What is body dysmorphic disorder? 7 signs to know

Health officials have advised that people seeking cosmetic procedures ought to be screened for body dysmorphic disorder (BDD).

The National Institute for Health and Care Excellence (NICE) said that healthcare professionals “do not routinely ask about or explore whether people have intrusive thoughts, images, urges, impulses, doubts, or worries about appearance”, and has called for greater efforts to identify those who may be experiencing BDD.

New draft guidance, aimed at improving the identification of BDD and obsessive compulsive disorder (OCD), recommends that professionals carrying out cosmetic procedures should use structured questions to explore patients’ concerns about their appearance before treatment goes ahead.

It advises that patients suspected of having BDD should be referred to a specialist for further assessment and support being proceeding with any procedures.

Despite affecting many people, body dysmorphic disorder remains widely misunderstood. We spoke to some experts about how the condition differs from everyday concerns about appearance, as well as seven common signs that could suggest someone may be struggling with BDD.

What is body dysmorphic disorder?

“BDD is a preoccupation with what someone either perceives as a defect in their appearance, or they’ve got excessive concern about something where there might be a slight physical anomaly,” explains Dr Lorna Richards, consultant adult psychiatrist at Central Health London.

“What we mean by the term preoccupation is an intrusive thought that is unwanted and takes up a lot of time.”

What makes it different to normal worries about appearance?

“The main characteristic that distinguishes BDD from day-to-day body concerns that we have generally in the population is an excessive concern about flaws in their appearance,” says Dr Michelle Carr, lead psychologist at Cygnet Health Care.

“It might be that all they want to talk about is the flaws that they’re seeing, which are often not noticeable or are very minor to other people, but it causes real distress for them.”

The psychologist highlights how these thoughts can have a significant impact on someone’s life.

“When they’re thinking about it so much, they might be unable to get their jobs and tasks done and might stop engaging with people,” says Carr.

Richards agrees and adds: “It can impact people’s intimate relationships and their ability to function socially or in an educational setting because of how self-conscious they feel about the perceived defect.

“They might even become housebound because of it.”

BDD can lead to depression, self-harm and even thoughts of suicide, according to the NHS website.

What are signs that might indicate someone is struggling with BDD?

1. Frequently checking mirrors

“People with BDD will often have repetitive behaviours, just like in OCD, to try and reassure themselves or to check on this thing that’s preoccupying them, so they might constantly checking themselves in mirrors, for example,” says Richards.

2. Skin picking

“They might start to pick at their skin or repetitively groom themselves,” says Carr.

3. Avoid reflective surfaces completely

“Although some people might frequently check their appearances in mirrors or in windows, there are some people with BDD on the complete opposite end of that who avoid mirrors and reflections altogether because they cannot tolerate what they’re seeing,” says Carr.

4. Start to dress differently

“If they have a concern about their body shape, they might start dressing to hide what they think is wrong or if they are conscious about something on their face they might change their hair to cover their face,” says Carr.

“These are little things that family members and loved ones who know them well will often pick up on, that someone less close might not notice.”

5. Seeking constant reassurance

“Seeking constant reassurance about their looks or the aspects of themselves which they feel aren’t right is also common for people with BDD,” says Carr.

6. Withdraw socially

“Some people with BDD start to avoid social situations,” says Carr.

Richard agrees and notes that this is often due to feelings of shame.

“When I see patients, they always feel a huge amount of shame and disgust and they often hide and don’t feel comfortable talking about it,” says Richards.

7. Have delusional beliefs

“In some people the beliefs can be delusional in intensity, so can be held to a really fixed intensity,” says Richards. “It’s not a preoccupation that people can sometimes talk themselves round and decide that actually maybe they’re being excessive in their concern about it. It goes beyond that and can become a delusional belief.”

How is it treated and managed?

The symptoms of body dysmorphic disorder (BDD) can get better with treatment.

“Most people have a combination of antidepressant medications and psychological therapy, largely Cognitive Behavioural Therapy (CBT),” says Richards.

“There’s a specific form of CBT that’s been adapted for the treatment of BDD which is usually about 16 to 20 sessions.”

Carr adds: “The CBT framework helps people work through these thoughts, feelings and behaviours and sense check them.”

Is there anything family members can do if they are worried?

“If you see a significant shift in a loved one, try to be really compassionately curious with that person in a non-judgmental way,” advises Carr.

“Instead of saying ‘why are you acting differently? Why have you changed this thing about yourself?’ etc, which can feel quite targeting, you could say ‘I’ve noticed that you are wearing different clothes or have changed your hair and I’m just wondering what’s made you do that?’”

“It’s about getting to the bottom of their internal world and finding out what has changed for them.”

She also encourages family members to seek urgent help if they suspect thoughts of self-harm or suicide due to EDD.

“Seek urgent help and do not delay,” advises Carr. “It might rupture the relationship initially because that person might not want professional help at that time, but it’s all about keeping that person safe.”