Body dysmorphic disorder

What is body dysmorphic disorder?

Body dysmorphic disorder (BDD) is a condition where a person spends a lot of time worried and concerned about their appearance. This is persistent over a long period of time, rather than just happening occasionally.

Symptoms of body dysmorphic disorder

A person with this disorder may:

• Focus on an apparent physical defect that other people cannot see; or

• Have a mild physical defect, but the concern about it is out of proportion to its actual severity.

For example, a person may think that he or she has a skin blemish or an odd-shaped nose, but either no-one else can see it, or it would be considered trivial by most people. The person becomes preoccupied with the imagined or slight imperfection. For example, he or she may spend a lot of time looking in the mirror or wear camouflaging make-up.

The thought of the defect is very distressing for people with BDD. In some cases the condition can have a great impact on day-to-day life and functioning, and may lead to other mental health conditions such as depression. For example:

• Many people with BDD will avoid social situations, or even avoid going out from the home. This is because they fear that their imagined or trivial flaw will get undue attention from other people.

• Some people with BDD consult a cosmetic surgeon to have the imagined or trivial defect corrected.

• Some people even become suicidal because of the distress caused by this condition.

What causes body dysmorphic disorder?

The cause of BDD is not clear. In some cases it runs in families and it is more common in those with eating disorders.

It is thought that BDD is a similar condition to obsessive-compulsive disorder (OCD). There are similarities between these two conditions. For example, like people with OCD, people with BDD often feel that they have to repeat certain things.

For example, checking how they look, or repeatedly combing their hair, or putting on make-up to cover an imagined defect. These compulsive acts may temporarily ease anxiety or distress.

This is similar to the way a compulsion may temporarily ease the anxiety or distress of an obsessional thought in someone with OCD. Also, the treatment of OCD and BDD is much the same (see below).

Despite their similarities, BDD and OCD are thought to be two different conditions. People with BDD tend to have a greater tendency to suicide, substance misuse and depression. See the separate leaflet called Obsessive-compulsive disorder for more information.

When to see a doctor about body dysmorphic disorder

If you feel that symptoms of BDD are affecting your life, it would be sensible to seek help.

Diagnosing body dysmorphic disorder

There are no tests to diagnose BDD - it is a clinical diagnosis. That means the doctor will make the diagnosis by talking to you about your symptoms, and carrying out a mental state examination which goes through different aspects of your mental health.

Who gets body dysmorphic disorder?

BDD can affect anyone. However, it most commonly first develops in the teenage years. The exact number of people affected is not known but studies suggest that BDD may affect about 1-2 in 100 people, in the general population. In other populations the number affected is higher - for example, up to 1 in 5 people seeking cosmetic surgery may have BDD, and it affects around 7 in 100 of those in mental health settings.

What is the treatment for body dysmorphic disorder?

The usual treatment for BDD is either a talking therapy (cognitive behavioural therapy, or CBT) or a specific type of antidepressant medicine. Sometimes a combination of CBT plus an antidepressant medicine is used. A treatment called exposure and response prevention (ERP) is often used alongside CBT. Each of these treatments is discussed below.

One problem with all treatments is that some people with BDD do not accept that they have a mental health problem. Getting someone to agree to treatment is, in itself, sometimes difficult. If the person does not accept that they have an issue, this is called having a lack of insight.

It is tempting to think that if you had cosmetic surgery, all your problems would be over. However, research suggests that people with BDD rarely do well after surgery and do not get the relief from their symptoms that they would expect to get.

Cognitive behavioural therapy (CBT)

What is CBT?

CBT is a type of specialist talking treatment (a specialised psychological therapy). It is probably the most effective treatment for BDD.

A particular variation of CBT called exposure and response prevention (ERP) therapy is often used for BDD. This means that you are encouraged by your therapist to face situations which arouse your BDD anxiety.

That is, you are exposed to your fearful situations. For example, this may simply be to go to a social event where you would normally be anxious that people would stare at you.

However, you are shown ways to cope with (respond to) your anxiety. For example, by using deep-breathing techniques. ERP treatment would only be given to you after counselling and when you are fully aware of what will happen.

People who have had this treatment often get great benefit from the feeling that they have faced their worst fears and nothing terrible has happened.

How can I get CBT?

Your doctor can refer you to a therapist who has been trained in CBT. This may be a psychologist, psychiatrist, psychiatric nurse, or other healthcare professional.

Therapy is usually done in weekly sessions of about 50 minutes each, for several weeks. This is sometimes done in a group setting, and sometimes one-to-one, depending on various factors, such as the severity of the problem. Sometimes, CBT can be done via regular telephone conversations with a therapist.

Medicines used to treat body dysmorphic disorder

Selective serotonin reuptake inhibitor antidepressants (SSRIs)

Although they are often used to treat depression, SSRI antidepressant medicines can also reduce the symptoms of BDD, even if you are not depressed. They work by interfering with brain chemicals (neurotransmitters), such as serotonin, which may be involved in causing symptoms of BDD. SSRI antidepressants include citalopram, fluoxetine, fluvoxamine, paroxetine and sertraline. The one most commonly used to treat BDD is fluoxetine, as this is the one with the most research evidence to say that it works well for BDD.

Some other points about SSRIs and BDD

Although symptoms may not go completely, they will often greatly improve. This can make a big difference to your quality of life.

You should not stop SSRI antidepressants suddenly. You should gradually reduce the dose as advised by a doctor at the end of treatment. In some people the symptoms return when medication is stopped.

An option then is to take an SSRI antidepressant on a long-term basis. However, symptoms are less likely to return once you stop an SSRI if you have had a course of CBT (described earlier).

Reasons why medication may not work so well in some people include:

• The dose is not high enough and needs to be increased.

• Medication was not taken for long enough - it may take up to 6 weeks to work.

• Side-effects became a problem and so you may stop the medication. Tell a doctor if side-effects are troublesome.

Other medicines that are used to treat BDD

If SSRIs do not help much, or cannot be taken (for example, because of side-effects) then another type of antidepressant called clomipramine is sometimes used. This is classed as a tricyclic antidepressant. Occasionally, other medicines that are used to treat mental health disorders are used.

Prognosis (outcome) for BDD

BDD is a chronic illness - it lasts for many years. About half of all people with BDD will find that their symptoms fully or partially go away with appropriate treatment, but if the symptoms are more severe or have lasted for many years before help has been sought, a cure is less likely. Of those whose symptoms do resolve, around half might then relapse (have more symptoms in the future). Information about outcome is limited by the fact that many people cannot access good-quality treatment for BDD.