Could you have body dysmorphic disorder?

It’s normal to pay attention to your physical appearance. How could you not? Our society places a lot of emphasis on beauty, health and physical fitness. Doing things that make you feel upbeat about your body can be good, whether it’s road-testing a new hair color or taking regular spin classes.

In fact, research finds that when you view your body positively, you’re more likely to eat healthy foods and exercise regularly. It’s a positive feedback loop.

But for some people, the focus on appearance moves from being normal into a psychiatric condition called body dysmorphic disorder (BDD). Disliking certain things about your body — such as the shape of your nose, or the curvature of your hips or stomach — becomes overwhelming with BDD. And the feelings that come up can get in the way of normal living.

“Body dysmorphic disorder is a type of mental illness where the distress about perceived body flaws interrupts functioning in work, relationships and life,” says Elizabeth Wassenaar, M.D. She is regional medical director with the Eating Recovery Center in Denver. “People with body dysmorphia often have delusional beliefs about perceived flaws, where others would not perceive any problem at all.”

In other words, someone with BDD truly believes their body looks distorted. And the feelings about that perception are intense, extreme and sometimes all-consuming.

Does this sound familiar? Learn the risk factors, how to spot BDD and when to seek help.

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Who is at risk for BDD?

This disorder can affect anybody. In the U.S., about 2.4% of adults, split equally between men and women, have BDD, says Dr. Wassenaar. It may be higher, too, because some people are undiagnosed. And “most people first develop the disorder in early adolescence,” she says. That’s when people really start comparing themselves to others, according to the Cleveland Clinic.

It’s tricky to say who is most vulnerable, because it varies from person to person. “Exactly when self-evaluation of appearance crosses this invisible line [from normal to disordered] can be hard to pinpoint,” says James Greenblatt, M.D. Dr. Greenblatt is a dual board-certified psychiatrist and chief medical officer of Walden Behavioral Care in Waltham, Massachusetts.

And it’s not always who you think. For instance, a fashion model whose livelihood depends on looking a certain way may not have BDD or ever develop it. This is despite being exposed to constant external critiques of his or her physical appearance. On the other hand, a shy college student who isn’t often in situations where people are obviously judging his or her appearance may develop the disorder.

Still, experts have found certain factors that can raise a person’s risk:

• Environmental influences. People with BDD are more likely to report having been teased about their body or experienced sexual abuse.
   
• Psychological traits. Perfectionism is linked to BDD. The condition is also seen in people with obsessive compulsive disorder (OCD).
   
• Biological elements. People with a family history of BDD may have a genetic tendency toward it.

“How significant each factor is in terms of the emergence of BDD is something that also varies among individuals,” says Dr. Greenblatt, author of Answers to Anorexia and medical director of Psychiatry Redefined. “And the presence or lack of a certain predisposing factor (such as a gene, or perhaps a rigid exercise regimen) does not guarantee that someone will experience BDD or any other psychiatric disorder,” says Dr. Greenblatt.

In other words, not all those who diet, exercise or care about their physical appearance will develop BDD.

And if you’re wondering whether healthy dieting and eating can cause BDD or vice versa, the simple answer is no. “People around the world diet and exercise every day, and of these, very few go on to develop BDD,” Dr. Greenblatt says.

Signs that you might have BDD

So how do you know if self-evaluation of your body is turning into BDD? Here are 5 signs to watch for:

1. Mirror checking is ruling your life. Checking the mirror a few times a day is normal. But when it starts interfering with daily tasks, routines and commitments — even creating feelings of anxiety if you’re not checking — that’s when it’s a problem, Dr. Greenblatt says.

2. You spend hours thinking about your physical fitness. It’s fine to reflect on how you’d like to improve your fitness level, Dr. Greenblatt says. But if you’re spending hours obsessing about your exercise program or skipping important events to work out, that’s a sign it’s affecting your normal functioning.

3. Comparing yourself to others has become extreme. Everybody wants to look their best in public. But if you’re constantly noticing how you measure up to others and becoming stressed by your own self-analysis, you could be dealing with BDD, Dr. Greenblatt says.

4. You withdraw from others. You might avoid social situations, miss school or work and pull back from relationships over concern about your appearance, Dr. Wassenaar says.

5. You pursue excessive body modifications. It’s not unusual for somebody with BDD to look into dermatologic treatments or plastic surgery. That doesn’t mean that everyone who visits a doctor for Botox or consults with a plastic surgeon about their nose has BDD. Still, dermatologists and plastic surgeons sometimes diagnose BDD if people compulsively seek their services, Dr. Wassenaar says.

What to do if you think you might have BDD

Talk with a mental health professional or your doctor if your body or thoughts about your body is a source of stress or disruption. There’s no shame in admitting you’re struggling, and there are professionals trained in this disorder who can be supportive partners.

Getting an expert on board will help you ease a major source of stress, and the sooner you seek treatment, the better your chances of recovering. “If this disorder is treated early, there’s a much higher chance of success and improvement in the distress around the core symptoms of BDD,” Dr. Greenblatt says.

If you’re diagnosed with BDD, a therapist or doctor may work with you using several treatment options, including:

• Cognitive behavioral therapy. Replacing negative thought patterns (“I’m so ugly,” “I’m fat”) with positive thoughts (“I’m thankful for my eyes,” “I did something good for my body today”) is key.
   
• Medication. Selective serotonin reuptake inhibitors (SSRIs) have been shown to be helpful for people with BDD. Treating other mental health conditions such as anxiety or depression with medication may help improve BDD as well.
   
• Nutritional counseling. This can help people have a healthier relationship with food because eating disorders and body dysmorphia can go hand in hand.

The most important thing to remember is that you don’t have to go through this alone.

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Additional sources
Facts about BDD: The Cleveland Clinic. Body Dysmorphic Disorder.
Positive body image associated with healthy habits: Body Image. (2015) What Is and What Is Not Positive Body Image? Conceptual Foundations and Construct Definition.
Causes of BDD: Psychiatric Annals. (2010) What Causes BDD: Research Findings and a Proposed Model.
Teasing and BDD: Oxford Medicine Online. (2017) Environmental Factors in Body Dysmorphic Disorder.
Psychological factors and BDD: Psychiatry Research. (2013) Personality Traits as Vulnerability Factors in Body Dysmorphic Disorder.
Treatment: International Clinical Psychopharmacology. (2021) Body Dysmorphic Disorder.
Treatment options: Evidence-Based Mental Health. (2017) Recent Advances in Understanding and Managing Body Dysmorphic Disorder.