Body Dysmorphic Disorder - FAQ

Dr David Veale, The Priory Hospital, North London

The aim of this site is to answer common questions about the nature and treatment of Body
Dysmorphic Disorder. It is designed for the lay public.
Body Dysmorphic Disorder (BDD) is a mental disorder defined as a preoccupation with a perceived
defect in one's appearance. If a slight defect is present, which others hardly notice, then the concern
is regarded as markedly excessive. In order to receive the diagnosis, the preoccupation must cause
significant distress or impairment in one's occupational or social functioning.
An Italian doctor, Morselli, first coined the term dysmorphophobia in 1886 from "dysmorph" a Greek
word meaning misshapen. It was subsequently renamed Body Dysmorphic Disorder by the American
psychiatric classification. Freud described a patient whom he called the "Wolf man" who had classical
symptoms of BDD. The patient believed that his nose was so ugly that he avoided all public life and
work. The media sometimes refer to BDD as "Imagined Ugliness Syndrome". This probably isn't
particularly helpful, as the ugliness is very real to the individual concerned.
The degree of handicap varies so that some people will acknowledge that they may be blowing
things out of all proportion. Others are so firmly convinced about their defect that they are regarded
as having a delusion. Whatever the degree of insight into their condition, sufferers often realise that
others think their appearance to be "normal" and have been told so many times. They usually distort
these comments to fit in with their views (for example, "They only say I'm normal to be nice to me" or
"They say it to stop me being upset"). Alternatively they may firmly remember one critical comment
about their appearance and dismiss 100 other comments that are neutral or complimentary.
What are the most common complaints in BDD?
Most sufferers are preoccupied with some aspect of their face and often focus on several body parts.
The most common complaints concern the face, namely the nose, the hair, the skin, the eyes, the
chin, or the lips. Typical concerns are perceived or slight flaws on the face or head, such as hair
thinning, acne, wrinkles, scars, vascular markings, paleness or redness of the complexion or
excessive hair. Sufferers may be concerned about a lack of symmetry, or feel that something is too
big or swollen or too small, or that it is out of proportion to the rest of the body. Any part of the body
may however be involved in BDD including the breasts, genitals, buttocks, tummy, hands, feet, legs,
hips, overall body size, body build or muscle bulk. Although the complaint is sometimes specific "My
nose is too red and crooked"; it may also be very vague or just refer to ugliness.
When does a concern with one's 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 or handicap in one's
social, school or occupational life. Most sufferers are extremely distressed by their condition. The
preoccupation is difficult to control and they spend several hours a day thinking about it. They often
avoid a range of social and public situations in order to prevent themselves feeling uncomfortable.
Alternatively they may enter such situations but remain very anxious and self-conscious. They may
monitor and camouflage themselves excessively to hide their perceived defect by using heavy makeup, brushing their hair in a particular way, growing a beard, changing their posture, or wearing
particular clothes or for example a hat. Sufferers feel compelled to repeat certain time consuming
rituals such as:

Checking their appearance either directly or in a reflective surface (for example mirrors, CDs,
shop windows)
Excessive grooming, by removing or cutting hair or combing
Picking their skin to make it smooth
Comparing themselves against models in magazines or television

Dieting and excessive exercise or weight lifting

Such behaviours usually make the preoccupation worse and exacerbate depression and self-disgust.
This can often lead to periods of avoidance such as covering mirrors or removing them altogether.
How common is BDD?
BDD is a hidden disorder and its incidence is unknown. The studies that have been done so far have
been either too small or unreliable. The best estimate might be 1% of the population. It may be more
common in women than in men in the community although clinic samples tend to have an equal
proportion of men and women.
When does BDD begin?
BDD usually begins in adolescence - a time when people are generally most sensitive about their
appearance. However many sufferers leave it for years before seeking help. When they do seek help
through mental health professionals, they often present with other symptoms such as depression or
social phobia and do not reveal their real concerns.
How disabling is BDD?
It varies from a bit to a lot. Many sufferers are single or divorced, which suggests that they find it
difficult to form relationships. Some are housebound or unable to go to school. 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 more productive and satisfying if they did not have the
symptoms. The partners or families of sufferers of BDD may also become involved and suffer.
What causes BDD?
There has been very little research into BDD. In general terms, there are two different levels of
explanation - one biological and the other psychological, both of which may be correct. A biological
explanation would emphasise that an individual has a genetic predisposition to a mental disorder,
which may make him or her more likely to develop BDD. Certain stresses or life events especially
during adolescence may precipitate the onset. Sometimes use of drugs such as ecstasy may be
associated with the onset. Once the disorder has developed, there may be a chemical imbalance of
serotonin or other chemicals in the brain.
A psychological explanation would emphasise a person's low self-esteem and the way they judge
themselves almost exclusively by their appearance. They may demand perfection and an impossible
ideal. By paying excessive attention to their appearance, they develop a heightened perception of it
and become increasingly accurate about every imperfection or slight abnormality. In the end there is
a big disparity between what they believe they should ideally look like and how they see themselves.
What a sufferer therefore "sees" in a mirror is what they construct in their head and this depends
upon a number of factors such as mood and their expectations. The way a sufferer avoids certain
situations or uses certain safety behaviours perpetuates the fear of others rating them and maintains
their excessive attention on themselves.
What are the other symptoms of BDD?
Sufferers are usually demoralised and many are clinically depressed. There are many similarities and
overlaps between BDD and Obsessive Compulsive Disorder (OCD) such as intrusive thoughts,
frequent checking and reassurance seeking. The main difference is that BDD patients have less
insight into the senselessness of their thoughts than OCD sufferers do. Many BDD patients have also
suffered from OCD at some time in their life. Sometimes the diagnosis of BDD is confused with
anorexia nervosa. However in anorexia, individuals are more preoccupied by self-control of weight
and shape. Occasionally, an individual may have an additional diagnosis of BDD when she is also
preoccupied by the appearance of her face.

Other conditions that frequently exist in combination with BDD or are confused with BDD include:
- Apotemnophilia. This is desire to have a disabled identity in which sufferers with healthy limbs
request one or two limb amputations. Some individuals are driven to DIY amputation such as putting
their limb on a railway line. Very little is known about this bizarre and rare condition. However there
are significant differences between apotemnophilia and BDD as cosmetic surgery is rarely successful
in BDD.
- Social phobia. This is a fear of being rated negatively by others leading to avoidance of social
situations or marked anxiety. This usually stems from the sufferers belief that he or she is revealing
themselves to be inadequate or inept. If the concern is only about appearance then the BDD is the
main diagnosis and the social phobia is secondary.
- Skin-picking and trichotillomania This consists of an urge to pluck ones hair or eyebrows
repeatedly). If the skin-picking or hair-plucking is out of concern with ones appearance then BDD is
the main diagnosis.
- Obsessive Compulsive Disorder (OCD). Obsessions are recurrent intrusive thoughts or urges,
which the sufferer usually recognises to be senseless. Compulsions are acts, which have to be
repeated until a sufferer feels comfortable or "sure". A separate diagnosis of OCD should only be
made if the obsessions and compulsions are not restricted to concerns about appearance.
- Hypochondriasis. This is a doubt or conviction of suffering from a serious illness which leads a
person to avoid certain situations and to check their body repeatedly. The International Classification
of Diseases (ICD-10) classifies BDD as part of hypochondriasis whereas the American classification
regards it as a separate disorder.
Are people with BDD vain or narcissistic?
No. BDD sufferers may be spending hours in front of a mirror but believes themselves to be hideous
or ugly. They are often aware of the senselessness of their behaviour, but none the less have
difficulty controlling it. They tend to be very secretive and reluctant to seek help because they are
afraid that others will think them vain.
How is the illness likely to progress?
Many sufferers have repeatedly sought treatment with dermatologists or cosmetic surgeons with little
satisfaction before finally accepting psychiatric or psychological help. Treatment can improve the
outcome of the illness for most sufferers. Others may function reasonably well for a time and then
relapse. Others may remain chronically ill. BDD is dangerous and there is a high rate of suicide.
What treatments are available?
As yet, there have been no controlled trials to compare different types of treatment to determine
which is the best. There have been a number of case reports or small trials that have shown benefit
with two types of treatment, namely cognitive behaviour therapy and anti-obsessional medication.
There is no evidence that psychodynamic or psychoanalytical therapy is of any benefit in BDD, in
which a lot of time is spent looking for unconscious conflicts that stem from childhood.
Cognitive Behaviour therapy
Cognitive Behaviour Therapy (CBT) is based on a structured programme of self-help so that a person
learns to change the way he thinks and acts. A persons attitude to his appearance is crucial as we
can all think of people who have a defect in their appearance such as a port wine stain on their face
and yet are well adjusted because they believe that their appearance is just one aspect of
themselves. It is therefore crucial to learn during therapy alternative ways of thinking about ones
appearance. BDD sufferers need to learn to confront their fears without camouflage (a process called

"exposure") and to stop all "safety behaviours" such as excessive camouflage or avoiding showing
ones profile. This means repeatedly learning to tolerate the resulting discomfort. Facing up to the
fear becomes easier and easier and the anxiety gradually subsides. Sufferers begin by confronting
simple situations and then gradually work up to more difficult ones.
Cognitive Behaviour Therapy has not yet been compared to other forms of psychotherapy or
medication so we don't yet know which is the most effective treatment. However there is definitely no
harm combining CBT with medication and this may be the best option.
Cognitive behaviour therapists come from a variety of professional backgrounds but are usually
psychologists, nurses or psychiatrists.
A directory of accredited cognitive behaviour therapists in the UK can be obtained from the British
Association of Behavioural and Cognitive Psychotherapies (BABCP), PO Box 9, Accrington, BB5
2GD, enclosing a cheque for 3 made payable to "BABCP". A similar organisation exists in the USA the Association for the Advancement of Behaviour Therapy (AABT).
Anti-Obsessional Medication
The second type of treatment is anti-obsessional medication - these are anti-depressants which are
strongly "serotonergic" (or "SSRIs"), which have some success in the treatment of OCD. These drugs
may be used either alone or in combination with a psychological treatment.
There are a number of SSRIs including:

Fluoxetine(UK trade name "Prozac"),

Fluvoxamine( "Faverin"),
Sertraline("Lustral")
Paroxetine("Seroxat")
Citalopram ("Cipramil").

A minority of people may experience nausea, diarrhoea, headache, difficulty sleeping, restlessness,
difficulties reaching orgasm or reduction in libido
The side effects can usually be minimised by taking the drug with food or reducing the dose. Most
people find the side effects are minor irritations and usually decrease after a few weeks. The
exception to this is the sexual side-effects which may persist. The drugs are not addictive and may be
stopped at any time without experiencing withdrawal symptoms. If and when medication is stopped, it
is sensible to reduce it slowly.
Another older alternative is a potent serotonin drug, clomipramine (UK trade name "Anafranil"). The
dose required may be quite high (250mg or more) and this can lead to a number of side-effects
including dry-mouth, blurred vision, constipation, drowsiness, dizziness on standing, inability to reach
orgasm
A doctor will be able to discuss how these side effects can be minimised.
In order to know whether a sufferer might be helped, it will be necessary to take a high dose of the
drug for at least 3 months (for example up to 80mg fluoxetine) . Those people who do get some
benefit may find that they still have some symptoms and that there is a high risk of relapse when they
stop taking the drug.
The risk of relapse can probably be minimised by combining the medication with cognitive behaviour
therapy. Medication is especially helpful when a person is depressed as it may help in improving their
motivation. A family doctor can prescribe you these drugs but he or she will probably refer a sufferer
to a psychiatrist who will be more aware of the condition and the doses of medication required.

An anti-psychotic drug may also be prescribed, such as:

Pimozide (trade name in UK "Orap").

Haloperidol ("Haldol")
Sulpiride ("Dolmatil")
Chlorpromazine ("Largactil").

These drugs are probably only useful in a low dose in a few patients as an additional treatment to
anti-obsessional drugs and after anti-obsessional drugs have been fully tried. They are not thought to
be helpful if used alone. They have different side effects such as stiffness in the limbs or slurred
speech that can be countered by medication such as procyclidine. In low doses the drugs may just
help reduce anxiety. There has been no controlled trials that compares one of these anti- psychotic
drugs with an anti-obsessional drug. Researchers have reported that even "deluded" patients will
respond to anti-obsessional drugs. Therefore if medication is used, these are the treatment of first
choice.
Books
The only book written for sufferers, which is highly recommended is "The Broken Mirror" by Katharine
Phillips. It is published by Oxford University Press and can be ordered at their website.
Patient support groups
In the UK, many sufferers have joined Obsessive Action, Aberdeen Centre, 22-24 Highbury Grove,
London N5 2EA. Although most of the members suffer from obsessive compulsive disorder, there are
a significant number who suffer from BDD that meet at an annual conference. There are also a
number of support groups around the country. In the USA, many sufferers join the OC Foundation.
Research & treatment
A research programme into BDD by Dr Veale is based at The Priory Hospital, North London, The
Bourne, Southgate, London, N14 6RA. Telephone 020 8882 8191. For further information, please
write or telephone and leave your details with Dr Veales secretary or email david@veale.co.uk. It is
difficult to obtain research funding into BDD, and we are always seeking donations for treatment
trials!
At present, Dr Veale does not have an NHS clinic for out-patients. If you require further information
regarding a private assessment or treatment, please telephone the same number and ask to speak to
Dr Veale's secretary.
When severe, the Hospital can provide an intensive programme of cognitive behaviour therapy as an
in-patient or treatment may be provided as an out-patient. An assessment may also be helpful to
obtain guidance on treatment in the NHS locally or at a specialist centre. It is also sometimes
possible to obtain NHS funding for an intensive programme as an in-patient at The Priory Hospital,
North London as it is an NHS provider. If a sufferer does not have medical insurance and there is no
regular income in the family then a reduced fee for an assessment will be considered.
Dr. Veale recognises that many sufferers feel too ashamed to go to their GP. So while he prefers to
have a referral from your GP (or specialist) this is not absolutely essential unless you wish to claim
your fees from your medical insurance.