Body dysmorphic disorder (BDD)

What is BDD?

BDD is a disorder where an individual believes they have a problem with the appearance of a part of their body, and that is all they can think about.

Another term for BDD still used in the UK is 'dysmorphophobia', although the media today sometimes refer to it as 'imagined ugliness syndrome' (which is a particularly unhelpful term as sufferers really believe they are ugly).

When does a concern with my appearance become BDD?

Many people are concerned with some aspect of their appearance, but to be diagnosed with BDD must be very distressing and have a serious effect on your life. For example, you may:

avoid social and public situations; or
try to hide the part of your body that you are not happy with by wearing heavy make-up, brushing your hair in a particular way or wearing loose clothes.

People who suffer from BDD may spend several hours a day thinking about their appearance and what they think is wrong with it. They may ask for constant reassurance about their appearance, repeatedly check their appearance in front of mirrors, pick their skin to make it smooth, or cut or comb their hair until they think it is perfect. They are very self-conscious, and may have a picture in their mind of the impression they give which no-one else can see and a feeling of shame that others do not experience.

What are the most common areas of the body involved in BDD?

People who suffer from BDD may think that there is something wrong with any part of their body, including their breasts or genitals. However, most sufferers are concerned with one or more aspects of their face. The most common concerns are with the nose, the hair, the skin, the eyes, the chin, the lips, or the overall body build. Sufferers may complain of a lack of symmetry, feel that something is too big or too small, or that it's out of proportion to the rest of their body.

How common is BDD?

It's hard to say as many people with BDD are too ashamed to talk about their problem, but one survey has suggested it affects nearly 1% of the population. It's more common in people with a history of depression and social phobia, and mild BDD is more common in women and young teenagers.

How serious is BDD?

With the most severe cases, BDD can affect your ability to work or study as well as your social and family life. Many sufferers are single or divorced, suggesting that they find it difficult to form relationships. Some sufferers may be housebound, in hospital or attempt suicide.

Are sufferers aware of their problem?

Some sufferers usually realise that other people believe that their appearance is 'normal' and acknowledge that they're blowing things out of all proportion. Others are firmly convinced that they have a problem with their appearance and feel very alone and misunderstood.

What causes BDD?

From what little research there is, causes are thought to be psychological and biological.

BDD may have a genetic influence, and it usually develops in the teens - a time when people are generally most sensitive about their appearance. They may have had bad experiences like being teased or bullied. They will have developed a low self-esteem, may fear being alone and isolated, and begin judging themselves by their appearance.

Is BDD linked with other illnesses?

Sufferers usually feel demoralised or clinically depressed, they may suffer from social phobia and be afraid of social situations. Many BDD patients have also suffered from obsessive compulsive disorder (OCD) at some time in their life.

Are people with BDD vain?

No! People with BDD believe they are ugly or there is something wrong with them. They tend to be very secretive and reluctant to get help because they're afraid others will think they are vain or self-obsessed.

How is the illness likely to progress?

Many people with BDD regularly receive treatment from dermatologists (skin specialists) or cosmetic surgeons but with little satisfaction, or they become concerned about a different feature. Only years later do they get psychiatric or psychological help. Even when they do get help from a doctor or therapist, they often present other symptoms such as depression, social anxiety or OCD, and do not reveal their real concerns.

What treatments are available?

Contacting your GP is often the easiest way to get help and further treatment. He or she may refer you to a specialist for further assessment. This may lead to outpatient treatment or, if more serious, day or inpatient treatment.

If you're worried about talking to your GP, consider writing down your concerns and questions. You can:

take a friend or family member with you;
see another doctor in the practice; or
join a new GP practice.

The type of professional support offered will depend on the services that are available in your area and the arrangements that your primary care trust (PCT) have with other health authorities or private providers. Treatment for BDD is also available privately through Priory.

There has been very little research on the treatment of BDD. Two treatments that have been shown to work include cognitive behaviour therapy and antidepressant medication.

CBT

Cognitive behaviour therapy (CBT) is based on a structured programme of self help, helping you learn to change the way you think and act. During therapy, you will learn different ways of thinking about your problem and to refocus your attention away from yourself. You would learn to confront your fears and stop your rituals, such as checking mirrors and grooming yourself more than normal.

What are the side effects of CBT?

The main side effect of the treatment is the anxiety you will feel in the short term. However, it will get easier and easier to face up to your fear and your anxiety will gradually reduce.

Antidepressants

Certain types of antidepressants called SSRIs have been shown to be helpful in the treatment of BDD.

How long will I need to take antidepressants?

You may have to take a high dose every day for at least 12 weeks so we can work out how effective it is. If the drug is effective, you will need to stay on it for at least a year.

What are the side effects of antidepressants?

Medication may have side effects, but most people suffer only minor irritations that decrease after a few weeks. If you do experience any side effects, we can adjust the dose or prescribe a different drug. The drugs are not addictive, but you should stop them only under medical advice.

Does treatment work?

Treatment works for many sufferers. However, some sufferers may feel reasonably well for a time then go back to old behaviour, while others remain chronically ill. Although there is no research on medication combined with therapy, if you have more severe symptoms then you are more likely to recover from BDD by combining the two.

Self help

Self help may be useful as the first stage of treatment or alongside other treatments. There are also several different self help leaflets and books available. You will need to find the right one for you.

Self help groups, such as those listed on the OCD Action website (www.ocdaction.org.uk), can be a useful support but they do not replace professional treatment. However, they can help sufferers and families understand that they are not alone, and offer valuable support and practical advice.

Finding help

If you feel that you or a close relative are affected by BDD and would like help or more information, you can ask your GP or contact any of the following organisations can provide support.

OCD Action
0207 226 4000 (www.ocdaction.org.uk)

NHS Direct (England and Wales)
0845 4647 (www.nhsdirect.nhs.uk)

NHS 24 (Scotland)
08454 242424 (www.nhs24.com)

The Samaritans
08457 90 90 90 (www.samaritans.co.uk)

The British Association of Behavioural and Cognitive Psychotherapists can provide a list of accredited cognitive behaviour therapists, both private and NHS
01254 875 277 (www.babcp.org.uk)

Priory
0845 2 774 679 (www.priorygroup.com)

If you are interested in receiving treatment from us, your GP will be able to refer you.

If you or your relative have private medical insurance, your insurer will probably insist that your GP refers you to us.

Why should I choose Priory?

Our service

At Priory, our committed and professional staff provide the highest standards of care, understanding and service for everyone. This service brings hope and confidence, allowing our patients to take control of their lives within a safe and secure environment.

Expertise and innovation

Through our close links with the public and private sectors, we've developed the expertise and innovation to offer consistent and successful treatment. And, as Europe's leading independent provider of specialist mental health, neuro-rehabilitation and special education services, we bring experience and an excellent reputation.

We admit patients 24 hours a day, seven days a week. For further information on the Priory hospitals that can help with BDD please click on the links below:

The Priory Hospital Hayes Grove
The Priory Hospital North London
The Priory Hospital Preson
The Priory Hospital Roehampton
The Priory Ticehurst House

Edited by Dr David Veale MD FRCPsych, with the help of Plain English Campaign (www.plainenglish.co.uk)

For more information please click here to download our self-help leaflet