Supporting patients with body dysmorphic disorder
Body dysmorphic disorder (BDD) is a body image problem. It is defined as a preoccupation with one or more perceived defects in appearance which other people can hardly notice, or do not believe to be important. BDD is usually associated with repetitive behaviours such as comparing oneself to others or constantly checking oneself in mirrors. The individual often avoids a wide range of social situations or activities. The perceived ugliness is very real to the individual concerned even if it is not apparent to others.
When does a concern with appearance become BDD?
Many people are concerned to a greater or lesser degree with some aspect of their appearance but to obtain a diagnosis of BDD, the preoccupation must cause significant distress in at least one area of a patient’s life.
Someone with BDD might avoid certain social and public situations to prevent themselves from feeling uncomfortable and worrying that people are rating them negatively. Alternatively, a person may enter such situations but remain very self-conscious. He or she may camouflage themselves excessively to hide their perceived defect by using heavy make-up, brushing their hair in a particular way, changing their posture, or wearing loose clothes. They may spend several hours a day thinking about their perceived defect and asking themselves questions that cannot be answered, for example, ”Why was I born this way?”.
They may feel compelled to repeat time consuming behaviours frequently, such as:
- Checking their appearance in a mirror or reflective surface
- Seeking reassurance about their appearance
- Cutting or combing their hair to make it ‘just so’
- Picking their skin to make it smooth
- Excessively comparing themselves against models in magazines or people in the street
Most people with BDD are preoccupied with some aspect of their face and many believe that they have multiple defects. The most common complaints concern the nose, hair, skin, eyes, chin, lips or overall body build. People with BDD may complain of a lack of symmetry, or feel that something is too big or too small, or that it is out of proportion to the rest of the body. Any part of the body may be involved in BDD including the breasts or genitals.
How common is BDD?
About 2% of the population suffers from BDD, although it is recognised to be a hidden disorder as many people with BDD are too ashamed to reveal their main problem. It is equally common in men and women and about 10% of people receiving treatment at cosmetic surgeries or dermatologists suffer from BDD.
BDD usually develops in adolescence – a time when people are generally most sensitive about their appearance. However, many sufferers wait years before seeking help. When they do seek help through mental health professionals, they often present with other symptoms such as:
How disabling is BDD?
BDD varies from slight to very severe. Many sufferers are single or divorced which suggests that they find it difficult to form relationships. It can make regular employment or family life impossible. Those who are in regular employment or who have family responsibilities would almost certainly find life to be more productive and satisfying if they did not have the symptoms. The partners of sufferers of BDD may also become involved and suffer greatly.
Is there a cause to BDD?
There has been very little research into BDD. In general terms, there are two different levels of explanation – biological and psychological.
A biological explanation would emphasise that a person might have a genetic predisposition to the disorder which, under certain stresses, make it more likely for them to develop BDD. Such stresses, especially during adolescence such as teasing or abuse, may precipitate the onset.
A psychological explanation would emphasise a person’s low self-esteem and judging themselves almost exclusively by their body image. This may be like a ghost from the past when they were teased or rejected. They may fear being alone and isolated all their life, or being worthless. Some may demand perfection in their appearance and an impossible ideal. Once the disorder has developed, it is maintained by:
- Excessive self-focused attention and ruminating
- Avoidance behaviours
- Excessive checking
- Comparing and reassurance seeking behaviours
What are the other symptoms of BDD?
Most people with BDD are usually demoralised and many are clinically depressed or have social phobia or OCD.
BDD is not vanity but rather those suffering with this mental health condition truly believe themselves to be ugly or defective. They tend to be very secretive and reluctant to seek help because they are afraid that others will think that they are vain or narcissistic.
How is the illness likely to progress?
Many individuals with BDD have repeatedly sought treatment from dermatologists or cosmetic surgeons with little satisfaction, before finally accepting psychiatric or psychological help. Treatment can improve the outcome of the illness for most people. Others may function reasonably well for a time and then relapse. Some may remain chronically ill. Research on outcomes without therapy is not known but it is thought that the symptoms of BDD may persist for many years if it is left untreated.
Supporting your patient and their family
Some patients will think that they may be blowing things out of all proportion whilst others are very firmly convinced about their defect. Whatever the degree of insight into their condition, sufferers have often been told that they look ‘normal’ many times but never believe this. It is therefore often unhelpful to tell a person that they look ‘normal’ or attractive. They don’t believe it and so it’s more helpful to open up a conversation about the degree of preoccupation, distress and impairment in their life because of their appearance concerns. It’s important to be compassionate and help the person to approach the difficult step of seeking appropriate help rather than a cosmetic practitioner.
What treatments are available?
NICE guidelines on BDD recommend two treatments
- Cognitive behavioural therapy (CBT)
- Serotonergic anti-depressant medications
CBT is based on a structured programme of self-help so that a person can learn to change the way that they think and act. During therapy, individuals learn to view their image as a bad memory and to refocus their attention away from themselves. They learn to give up comparing their appearance and ruminating and confront their fears without their camouflage, in an attempt to stop rituals such as checking and excessive grooming.
The main side effects of the treatment are the anxiety that occurs in the short term, however facing up to the fear gets easier and easier and the anxiety gradually subsides.
The second type of treatment is anti-depressant medication which is strongly ‘serotonergic’. The dose may need to be in the high range and taken daily for at least 12 weeks to determine its effectiveness.
The medication may provide to be either a total cure or of no benefit at all. If the drug is effective then a person will need to remain on it for at least a year, often longer, as discontinuing the medication may lead to high rate of relapse. We recommend that medication should be used in combination with CBT.
Medication may have side effects but for most people, these are minor irritations that usually decrease after a few weeks. Alternatively, the dose may be adjusted or an alternative drug may be prescribed. Medication is especially helpful if depression is present, as it may help in improving your motivation to take advantage of the CBT.
If you are concerned that a patient may be suffering from BDD, your advice and support will be imperative. Making a referral to a facility that can provide the treatment detailed above will help a patient’s recovery significantly.
Priory has a nationwide network of mental health hospitals and wellbeing centres which provide expert care and treatment for OCD and BDD. Dr Veale is based at The Priory Hospital North London which is known for its specialist OCD and BDD unit. This facility is commissioned by NHS England for sever treatment refractory cases of BDD.
Websites such as www.bddfoundation.org can also be provided to patients. This is the only dedicated charity to BDD.