An Epidemic of Ugliness

There is a disorder known as Body Dysmorphic Disorder (BDD), which is understood to be on a spectrum with or closely related to obsessive-compulsive disorder (OCD) and or depression. This problem has had different names and is not as well known as OCD but turns out to be quite common. New research suggests that BDD may occur in 1-2% of the general population and in approximately 8-12% percent of people seeking help from mental health professionals for problems like depression. Researchers have found it to be common but usually not identified in people seeking hospitalization for depression, people seeking treatment from dermatologists, plastic surgeons and among general medical patients.

What is BDD?

It is a disorder which involves preoccupation with a defect in appearance. The defect however is either nonexistent or so minor as to be insignificant as far as others are concerned. The preoccupation and behavior generated to deal with the concern take up a significant amount of time and cause important interference with the persons functioning. The person with BDD may invest large amounts of time, money and effort into trying to correct or hide the defect or may try to avoid situations where the defect will be noticed. They may spend significant amounts of time checking on their defect or comparing their appearance with others.

The concern with appearance is like an obsession and the behavior can be seen as compulsive. BDD is often called the disease of imagined ugliness because although the person who has it thinks the defect is significant others don’t see it that way. This lack of agreement on the existence or importance of the defect is described as lack of insight. Because most people with BDD have limited insight into their disorder they are more likely to go to a dermatologist or plastic surgeon than to a mental health professional for help. The defect or concern can be focused on almost any part of the body but most common concerns involve the face. Many people with BDD have more than one defect that bothers them. Over time the concern may shift.

People with BDD often have other problems like OCD and even more commonly depression. It is estimated that 80-90% of people with BDD have serious depression. Depression is often so severe that it leads to significant impairment by itself and most people with BDD have had serious suicidal thoughts connected with their appearance concern. Dr Katherine Phillips a leading BDD expert reports that approximately 25% of BDD patients she sees have attempted suicide because of their BDD/depression problem.

If BDD is both as common and as serious as these figures suggest why is it so unrecognized? There are two factors that seem to explain it. One is that most professionals don’t ask. In a study of 122 patients admitted to an inpatient psychiatric unit at a university teaching hospital 13.1% (16 patients) were found to have BDD. However none were given the diagnosis by the psychiatrist treating them. They were never asked about possible symptoms or concerns that would have identified the disorder. The second factor is that people with BDD feel so much shame they almost never volunteer information about the complaint. In the same study all 16 patients with BDD said they would not tell about their concerns because of shame unless they were directly asked.

What can be done to help someone with this problem?

The treatments of BDD that have evolved are the same as those that work for OCD. Medication, primarily the serotonin reuptake inhibitors,can be effective for many people with BDD. Cognitive behavioral therapy (CBT) including exposure and ritual prevention has been found to be an important tool for BDD. Some researchers report that CBT may be more effective than medication. Although the research is still preliminary, a treatment plan combining these approaches is often considered the best choice for most people with BDD. This is especially true if their disorder is severe or accompanied by significant depression. There is no data on self-help treatment of BDD but we know that people with OCD can make important progress working on their own and the same sort of approach would be expected to help BDD. There are only a few books on BDD The Broken Mirror by Phillips and The Adonis Complex by Pope, Phillips and Olivardia. I have written The BDD Workbook with co-author Cherry Pedrick which is a self-help book for people. It was published by New Harbinger.