosed with BDD and stabilized on medication will require the medication throughout their adult life or will outgrow the symptoms.

My 14-year-old son refuses to attend family events because of how he thinks he looks—what can I do?

Besides encouraging attendance at such events, the parents of a BDD sufferer should attempt to get the adolescent into psychiatric treatment. The combination of medication plus cognitive/behavioral therapy can be very helpful in allowing your adolescent to attend family and other social situations.

My 16-year-old wants cosmetic surgery. What should I do?

Research to date shows that surgical treatment is not helpful for adolescents and other sufferers with BDD. Individuals who have surgery are usually dissatisfied with the results, or, if satisfied, tend to re-focus their concerns on another part of the body. Remember, Body Dysmorphic Disorder is a psychiatric and not a surgical disorder.

How do I parent a teenager with Body Dysmorphic Disorder?

There are several things parents can do to alleviate their child's suffering. First, take the disorder seriously. Second, avoid reassuring your child that they look okay but instead encourage them to talk openly about their concerns. Third, encourage and support psychiatric treatment and discourage surgical treatment.