BDD is a mental health problem related to body image, in which an individual has a preoccupation with one or more perceived or slight defects in his or her appearance. BDD is diagnosed only if the preoccupation causes significant distress, disrupts daily functioning or both 1.
The older term for BDD is 'dysmorphophobia', which was first used by Italian psychiatrist Enrique Morselli over a hundred years ago and is sometimes still used in the UK. The media sometimes refers to BDD as 'imagined ugliness syndrome', but this is inappropriate because the perceived ugliness is very real to the individual concerned. Some people with BDD acknowledge that their distress may be an extreme response to the perceived or slight defect, whereas others are so firmly convinced about their perception that they are regarded as having a false belief. Whatever the degree of insight into their condition, people with a diagnosis of BDD usually realise that others believe their appearance to be 'normal' and have been told so many times; nevertheless, their perception of ugliness is very real to them.
Most people living with BDD are preoccupied with some aspect of their face and many believe that they have several defects. The most common complaints (in descending order) concern the nose, hair, skin, eyes, chin, lips, and the overall body build. People living with BDD may complain of a lack of symmetry. They may feel that something is too big or too small or that it is out of proportion to the rest of the body. BDD may relate to any part of the body, including the breasts and genitals.
Many people have some degree of concern about some aspect of their appearance. To receive a diagnosis of BDD, the person's preoccupation must cause significant distress or impairment in at least one area of their life. For example, someone living with BDD may avoid a range of social situations because of the anxiety and discomfort these situations create. Alternatively, a person may enter such situations but remain very self-conscious. They may camouflage themselves excessively to hide the perceived defect by using heavy make-up, brushing their hair in a particular way, changing their posture, or wearing heavy clothes. They may spend several hours a day thinking about their perceived defect and asking themselves questions that cannot be answered, such as, "Why was I born this way?"
People with BDD may feel compelled to frequently repeat time-consuming behaviours such as:
BDD is recognised to be a hidden disorder, as many people are too ashamed to reveal their problem. Thus, it is not known how many people have experience of BDD. It is also known that BDD is often missed by doctors: 2 people with BDD often have other mental health problems 3 and the BDD may be misdiagnosed or not recognised.
The diagnosis of BDD was removed from the International Classification of Diseases (the diagnostic system used in the UK) in 1992, and instead was included under 'hypochondriacal disorder and other persistent delusional disorders' . 4 , 5 The generally accepted definition of BDD used today comes from the Diagnostic and Statistical Manual of Mental Disorders (DSM) used in the USA. 6
A recent review estimated that between 1 per cent and 4-5 per cent of the population is affected by BDD at any one time. 7 People with a diagnosis of BDD are often seen in dermatology (skin) and cosmetic surgery settings. One study showed that up to 12 per cent of patients seen by dermatologists and up to 15 per cent of patients seeking cosmetic surgery had a diagnosis of BDD. 8
BDD is most likely to develop in adolescence, a time when people are often sensitive about their appearance, but it can also develop in childhood. However, many people live with BDD for many years before seeking help. When they do seek help from mental health professionals, they often do so with other symptoms such as depression, social anxiety or obsessive-compulsive disorder, but do not reveal their real concerns.
As is the case for other mental health conditions, the type and severity of BDD symptoms vary from person to person. Many people living with BDD experience difficulties in relationships with family members and friends because of the behaviours and feelings related to their condition. The symptoms of BDD can also be a barrier to education, employment and leisure activities. Feelings of self-consciousness may lead someone to avoid work, school and social situations. 9 As a result, people living with BDD are likely to experience social isolation. Many have reported feelings of shame, guilt and loneliness.
People living with BDD are usually demoralised. Many have clinical depression or social phobia. In extreme cases, they may be unable to leave their homes. Suicidal thoughts are common, as are suicide attempts. 10 , 11 One study reported that 19 per cent of people diagnosed with BDD had suicidal thoughts, and 7 per cent attempted suicide because of their appearance. 12 Studies have also shown that people with a diagnosis of BDD have a worse quality of life than those with depression. 13
There has been very little research into BDD. In general terms, there are two different theories - one biological and the other psychological. The biological explanation suggests that some people are more likely to develop BDD because of their genetic make-up. Certain stresses or life events, such as teasing or abuse, particularly during adolescence, may trigger the condition. Once the disorder has developed, there may be a chemical imbalance of serotonin or other chemicals in the brain.
The psychological explanation relates BDD to low self-esteem and the way a person judges themselves almost exclusively by their appearance. They may fear being alone and isolated all their life, or believe that they are worthless if they cannot correct the aspect of their appearance that causes distress (the perceived defect). They demand perfection, or an impossible ideal, in their appearance. Once the disorder has developed, it is then maintained by excessive self-focused attention and behaviour, such as checking the perceived defect, making comparisons with other people, avoiding social situations and seeking reassurance.
People living with BDD are not vain, but 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 them vain or self-obsessed.
How is the condition likely to progress?
Many individuals with experience of 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 condition for most people. 14
Some people living with BDD may function reasonably well for a time and then relapse. Others may remain chronically unwell. Research on outcome without therapy is not known, but it is thought that the symptoms persist for many years.
Substance misuse can be common - in one study 49 per cent of patients sampled had a lifetime substance misuse problem and 68 per cent said that their BDD symptoms contributed to their substance misuse. 15
What treatments are available?
There has been little research on the treatment of BDD; however, the National Institute for Health and Clinical Excellence (NICE) has drawn up guidelines based on the evidence available to help healthcare professionals treat BDD. 16
The NICE guidelines state that adults and adolescents experiencing BDD should initially be offered cognitive behaviour therapy (CBT; described below) and be given self-help materials. If this is not effective, they should be offered the choice of more intensive CBT, a course of a serotonin-specific reuptake inhibitor (SSRI) antidepressant, or a combination of the two.
The treatments recommended in the NICE guidelines are not appropriate for everyone. As is the case for all mental health problems, the person may be able to manage and recover from the condition with the help of other therapies, including talking therapies other than CBT, or by using the information available to develop their own solutions.
Some people have resorted to cosmetic surgery (including dangerous and painful 'Do it yourself' surgery 17 ), which can cause high levels of distress, is unlikely to improve the symptoms and has been shown to have poor outcomes. 18
Cognitive behaviour therapy (CBT)
CBT is a combination of psychotherapy and behaviour therapy. The aim is to help a person challenge the thoughts, images, beliefs and attitudes (their cognitive processes) that have negative effects on their feelings and behaviour.
Through CBT, a person develops new ways of thinking and of coping with emotional difficulties. With successful therapy, the person chooses to give up old self-destructive forms of behaviour and experiences improvements in mood and emotional wellbeing.
The focal points of CBT for people with body dysmorphic disorder are attitudes and beliefs about physical appearance in general, and the person's perceived defect in particular.
During therapy, people learn alternative ways of thinking, including ways of directing their attention away from themselves. They learn to give up comparing their appearance with others' and dwelling on their perceived defect. They confront their fears without their camouflage and learn to stop rituals such as checking and excessive grooming. A possible adverse effect of treatment is that anxiety may occur in the short term. However, facing up to the fear is likely to get easier over time and the anxiety gradually subsides.
CBT techniques that may be used are:
These can be delivered individually or in a group. 19
The most commonly practiced CBT technique used for treating BDD is termed 'exposure and response prevention' (ERP). This behaviour therapy works by repeatedly exposing an individual to their perceived defect, obsession or phobia over time so that they become 'habituated', reducing the symptoms. 20
Mind has produced booklets on CBT and other talking treatments (see 'Further reading' for details).
SSRI (serotonin-specific reuptake inhibitors) antidepressants have been available in the UK since 1989. Depression is thought to be associated with lower levels of certain chemicals in the brain, including serotonin. SSRIs block the reuptake of serotonin back into the nerve cells that originally released them, thereby prolonging its action.
SSRIs are prescribed for mental health conditions other than depression, and have had some success in treating people with BDD. However, in its guidelines, NICE has pointed out that evidence for the benefit of SSRIs in treating BDD is limited and less certain than for other mental health problems. Also, it is not known how SSRIs work on the brain to alleviate the symptoms of BDD.
The NICE guidelines recommend that an SSRI is taken daily for at least 12 weeks to determine its effectiveness. If it is effective, treatment should continue for at least 12 months, to allow for further improvements and to prevent a relapse. When the treatment is complete, or the person chooses to stop taking the drug, the dose should be reduced gradually to minimise the possibility of withdrawal symptoms.
More detailed information about SSRIs can be found in Mind's booklet, Making sense of antidepressants (see 'Further reading').
What if treatment doesn't work?
If a first course of SSRIs and CBT with exposure and response prevention (ERP) is not effective, the next step is to try a different SSRI or another antidepressant called clomipramine. Alternatively, referral to a psychiatrist or service that specialises in BDD may be appropriate.
If the symptoms of BDD are severe, other treatment options have not worked, psychotic symptoms are present or there is a risk of self-harm or suicide, a healthcare professional may recommend treatment at a residential or inpatient unit. However, most people with BDD do not have to stay in hospital for treatment.
Many resources are available to help people experiencing BDD who want to learn to cope with and recover from the condition. Organisations such as OCD Action can give advice, information and support (see 'Useful organisations').
Having high-quality, reliable information will help you to assess your situation and choose your next course of action. If you are living with BDD, it will help you feel more confident and less anxious as you learn that you are not alone and that the condition is treatable.
You may be able to manage the condition yourself using a self-help approach and gradually work towards recovery: many books are available as well as online self-help. The internet allows anonymity and physical invisibility: some of the organisations listed under 'Useful organisations' provide online discussion forums and 'virtual self-help'.
You may also want some guidance and support to put a self-help approach into practice. In this case, it is worth finding a counsellor or therapist who uses the same approach as the self-help programme. Accredited CBT therapists can be found through the British Association of Behavioural and Cognitive Psychotherapy (BABCP) and the British Association for Counselling and Psychotherapy (BACP); other types of therapist can be also be found via BACP. Details of both are given under 'Useful organisations'. Some therapists offer sliding rates, depending on a person's ability to pay. Counselling may also be available at your health centre or GP practice or through voluntary organisations in your area. For contact details of voluntary organisations, call Mindinfoline or consult your telephone directory.
Many people living with BDD find it useful to join a self-help group. Meeting others with the condition can help to overcome feelings of shame and isolation. Self-help groups can provide moral support and useful information, including practical tips on how to cope with BDD in daily life. Some groups are online and some meet in person. To find out if there are any self-help groups in your area, contact Mindinfoline or the organisations listed under 'Useful organisations'.
If you feel that you, or a friend or relative, may need medical help for BDD, the first step is to make an appointment with your GP. He or she may suggest that you first try to treat the problem within the GP practice (primary care). This is likely to consist of talking about issues with your GP and possibly taking an SSRI. If your GP practice provides counselling, you may be referred to this service, particularly if CBT is available.
If your problems cannot be treated effectively at the primary care level, your GP can refer you to your local Community Mental Health Team (CMHT) for an assessment and further treatment. All NHS mental health services should be able to provide CBT, though waiting times for treatment vary across health authorities in England and Wales.
If treatment within your local area has proved unsuccessful, your CMHT can refer you to a specialist clinic for BDD. The only NHS specialist clinic for BDD is based at the Maudsley Hospital in South London. Many private hospitals also run BDD specialist services and may accept NHS referrals. However, waiting times may be long because of the high demand for these services, especially for NHS referrals. Waiting times are likely to be weeks for a first assessment and potentially months until the start of treatment, depending on the service being used.
During this waiting period, it is important to take advantage of all available resources that can help you to understand and manage your condition and provide support through difficult times. Your GP, other practice staff (such as counsellors and nurses) and your CMHT can provide valuable support for you during this time.
Anxiety UK
Zion Community Resource Centre, 339 Stretford Road, Hulme, Manchester M15 4ZY
tel: 08444 775 774
email: info@anxietyuk.org.uk
email support: support@anxietyuk.org.uk
website: www.anxietyuk.org.uk
The leading UK charity dealing with anxiety and phobias.
BDD Central
web: www.bddcentral.com
A comprehensive US website for BDD, including discussion forums and an online support group.
British Association for Behavioural and Cognitive Psychotherapies (BABCP)
tel: 0161 797 4484
email: babcp@babcp.com
website: www.babcp.com
The BABCP is the leading organisation for CBT in the UK; its membership includes nurses, counsellors, psychologists, psychologists and trainees, and it is the only organisation that provides accreditation for CBT therapists. The website provides listings of CBT therapists.
British Association for Counselling and Psychotherapy (BACP)
BACP House, 15 St John's Business Park, Lutterworth LE17 4HB
tel: 01455 883 316
email: bacp@bacp.co.uk
web: www.bacp.co.uk
Use the website to search online for a therapist or write for a list of local practitioners, enclosing an A5 stamped addressed envelope.
Centre for Anxiety Disorders and Trauma
South London and Maudsley Trust, 99 Denmark Hill, London SE5 8AZ
tel: 020 3228 2101 or 020 3228 3286
email: anxietydisordersunit@slam.nhs.uk
web: http://psychology.iop.kcl.ac.uk/cadat/
A national specialist clinic and residential unit jointly run by the Specialist Director of the South London and Maudsley Trust and the Institute of Psychiatry (King's College, London).
First Steps to Freedom
PO Box 476, Newquay TR7 1WQ
helpline: 0845 841 0619
email: first.steps@btconnect.com
website: www.first-steps.org
A charity that aims to give practical help to people with obsessions, compulsions and phobias. Services include a telephone helpline, telephone self-help groups and telephone counselling and befriending.
National Institute for Health and Clinical Excellence (NICE)
MidCity Place, 71 High Holborn, London WC1V 6NA
tel: 020 7067 5800
email: nice@nice.org.uk
web: www.nice.org.uk
Independent organisation providing guidance on the promotion of good health and the treatment of ill health. Information for patients is available from the website in addition to full NICE guidance.
OCD Action
Suite 506-509 Davina House, 137-149 Goswell Road, London EC1V 7ET
tel: 0845 390 6232 (9am-5pm, Mon-Fri)
email: support@ocdaction.org.uk
website: www.ocdaction.org.uk
The leading national charity focused on obsessive-compulsive and related disorders, including BDD. Services include self-help groups and an online discussion forum.
The BDD Foundation
email: admin@thebddfoundation.com
web: www.thebddfoundation.org
The BDD Foundation aims to increase awareness and understanding of BDD.
1 American Psychiatric Association 2000, Diagnostic and Statistical Manual, 4th ed, text revision, American Psychiatric Association
2 Grant, J et al. 2005, 'Recognizing and treating body dysmorphic disorder', Annals of Clinical Psychiatry, vol. 17, pp. 205-10 www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1672181
3 Phillips, K 2004, 'Body dysmorphic disorder: recognizing and treating imagined ugliness', World Psychiatry, vol. 3, pp. 12-17 www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1414653
4 Veale, D 2001, 'Cognitive-behavioural therapy for body dysmorphic disorder', Advances in Psychiatric Treatment, vol. 7, pp. 125-132 http://apt.rcpsych.org/cgi/content/full/7/2/125
5 WHO 1992, International Classification of Diseases :Tenth Revision, World Health Organisation www.who.int/classifications/icd/en/
6 Thompson, C 2007, 'Editorial: An increasing need for early detection of body dysmorphic disorder by all specialties', Journal of the Royal Society of Medicine, vol. 100, pp. 61-2 http://jrsm.rsmjournals.com/cgi/reprint/100/2/61
7 Ipser, J 2009, 'Pharmacotherapy and psychotherapy for body dysmorphic disorder', Cochrane Database of Systematic Reviews, issue 2, CD005332. http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD005332/frame.html
8 Thompson, C 2007, 'Editorial: An increasing need for early detection of body dysmorphic disorder by all specialties', Journal of the Royal Society of Medicine, vol. 100, pp. 61-2 http://jrsm.rsmjournals.com/cgi/reprint/100/2/61
9 American Psychiatric Association 2000, Diagnostic and Statistical Manual, 4th ed, text revision, American Psychiatric Association
10 Grant, J et al. 2005, 'Recognizing and treating body dysmorphic disorder', Annals of Clinical Psychiatry vol. 17, pp. 205-10 www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1672181
11 Phillips, K and Menard, W. 2006, 'Brief report suicidality in body dysmorphic disorder: a prospective study', American Journal of Psychiatry, vol. 163, pp. 1280-2 http://ajp.psychiatryonline.org/cgi/content/abstract/163/7/128012 Rief, W 2006, 'The prevalence of body dysmorphic disorder: a population-based survey', Psychological Medicine, vol. 36, pp. 877-85
13 Veale, D 2001, 'Cognitive-behavioural therapy for body dysmorphic disorder', Advances in Psychiatric Treatment, vol. 7, pp 125-132 http://apt.rcpsych.org/cgi/content/full/7/2/125
14 Veale, D 2004, 'Body dysmorphic disorder', Postgraduate Medical Journal, vol. 80, pp. 67-71
15 Grant, J et al. 2005, 'Recognizing and treating body dysmorphic disorder', Annals of Clinical Psychiatry, vol. 17, pp. 205-10 www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1672181
16 National Institute for Health and Clinical Excellence (NICE), 2005, Obsessive compulsive disorder: core interventions in the treatment of obsessive compulsive disorder and body dysmorphic disorder. www.nice.org.uk/cg031
17 Veale, D 2000, 'Outcome of cosmetic surgery and 'DIY' surgery in patients with body dysmorphic disorder', Psychiatric Bulletin, vol. 24, pp. 218-20 http://pb.rcpsych.org/cgi/content/abstract/24/6/218
18 Thompson, C et al. 2007, 'Editorial: An increasing need for early detection of body dysmorphic disorder by all specialties', Journal of the Royal Society of Medicine, vol. 100, pp. 61-2 http://jrsm.rsmjournals.com/cgi/reprint/100/2/61
19 Grant, J et al. 2005, 'Recognizing and treating body dysmorphic disorder', Annals of Clinical Psychiatry, vol. 17, pp. 205-10 www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1672181
20 Anon 2006, 'Treatments for OCD: cognitive-behavioural therapy', Centre for Addition Mental Health
www.camh.net/About_Addiction_Mental_Health/Mental_Health_Information/OCD/ocd_treatments.html
National Institute for Health and Clinical Excellence (NICE), 2005, Obsessive compulsive disorder: core interventions in the treatment of obsessive compulsive disorder and body dysmorphic disorder. www.nice.org.uk/cg031
This factsheet was written Dr David Veale MD, FRCPsych, August 2005; updated by Rachael Twomey, Mind Information Unit, May 2006; and updated by Arj Subanandan, Mind Information Unit, June 2009.