Research & Education

Body Dysmorphia

In an age where there is a growing disconnect between the shapes and sizes of the majority of everyday people “in real life” and those of men and women whose physiques are advertised as some sort of ideal on television online and in print media the issue of body dysmorphia is becoming more common. It’s a rare individual who doesn’t have something about their body they wish were different. But body dysmorphia is more than that. It involves chronic unrelenting self-ridicule that may take over someone’s thoughts to the extent that it interferes with work socialization and mental and physical health.

Body dysmorphia—more formally called body dysmorphic disorder (BDD)—is more than fretting over some post-pregnancy stretch marks a few gray hairs or a couple of pounds that have crept up around the midsection over the years. BDD is characterized by a self-perception that is detached from reality. Individuals may imagine flaws that are nonexistent or they may view very mild and extremely common “faults” in their appearance—things other people don’t even notice—as so disfiguring and aesthetically unpleasing that they take over the person’s thoughts and interfere with everyday life. Put simply individuals with BDD see things that aren’t there. They become obsessed with perceived shortcomings about their physical body either completely imagining things or taking things that are there—blemishes perhaps or scars cellulite or excess body fat—and blowing them out of all rational proportion.

BDD may become so severe that the Mayo Clinic classifies it as “a type of chronic mental illness.” (Indeed BDD is recognized as a unique diagnosable condition in the DSM-IV.) Negative thoughts about one’s appearance can become so pervasive and all-encompassing that they actually lead to more severe conditions such as anxiety eating disorders substance abuse and unnecessary and dangerous cosmetic procedures.

According to the Anxiety and Depression Association of America “BDD most often develops in adolescents and teens and research shows that it affects men and women almost equally. About one percent of the U.S. population has BDD.” It may be surprising that these self-critical thoughts affect men and women nearly equally. It could be that the era of “selfies” and near-fetishizing of tan chiseled male forms rippling with muscles has begun to affect boys’ and men’s psyches the way decades of magazine covers featuring airbrushed and edited photos of perfectly proportioned female models have led some women to believe that their self-worth is determined solely by the size of their waist hips and breasts. 

The precise causes or triggers for BDD are unknown but they may include negative life experiences that lead a lasting imprint such as childhood teasing; a baseline of low self-esteem; pressure to conform to societal standards of attractiveness; and having other psychiatric disorders such as anxiety or depression. Psychiatric comorbidities are common and it may not be possible to tease out which are the causes and which are the effects. For example social anxiety disorder (SAD) and BDD are common comorbidities. It seems logical that BDD could cause SAD but one study suggests that BDD is a subset of SAD.

In a small study at a Veteran’s Affairs primary care behavioral health clinic BDD was found to be associated with “a substantially elevated rate of suicide attempts major depression and obsessive-compulsive disorder.” This trend also applies beyond veterans to the general population where there is a noted high rate of comorbidity between BDD depression and suicide. Obsessive-compulsive disorder (OCD) is a common comorbidity with BDD but the two conditions have significant distinctions and an individual may experience remission in one but not the other.

Healthcare professionals are in a unique position to help identify this problem in their patients. Obviously most family doctors these days encounter patients who do have genuine physical signs of metabolic disturbance such as abdominal obesity skin tags acanthosis nigricans and more. But they may also come across men and women who exhibit some of the signs and symptoms of BDD and these practitioners may be the only people in the patients’ lives who recognize the issue and are willing to broach the subject. It’s difficult to specify the signs to look for but one red flag may be a patient who is at a healthy weight or possibly even underweight yet is seeking advice for achieving an even lower body weight. Other things for practitioners to look out for include signs and symptoms of over-exercising (particularly when combined with undereating) such as fatigue adrenal dysregulation anemia and frequent illness or injury. Among women specifically if patients present with the female athlete triad healthcare professionals may wish to investigate further to see if something psychological is at work beyond physically overtaxing the body. 

As for treatment strategies cognitive behavioral therapy may be helpful and serotonin reuptake inhibiting medication may also alleviate symptoms. Compared to placebo the SSRI escitalopram led to significant improvement of BDD symptoms with the drug delaying time to relapse and fewer escitalopram-treated subjects relapsing than placebo-treated subjects. Additionally consider evaluating these patients for micronutrient deficiencies. Vitamin and mineral deficiencies are recognized as exacerbating other conditions involving unstable moods anxiety depression poor stress tolerance and a negative outlook. Some of the nutrients that may be of benefit include B12 B6 folate omega-3 fats zinc and magnesium.