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What Is Body Dysmorphic Disorder?

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What is BDD? Why are so many people unhappy with their bodies? What can you do to be happier with your body? How do people overcome BDD?

body dysmorphic disorder is a mental health condition (classified in the DSM V under the category of obsessive-compulsive disorders) in which the person with BDD is unhappy with one aspect or more of their body. For instance, the person may feel their teeth are too large or too small. Or their eyes are somehow “wrong”. Body dysmorphic disorder can be linked to any part or parts of a person’s body.

What are the indicators that someone is experiencing dody dysmorphic disorder?

People experiencing body dysmorphic disorder display several key indicators. Firstly, they express discontent with one or more aspects of their body, either to themselves or to others. This discontent escalates to the point of preoccupation, similar to an obsessive compulsion, especially if they think about it for more than one hour a day. Moreover, this preoccupation with the perceived flaw leads to noticeable impairment and detriment in the person’s life.

Repetitive behaviours are associated with preoccupation, such as the following:

  1. They either avoid mirrors (to escape being confronted with the perceived flaw/s) or regularly look in the mirror to confirm that the flaw/s is/are as bad as they thought.
  2. Attempting to or successfully hiding the concerning body part/s.
  3. Engaging in exercise or grooming beyond normal or healthy frequency.
  4. Comparing themselves to others much more than most people do.
  5. Either seeking validation from others more than the norm or avoiding situations that may allow others to see and comment (negatively) on the perceived flaw.
  6. The fear of being judged may drive elements of agoraphobia or social phobia.
  7. Anxiety is present and is focused on the perceived bodily flaw/s.

In many, if not most, cases of dody dysmorphic disorder, the flaw is only seen by the person experiencing the BDD.

To outsiders, the focus of the BDD may seem trivial or even imaginary. Not so for people with BDD; 2% of the adult population experience BDD, and around 2% are so disturbed by their perceived flaw that they attempt suicide. To sufferers of BDD the emotional pain is very real.

In therapeutic settings, it is relatively common for a client to present a problem such as social anxiety, agoraphobia, or excessive people-pleasing when the root cause of those apparent problems is body dysmorphic disorder.

Other forms of body dysmorphic disorder include muscle dysmorphia, where the person works out in the gym excessively to build muscle. It is almost always males who are so impacted. They have an obsessive diet, which sometimes crosses the line into dysfunctional eating, which does more harm than good. Some, not all, bodybuilders experience Muscle Dysmorphia.

Many mental health disorders are conditions of proxy; that is, one person has the disorder through another. Body dysmorphic disorder by proxy is the label that describes one person being excessively concerned about another person’s real or imagined bodily imperfections.

A feature of Body Dysmorphic Disorder that makes it worse is that sufferers are so ashamed of the flawed part/s of their bodies that they are afraid or embarrassed to ask for help. Many have suffered for over 10 years before getting help.

As most people know, youngsters are prone to comparing themselves to others. It will come as no surprise, therefore, that most cases of BDD emerge between puberty and the early twenties, although any treatment can come much later.

What causes Body Dysmorphic Disorder?

Is there any known pathogen? No. Are there any biochemical imbalances causing it? If there are, we haven’t yet found them.

Perhaps we can look for an explanation by exploring the response of people who have bodily variations which are profoundly different from the norm: Amputees, those born with highly visible genetic or congenital differences, such as scoliosis, dwarfism, Marfan syndrome and many others.

We can ask: do all such people suffer from body dysmorphic disorder? Absolutely not. Are they aware of their differences? Yes. Do they acknowledge their differences? Yes. Do they suffer mental health problems that are focused on their differences? No, most do not.

In some cases, the exact opposite is the case. Paralympians, for example, are mentally very fit, much fitter than most of the population, as is usually the case with elite athletes in any category. Many (most?) embrace their difference and seek to make the best of them.

That tells us that whatever is the cause of body dysmorphic disorder, it is unlikely to be in any actual physical difference and more likely to be rooted in the way any real or imagined difference is processed.

How do people with highly visible differences cope with the almost inevitable attention of others; people doing a “double take” as they notice the difference, people staring, people avoiding eye contact from their own discomfort at seeing such a difference?

In my experience, those with profound variations from the norm acknowledge that people notice their differences. They know that some observers are curious (and look more than is normal), and others over-empathise, and can’t engage because of the fear it generates… In brief, most people with highly visible differences accept that others will react in their own way to what they see.

Why does one person with a profound bodily difference become an elite Paralympian and another with a difference only discernible to themselves becomes disabled by Body Dysmorphic Disorder?

What causes Body Dysmorphic Disorder?

There is no shortage of vague and untestable theories, as is the case in most of the fields of mental health. Here are some: Childhood trauma, negative role models, family history of obsessive and/or anxiety disorders.

Almost all mental health problems involve so many variables which could, theoretically, be causal, that asserting a cause for any such condition in any one person is… (searching for a diplomatic phrase) … at best, speculatory, and at worst, delusional.

If I were to join the mass ranks of speculators opining about the causes of body dysmorphic disorder, I would suggest that the most likely cause starts with a comparison to others, coupled with lower self-esteem. That then leads to negative self-talk, which creates unpleasant emotions, turning into habits and eventually into the person’s identity.

Some drugs are used to ‘treat’ Body Dysmorphic Disorder. Treat is emphasised to allude to the key problem in BDD: if we don’t know what causes it, then any drug “treatment” given is prescribed in hope, not knowledge.

The drugs most often used to “treat” BDD, are SSRIs, (Selective serotonin reuptake inhibitors). The fact that SSRIs are used for so many completely different mental health problems (from depression to anxiety, from OCD to PTSD), tells us how little we really understand about the causes of such challenges.

At best, we can say that increasing serotonin levels may improve mood to the point where talking therapies can help. Alas, the evidence indicates that SSRIs are no more effective than placebos (and in some cases, they are less effective). Talking therapies are typically 10–30% effective. Expressed the other way around, they are 70–90% ineffective. Would you hire a professional, say a plumber, with a 70–90% failure rate? Of course not. Yet the mental health ‘profession’ fails that often, every day.

That said, some (very rare) therapists consistently achieve more successful outcomes. What seems to help best with BDD (and other mental health problems) is the quality of the rapport with the therapist and the commitment the BDD sufferer has towards overcoming the problem.

Generally, the more engaged a person, and the more they take self-responsibility for overcoming their problem, the more likely they are to overcome it.

In cases of body dysmorphic disorder, what helps most? In my experience, helping people to change their mental and emotional habits. Substituting disempowering mental and emotional states for empowering ones.

Identifying and replacing self-destructive beliefs with those that help. The better the rapport with the therapist, the more the person will feel safe to try better ways of overcoming the problem (than those that previously did not work). The better the rapport, the more supported the person feels in undertaking the journey to recovery. The better the rapport, the more they believe recovery is possible.

If you experience BDD and you want a therapist, choose one who has faith in you, who sees your potential, who expects you to get better, and ideally, who expects you to turn what was a liability in to an asset. If you have found a good therapist, you will know: you will have with them one of the best rapports of your life.

The more you and the therapist connect and believe that you can and will recover, the more persistent you will both be, in finding the best way for you to be, your best you.

Choose your BDD therapist, or any other therapist, carefully.

Professor Nigel MacLennan runs the performance coaching practice PsyPerform.


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