Body dysmorphic disorder (BDD)

Many people have parts of their body they dislike. Body dysmorphic disorder goes much further: the concern takes up hours of the day, feels extremely distressing and drives repetitive behaviors aimed at checking, hiding or fixing the perceived flaw.

Common areas of concern include the skin, hair, nose, teeth, weight, body shape, facial symmetry or genitals, though any part of the body can be involved. The focus can shift over time.

BDD is related to obsessive-compulsive disorder, and the preoccupations work in a similar way: intrusive, distressing thoughts followed by compulsions that offer brief relief but keep the cycle going. People with body dysmorphia often feel deep shame and may be reluctant to talk about it, worried they'll be seen as vain.

BDD is not vanity. It is a serious condition that can lead to social isolation, depression and, for some, thoughts of suicide. It often begins in adolescence and affects people of all genders.

Body dysmorphia symptoms include preoccupations and repetitive behaviors such as:

• Spending a lot of time thinking about perceived flaws
• Frequent mirror checking, or avoiding mirrors altogether
• Comparing your appearance with others
• Excessive grooming, skin picking or makeup application
• Camouflaging with clothing, hair, hats or posture
• Seeking reassurance about appearance, or seeking it and not believing it
• Taking many photos to check how you look
• Repeated cosmetic procedures or seeking dermatology treatments without feeling satisfied

People with BDD often believe others are noticing or judging the flaw. They may avoid social events, work, school, dating or being photographed. Insight varies: some recognize their beliefs are probably exaggerated, while others are convinced they're accurate.

Body dysmorphia commonly overlaps with depression, social anxiety and eating disorders. Negative body image and body image issues are common in many people, but when they consume time and limit life, a professional assessment is worthwhile.

Muscle dysmorphia is a form of BDD in which a person believes their body is too small or not muscular enough, even when they are visibly fit. It's more commonly reported in men and in people involved in bodybuilding or weight training, but it can affect anyone.

Signs include rigid training routines that take priority over work, relationships or injuries; strict dieting; constant checking of muscle size; distress if a workout is missed; and, in some cases, use of performance-enhancing substances.

BDD also differs from eating disorders, though they can overlap. In eating disorders like anorexia nervosa, concerns usually center on weight and shape and drive eating behaviors. In BDD, concerns can involve any feature. If the main concern is body weight or fat, a clinician will consider whether an eating disorder is a better explanation.

Body image issues and negative body image are much broader and very common. They aren't the same as BDD, but they can still benefit from support.

Researchers believe BDD develops from a combination of factors:

• Genetics: BDD and OCD-related conditions are more common in some families
• Brain differences: people with BDD may process visual details differently, focusing on small features rather than the whole picture
• Life experiences: bullying, teasing about appearance, childhood adversity or abuse are associated with increased risk
• Personality traits: perfectionism, sensitivity to rejection and anxiety
• Cultural pressures: messages about ideal bodies, including through social media and image-editing, can amplify appearance concerns

None of these alone causes BDD, and many people exposed to them don't develop it.

Cosmetic procedures rarely relieve body dysmorphia and may make it worse. Even when the procedure is technically successful, the preoccupation often shifts to another feature or the person remains dissatisfied. This is why mental health treatment is usually recommended before considering any appearance-changing procedure.

Body dysmorphic disorder is treatable, and two main approaches have evidence.

Cognitive behavioral therapy (CBT) for BDD is the leading psychological treatment. It typically includes:

• Understanding the cycle of preoccupation and compulsions
• Exposure and response prevention: gradually facing feared situations, such as going out without camouflage, while resisting checking or reassurance
• Perceptual retraining to view yourself as a whole rather than zooming in on details
• Addressing beliefs about appearance and self-worth
• Reducing time spent comparing and checking

Medication may be recommended by a psychiatrist, particularly for moderate to severe BDD or when depression is present. It's often combined with CBT.

Treatment works best with a clinician experienced in BDD or OCD-related conditions, because standard approaches to self-esteem alone may not address the compulsive patterns. Family members can be involved, especially for teenagers, to reduce reassurance-giving that keeps the cycle going.

A clinical psychologist, psychologist or psychiatrist experienced in BDD or OCD is the best starting point. Because many people with BDD first visit dermatologists or cosmetic surgeons, those clinicians may also refer patients to mental health care.

In a first appointment, expect questions about the features that concern you, how much time you spend thinking about them, behaviors such as checking or camouflaging, how your life is affected and your mood. It's okay if it feels embarrassing to talk about. Clinicians who work with BDD are familiar with these concerns.

Seek help if appearance concerns take up an hour or more a day, you avoid social situations, or you feel hopeless. If you have thoughts of suicide, seek help immediately: call 911 or your local emergency number, or call or text 988 in the US (Samaritans 116 123 in the UK and Ireland).

Meanwhile, try limiting mirror checking and photo-taking, and take breaks from appearance-focused social media.