• Body Dysmorphic Disorder (BDD) is characterised by persistent and disruptive preoccupation with one of more aspects of your appearance

  • Emma Kilburn shares her own experience of BDD as well as exploring the disorder in more detail

  • We have therapists and counsellors who specialise in body image issues and BDD – find yours here

Body Dysmorphic Disorder (BDD) is a psychiatric disorder whose sufferers are preoccupied with one or more perceived defects or flaws in their appearance. Those defects are usually barely or not at all visible to other people, who are likely to view the person suffering with BDD as ‘normal’ looking, or even attractive.

There is no set pattern in terms of the kinds of defects sufferers identify and then worry about: any part of the body can be disliked. However, whereas people in the general population more often dislike their weight or weight-related aspects of their appearance, those suffering from BDD more commonly dislike their skin, hair or face. And while many people are dissatisfied with the way they look, or have a distorted view of their physical appearance, Body Dysmorphic Disorder goes beyond these more common concerns.

There are three key components to BDD: preoccupation, impairment in functioning, and distress. People suffering from BDD can be constantly preoccupied with negative thoughts about their physical defects. It has been estimated that a third of those with BDD think about their appearance for between one and three hours a day, 40% for between three and eight hours, and a quarter for more than eight hours. Even if someone with BDD is able to think actively about their concerns for only a part of the day, those concerns are always in the back of their mind. Those suffering from BDD can often have only limited control over their thought processes, and find it difficult to resist thinking about their perceived physical defects, however much pain this may cause them. 

Unsurprisingly, a constant preoccupation with their physical appearance can lead to impaired functioning in other areas of a person’s life. People with BDD may experience difficulties in terms of their relationships and social life. It can have a negative impact on their ability to function at school, university or in their job. This can be for a number of reasons. Firstly, thoughts and behaviours caused by BDD can disrupt concentration, making it harder to focus on day to day activities. Secondly, people suffering from BDD may limit themselves, avoiding people and situations due to how negatively they feel about how they look.

Finally, BDD causes distress to those suffering from it. This can vary from mild to moderate to severe, extreme or even debilitating distress. The contents of the sufferer’s thoughts can be very distressing, and can lead to depression, anxiety, and feelings of fear, shame or embarrassment. Feelings of distress can often be exacerbated by a sense of the incommunicability of the sufferer’s feelings. As mentioned, the majority of sufferers appear ‘normal’ to those around them. Even when an imperfection is present, this is likely to be slight and not noticeable to other people. The person with BDD, however, assumes it to be prominent and very obvious to others. 

BDD is not about how sufferers actually look, but about their relationship with their body image, which is a very negative one. Body image is the picture of our body that we carry in our mind. There is always a mismatch between how we see ourselves and how others see us. However, in BDD, there is a much greater discrepancy between these two perceptions, and the sufferer is far too wedded to their own body image to consider any possible, more positive alternatives suggested by how others interact with them, or respond to their physical appearance.

My experience of Body Dysmorphic Disorder

My current therapist first mentioned BDD to me a few months ago. We have discussed my physical appearance relatively infrequently over the three years I have been seeing her, which is surprising given my difficult relationship with it. I think in part this is due to the fact that my negative feelings about it have been normalised over the years, and given that they feel largely immutable, there have seemed to be more pressing issues to discuss in our sessions.

After our initial discussion, I went away and researched the condition. Although it is estimated that between 1 and 3% of the population suffer from BDD, there has been relatively little written about it, compared to some other mental health disorders. Dr Katharine Phillips, a psychiatrist based in New York, has researched and written about BDD, and her books have been immensely helpful to me. In the UK, the Body Dysmorphic Disorder Foundation has a website with sources of support and information. Their website also includes a diagnostic questionnaire that can be used to identify whether someone is suffering from BDD. While I have not seen a doctor to seek a diagnosis, the questionnaire and the literature have both made it clear to me that I most probably am.

Thinking about my relationship with my physical appearance in terms of BDD has actually been quite liberating. Since I have begun to research the condition, I have felt able to consider my negative body image as an issue in its own right, rather than simply as an aspect of my depression and anxiety. This in turn has enabled me, at least partially, to sever the link between my negative views about how I look and low self-esteem. Too often, my perception of my flawed appearance has served to reinforce my sense of myself as inadequate on a broader scale. Like infinite reflections in two perfectly aligned mirrors, each has served to confirm and magnify the other. Yet since I have considered my body image in terms of BDD, I have been able to entertain the idea that it is something that exists apart from my wider sense of self. That’s not to say that this new awareness has enabled me to view either in a new, entirely positive light. Nor has it prevented me, in darker moments, from retreating from my new understanding down a well-trodden path on which I am clear that my external flaws reflect fundamental, inner inadequacies and unattractive qualities. 

One key feature of BDD is the sufferer’s belief that the disliked aspects of their appearance are unchangeable. Despite the feelings of helplessness and despair this provokes and as is the case in other conditions associated with distorted body image, such as anorexia, these deeply self-limiting beliefs are very difficult to dislodge. It is interesting to consider why this might be the case. Research has shown that those suffering from BDD are likely to experience other mental health issues, and in particular longer-term depression. As is often the case with related disorders such as anorexia or bulimia, BDD may be provoked by a particular incident in a person’s life, though it may be hard to identify the precise reason why the body and an individual’s distorted image of it becomes a focus in terms of poor mental health.

From my own point of view, I can trace a sense of dissatisfaction with my physical appearance back to a brief period when I was bullied about my hairline when I started at secondary school. Over time, my physical appearance became a focus for my negative feelings about myself. My appearance and my body became things that had to manage or conceal. I grew quickly in my teenage years, and felt there was too much of me, too much of a body that I had to squeeze into small spaces, whether in the classroom, in assembly or on the bus. That growth spurt worsened my scoliosis - a curvature of the spine - which in turn led to three years wearing a bulky, uncomfortable, fibreglass back brace. The brace and the body beneath it, along with all the other defects I identified along the way, became objects almost external to me that I had to hide, and which were a potential source of shame and embarrassment should I fail to do so. At the same time, my body was an object that couldn't help but look at and engage with, and always negatively.

Aside from the understanding that my relationship with my body image is a distinct one that can be considered and potentially adjusted, my reading around BDD has also given me a valuable insight into possible reasons why sufferers relate to their appearance in the way they do. While neuroscientific research into BDD is still in its infancy, researchers have suggested a link between the condition and an individual’s visual processing. This determines how we see our visual environment and also ourselves. Research suggests that people with BDD may process visual information in a different way to other people. They may over-focus on small details. This is the case not only in terms of their own appearance, but also in relation to the world around them and to other people’s faces in particular. They seem to attempt to extract more information from others’ facial expressions that would ordinarily be the case and have a propensity to misinterpret others’ expressions as dismissive or angry. 

In terms of their own body image, they are more likely to focus too much on minor aspects of their physical appearance, which then dominate their view of themselves, and which have a negative effect on their body image. From my own perspective, this makes a lot of sense, and helps me understand that there may be some truth in other people’s reassurances that they do not see me in the same way that I see myself. I have also, recently, become more aware of the way my visual processing can change in line with whatever aspect of my appearance is most preoccupying me at any particular time. I often look back through old pictures in an effort to establish whether a particular defect has stayed the same or got worse. While scrolling through pictures on my phone recently, having read about the neuroscience possibly underlying BDD, I was aware that the way in which I was viewing images of myself was changing, almost before my very eyes, as aspects of my appearance that are currently most problematic for me seemed to shift and loom larger in the photos, while others receded into the background. Although this was quite a destabilising experience, it helped me understand the shifting subjectivity that underpins my relationship with my physical appearance, and perhaps further emphasised that I should not automatically accept whatever I see in the mirror as an objective reality.

Talking about BDD

People struggling with BDD can find it difficult to discuss the condition with other people. It can leave sufferers feeling very exposed and convinced that their friends will increasingly notice and scrutinise any defect they mention, eventually coming to share their opinion of it. I put a lot of time and effort into concealing and distracting attention away from my perceived flaws. 

While discussing them with friends may help them to understand my anxieties, for people with BDD, any such discussion inevitably draws people’s attention precisely to the things that they are most worried about, and at great pains to conceal. And whichever way the conversation goes, it feels like its outcome is a lose-lose. If friends seek to reassure, the sufferer is unable to take that reassurance on board. Worse still can be the experience of friends telling them that they look fine, that they have nothing to worry about, or comparing their concerns to some aspect of their own appearance with which they are unhappy. BDD sufferers can be left feeling that their difficulties are being minimised, not taken seriously, or even that their friends are being dishonest. 

While I am lucky to have wonderful and supportive friends, my body image has always been my achilles heel in terms of my confidence in my relationships with them. During periods when I have been most self-critical of my physical appearance, I have assumed my friends do not refer to it out of kindness, which nonetheless introduces an element of dishonesty, or concealment, into their relationship with me, which can be very difficult to understand and to deal with. In better moments, I am able to understand that they have a different perception of how I look, which then determines if and how they refer to my physical appearance. Nonetheless, a general sense of being unable to communicate their concerns and make them understood can often leave those with BDD feeling very isolated. And of course, the sufferer’s greatest fear remains that, should they share them, others will validate their concerns. While I may be convinced that my view of my appearance is accurate, as long as I do not discuss it with anyone, there can be some degree of concealment, or possibility of a different view. Once the concerns are out in the open, that concealment no longer seems as possible as it once was, and the greatest danger is that others will feel the same way as the person with BDD. Much better to keep it secret, and to find other ways to manage the anxiety.

Managing Body Dysmorphic Disorder

That need to manage the anxiety caused by BDD consumes huge amounts of the sufferer’s time and emotional energy. This links to the impairment in functioning and preoccupation, the second and third consequences of the condition after the distress it can cause. In BDD, the preoccupation can be almost constant: even when a sufferer is not actively thinking and worrying about their physical appearance, they carry a painful awareness of their body image in their mind. People with BDD seek to manage their distress through certain behaviours, many of which have obsessive compulsive qualities. They can check their appearance regularly and even obsessively in mirrors and other reflective surfaces, seeking to control and/or understand what others see, even if the image reflected back then provokes greater anxiety. Along with other BDD-related behaviours, such as spending lots of time on personal grooming and lots of money on beauty products or clothes, this can sometimes lead others to misinterpret the sufferer’s concerns as vanity or pride - not least since they are generally unaware of the defect on which the person with BDD is focused.

Other behaviours that reflect an attempt to control how the sufferer presents themselves to others can include frequently touching the disliked body part, to check that it is ‘okay’, avoiding photographs, attempting to hide certain aspects of their appearance by maintaining a certain body position, excessive exercise or unnecessary dieting. Of course, none of these behaviours can permanently achieve the outcome the sufferer would want, and both this and the behaviours themselves can create intolerable levels of anxiety.

Psychological behaviours also contribute to this anxiety. Someone living with BDD is likely to frequently compare themselves negatively to other people, a tendency that has been exacerbated and facilitated for many of us by the proliferation of social media. Sufferers feel angry or frustrated about how they look, and may sometimes externalise that anger, which can then have a knock-on effect for their relationships with other people, who are unlikely to understand where that anger is coming from. At times, the anger can be internalised, leading to self-harm or even suicidal feelings, since sufferers often feel that life is not worth living due to their sense of how they look.

The lives of people living with BDD may well be less fulfilling than those of other people. Beyond the psychological toll of a constant preoccupation with their body image, sufferers may often fail to take opportunities that life presents to them due to their concerns about their physical appearance. They may isolate themselves from others, attempting to preempt the rejection they feel is inevitable due to how they look. Sufferers often avoid dating for similar reasons, and it is estimated that around a third of people with BDD struggle with some form of social or performance anxiety. The extent to which the condition impacts an individual’s life obviously varies according to its severity. Many people living with BDD can appear to be thriving professionally and personally, not least because their limiting beliefs and behaviours are usually hidden from others. In the worst cases, sufferers may leave their job or abandon their studies, and confine themselves to their homes.

Treatment for BDD

There are a range of treatments that can help people living with BDD. One that is not recommended is cosmetic surgery. While it is estimated that up to half of people seeking this kind of medical intervention may suffer from some form of BDD, a key element of the condition is the preoccupation with perceived flaws. It is a psychological disorder that requires appropriate treatment. A sufferer who undergoes cosmetic surgery is unlikely to be satisfied with the outcome. There is a danger that their focus will shift to another aspect of their physical appearance, or that they will seek further surgery to rectify flaws whose origins are psychological rather than physical. 

Instead, therapy, and in particular CBT, has been shown to help sufferers challenge and adjust their negative thought processes and limiting behaviours. Given the limited research into and understanding of the condition, the Body Dysmorphic Disorder Foundation emphasises how important it is to find a therapist who has had experience of working with clients with BDD, or some training in the condition. Finally, people may be offered a course of antidepressants, often in conjunction with therapy.

Hopefully, with increased research into and awareness of the condition, further treatments will be identified and sufferers will be able to access the support but also the understanding they need.

For further information, see the website of the Body Dysmorphic Disorder Foundation: https://bddfoundation.org/

You can find therapists for body dysmorphic disorder on welldoing.org here

Dr Katharine Phillips has written a number of books about BDD, including Understanding Body Dysmorphic Disorder: An Essential Guide, and The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder

Emma Kilburn is a writer, teacher and trainee psychotherapist 

Further reading

5 steps towards a better body image

A letter to my body

My journey in body awareness

Staying body positive when the sun is shining

The psychological costs of body shame and self-objectification