For seven years, Racheal Baughan wouldn’t leave the house and hid behind a veil or a mask. “I tried to cut the fat off my legs with a knife,” says the author of The Butterfly Girl, a book about body-image problems. Baughan suffers from body dysmorphic disorder (BDD), a mental health condition that affects a person’s body perception.
Ironically, Baughan, who also developed an obsessive-compulsive disorder (OCD) and eating disorder, is the owner of a modelling agency. She explains body dysmorphic disorder as such: “While some have a phobia of spiders, I have a fear of my face and body. Every time I see my reflection or a picture of myself, I see an alien.” She relates to those wanting a sex change who don’t feel that they’re in the right body. “But unlike them, I don’t know what body I should be in,” she adds.
Her mother entered her in the Miss England contest without her knowledge to show how others viewed her. Though she found this intervention upsetting, it helped her overcome BDD.
What is BDD?
Body dysmorphic disorder, aka dysmorphophobia or, colloquially, ‘imagined ugliness syndrome’ is a severe mental illness that involves “preoccupation with an imagined defect in appearance that leads to significant distress and impairments to daily functioning .”
BDD sufferers imagine that they have disfigured faces or other deformities that make them repulsive and disgusting. They believe this false perception to be real, despite assurances that others don’t see their disfigurement. They’re so consumed with their appearance, they spend a lot of time either examining the perceived defect or trying to disguise it.
To compensate for this fixation, they indulge in compulsive behaviour like under/overeating, substance abuse, exercise/sex addiction, or self-harm such as excessive skin-picking (dermatillomania), hair pulling (trichotillomania), and the ingestion of toxic substances or objects.
Body dysmorphic disorder is estimated to affect one in 50 individuals. It usually develops in adolescence, when people are most sensitive about appearance. It affects both men and women. BDD commonly occurs with other types of mental disorders, such as depression, post-traumatic stress disorder, eating disorders, and anxiety. BDD can be so severe, it affects a sufferer’s life, wellbeing, and ability to function. Early intervention is crucial because BDD patients will often self-mutilate or commit suicide.
Italian psychiatrist Enrico Morselli first mentioned body dysmorphic disorder as dysmorphophobia in 1891. The term was derived from the word ‘dysmorphia’, Greek for ugliness. Dysmorphia first appeared in the Histories of Herodotus, referring to the “ugliest girl in Sparta.”
The most famous BDD patient was the Wolf Man, a Russian aristocrat disturbed by his nose. The interpretation of his recurrent dream of being stared at by white wolves was that his nose represented his penis and that he desired to be castrated.
DSM and ICD
Dysmorphophobia was first described in the Diagnostic and Statistical Manual of Mental Disorders (DSM)-III in 1980 as an example of an ‘atypical somatoform disorder’. The term ‘body dysmorphic disorder’ was first used as a diagnosis in DSM III-R in 1987. BDD was justified as patients don’t have phobic avoidance of a physical defect. But most often avoid anxiety-provoking situations or activities. The 5th edition retained BDD in a new section of obsessive-compulsive and related disorders.
The World Health Organization’s International Classification of Diseases (ICD-10) described dysmorphophobia as an example of hypochondriacal disorder*, but ICD-11 now recognizes it as a separate diagnosis.
Psychiatrist David Veale, one of the world’s BDD experts, says symptoms include repeatedly checking one’s appearance and camouflaging or altering imagined defects. Many patients undergo needless cosmetic procedures.
Biological—genetic predisposition; appears after exposure to stressors like abuse. Once body dysmorphic disorder has developed, an imbalance in ‘happy hormones’ may worsen the problem.
Psychological—low self-esteem and a tendency to judge oneself according to appearance. Many BDD sufferers have common histories, which include loved ones’ demise, parents divorcing, being bullied, being abandoned, weight problems, and the feeling of being different.
Social—contributory factors include bullying and social media.
A 1998 study  comparing anorexia or bulimia nervosa to body dysmorphic disorder found that eating disorder patients were preoccupied with weight and body shape. BDD subjects had varied physical complaints and reported more negative self-evaluation and avoidance because of appearance. Both categories had negative self-esteem, but eating disorder patients had more widespread psychological symptoms. Both groups showed equally severe body image symptoms.
Men and women did not significantly differ, although women were more likely to be preoccupied with hips and weight, skin-picking, camouflage with makeup, and have simultaneous bulimia nervosa.
Male subjects were more preoccupied with body build (muscle dysmorphia), genitals, and hair thinning, using a hat for camouflage, and had alcohol dependence. Both genders were likely to seek non-psychiatric medical and surgical treatment. Although BDD’s clinical features appear similar in both genders, cultural norms and values may influence symptoms .
BDD & Eating Disorders
Some overlap exists between their characteristics, including body image dissatisfaction and disturbance, appearance-related rituals and behaviours, and a tendency to compare.
The BDD Foundation reports that 40% of BDD sufferers will also have anorexia. The majority of bulimia nervosa patients say that body dysmorphic disorder contributed to their alcohol use and that they drank to cope with due to body image distress . Drinking as a way to cope with negative effects is associated with lifetime rates of attempted suicide. So young patients with body dysmorphic disorder and co-occurring alcohol use disorder should be carefully monitored for suicidal ideation.
A 2015 UCLA study revealed that people with anorexia nervosa and those with BDD have similar abnormalities in their brains that affect their ability to process visual information . Using functional magnetic resonance imaging (fMRI) and electroencephalography (EEG), researchers found that people with both disorders had abnormal activity in the visual cortex of the brain. Similar distortions in perception shared by anorexia nervosa and body dysmorphic disorder may have similar neurobiological origins. Results may lead to new treatment strategies.
BDD & Aesthetic Procedures
Though patients are concerned about any part of their body, common areas include skin, hair, eyelids, nose, mouth, chin, breasts, and genitals. Because of their lack of insight, BDD patients turn to cosmetic procedures, though less than 10% are satisfied with the outcome. Even when they are, 50% develop a preoccupation with another previously unaffected body part . Addiction with procedures like augmentation or excessive tattoo application then ensues.
BDD & Sexuality
Those with BDD are significantly more likely to have depression, PTSD, or anxiety, and engage in compulsive sexual behaviour. Questionnaire-based measures revealed higher levels of both compulsivity and impulsivity . BDD appears to be common in young adults.
BDD & Dermatillomania
A 2015 study  reported that skin-picking disorder (SPD) simultaneous with BDD resulted in worse picking behaviour, increased impulsivity, and greater cognitive inflexibility. This means that when SPD co-occurs with BDD, unique clinical and cognitive aspects of SPD may be more pronounced.
BDD & Social Anxiety
BDD can trigger anxiety disorders, such as phobias and social anxiety. Those with body distortions have difficulty relating to others for fear of being rejected, shamed, or ridiculed. They avoid social situations because they don’t want others to see and judge them and because their perceived defect causes them to be afraid of dating or intimacy.
BDD in Young People
Pediatric dermatologists can play an important role in detecting BDD‐like symptoms, which may occur in 20% of dermatology patients .
Despite scant research, some studies suggest that comorbidity** in adolescents are similar to those in adults, but the association between BDD and developmental disorders, such as attention-deficit hyperactivity disorder or autism spectrum disorder, has not been studied. Though comorbid substance abuse and body dysmorphic disorder has been associated with higher rates of lifetime suicide attempts, the risk for alcohol abuse in young BDD patients is unknown .
BDD & Substance Abuse
To help them endure symptoms, BDD sufferers employ harmful strategies, such as drinking alcohol or using drugs to excess, or they may become housebound. Lifetime prevalence rates of alcohol use disorders in body dysmorphic disorder are high.
Study participants reported drinking because of body image upset (49.5%), to forget about these concerns (52.5%), or to feel more comfortable about their appearance around others (59.4%). Coping and enhancement motives were positively associated with lifetime BDD severity and attempted suicide .
BDD & OCD
Considering BDD’s obvious symptom similarities with OCD, Rossell et al compared the two using neuroimaging techniques . They found that there are limbic and visual cortex abnormalities in BDD, compared to frontostriatal differences in OCD. This means visual training may be useful in BDD.
BDD patients are at high risk for depression and suicide. They have a greater degree of distress than people with depression, diabetes, or bipolar disorder. Surveys report approximately 80% of BDD individuals reported suicidal ideation, and about 25% had attempted suicide. Approximately one-third of BDD sufferers reported violent behaviour .
“One in 330 people commit suicide each year because of BDD, so the media should help to raise awareness and reinforce that it’s a treatable condition,” says Veale.
People who manifest BDD symptoms are advised to consult mental health professionals for specialized treatments, such as exposure therapy, medications, response/exposure prevention, and family support. The best evidence-based BDD treatment is a combination of antidepressants and cognitive behavioural therapy (CBT).
Perceptual retraining, a behavioural exercise that adjusts or corrects participants’ balance of global and detailed processing, is also effective.
Visual training with eye-tracking software and neuropsychological tests like Stroop Task help in showing patients their distorted views compared to the norm.
Evidenced-based treatment is minimal due to lack of research. As people are hesitant to ask for help and medical professionals often misdiagnose the condition, education and awareness campaigns are crucial.
While body dysmorphic disorder is not an eating disorder, it may be incorrectly perceived as such. Those with eating disorders should also be screened for BDD to appropriately address these with a comprehensive and individualized treatment plan. Further research is needed to better understand the complexities of this mental illness and improve treatment methods.
* Hypochondria: abnormal anxiety about one’s health.
** Comorbidity: the simultaneous presence of two chronic diseases or conditions in a patient.
 Diagnostic and Statistical Manual of Mental Disorders
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