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Body dysmorphic disorder (BDD)
Body dysmorphic disorder (BDD)
Explains what body dysmorphic disorder (BDD) is, the symptoms and possible causes of BDD and how you can access treatment and support. Includes tips for helping yourself, and advice for friends and family.
What is body dysmorphic disorder (BDD)?
Body dysmorphic disorder (BDD) is an anxiety disorder related to body image.
You might be given a diagnosis of BDD if you:
- experience obsessive worries about one or more perceived flaws in your physical appearance, and the flaw cannot be seen by others or appears very slight
- develop compulsive behaviours and routines, such as excessive use of mirrors or picking your skin, to deal with the worries you have about the way you look.
If you have BDD, these obsessions and behaviours cause emotional distress and have a significant impact on your ability to carry on with your day-to-day life. In this way, BDD is closely related to obsessive-compulsive disorder (OCD).
BDD can vary in severity from person to person and from day to day. For some of us, concerns around appearance may make it difficult to go out in public or see other people. This can have an impact on our work life and relationships with other people.
“It varies day-to-day. It can sit quietly or it can be completely debilitating.”
BDD may also cause other problems, such as:
- feelings of shame, guilt or loneliness
- isolating yourself to avoid situations that cause you anxiety or discomfort
- depression or anxiety
- misuse of alcohol or other drugs
- feeling you need unnecessary medical procedures, such as cosmetic surgery
- eating disorders
- self-harm
- suicidal thoughts.
Many people with BDD do not seek help because they are worried that people will judge them or think they are vain. This means that many people with BDD are likely to experience it for a long time before seeking support.
What are the common signs and symptoms of BDD?
People with BDD see themselves differently to how others see them. Although everyone’s experience of BDD is unique, there are some common signs:
Common obsessive worries about the body
If you have BDD, you experience intrusive, negative thoughts about one specific area of your body, or several areas of your body, which you think are:
- out of proportion
- too big or too small
- disfigured
- lacking symmetry.
These thoughts cause you significant anxiety, and you will often spend several hours a day thinking about the area or areas of concern.
BDD can affect any area of the body, but common areas of anxiety include your skin, hair, nose, chin, lips or genitals.
BDD and eating disorders
BDD and eating disorders share similar symptoms, such as:
- having poor body image
- worrying excessively about your physical appearance
- developing compulsive behaviours to try to deal with these worries.
However, BDD and eating disorders are not the same. When a person is experiencing an eating problem, such as anorexia nervosa, they are mainly concerned about their weight and shape. Someone experiencing BDD is likely to experience other concerns around body image – for example, they may also have concerns about a particular facial feature.
Some people with BDD experience an eating disorder but not all people with eating disorders have BDD.
A mental health professional, such as a psychiatrist, can assess your symptoms to help you find out whether you are experiencing BDD, an eating disorder or both. For more information, see our pages on eating problems.
“I’ve struggled with BDD for 13 years. It changes. Sometimes it is something little, like my nose, that is really bothering me that day. Sometimes it is every centimetre of my body that just feels wrong.”
Common compulsive behaviours
If you have BDD, at some point during the course of your obsessions you develop compulsive behaviours and routines to deal with the anxiety you feel about your appearance.
You may spend hours each day carrying out these behaviours to try to reduce your anxiety. The behaviours may briefly lessen your worries, or they may make you feel worse.
Common compulsive behaviours include:
- obsessively checking your appearance in mirrors, or avoiding mirrors completely
- using heavy make-up to try to hide the area you’re concerned about
- changing your posture or wearing heavy clothes to disguise your shape
- seeking constant reassurance about your appearance
- exercising excessively, often targeted at the area you’re concerned about
- frequent body checking with your fingers
- picking your skin to make it smooth
- excessive use of tanning products
- frequent weighing
- brushing or styling your hair obsessively
- constantly comparing yourself with models in magazines or people in the street
- seeking cosmetic surgery or having other types of medical treatment to change the area of concern.
What is muscle dysmorphia?
Muscle dysmorphia (or muscle dysmorphic disorder) is a type of BDD where you experience obsessive worries about your body being too small, skinny or not muscular enough. Despite these worries, you are of average build or, in some cases, exceptionally muscular.
This often leads to compulsive behaviours that focus on building muscle, such as:
- spending excessive time exercising, specifically lifting weights
- taking nutritional supplements
- busing steroids and other substances.
You can find out more about muscle dysmorphia on the Body Dysmorphic Disorder Foundation website.
What causes BDD?
No one knows exactly what causes BDD. However, recent research suggests that there are a number of different risk factors that could mean you are more likely to experience BDD, such as:
- abuse or bullying
- low self-esteem
- fear of being alone or isolated
- perfectionism or competing with others
- genetics
- depression, anxiety or OCD
Abuse and bullying
Experiencing abuse or bullying can cause you to develop a negative self-image and may lead you to have obsessions about your appearance. This is particularly true if you experience abuse or bullying when you are a teenager, when you may be more sensitive about the way you look or how your body is changing.
Fear of being alone or isolated
If you worry about not fitting into a group of friends or being lonely, you may develop thought patterns that can lead to BDD. For example, if you believe that you need to look a certain way to maintain friends or find a partner, you may develop unhelpful concerns about your appearance. If a relationship then breaks down or a friendship group changes, this could make your concerns worse.
“There have been so many times where I have looked in the mirror and just cried. Or I’ve thought I looked okay but two seconds later I will feel that it is all still wrong.”
Perfectionism or competing with others
If you try to appear physically ‘perfect’ or you regularly compare your appearance to other people, you may be more likely to develop BDD. If you have a hobby or job that is very focused on your body – for example, modelling, bodybuilding or gymnastics – you may be at greater risk.
What treatments are available for BDD?
If you think you may have BDD, going to your GP is a good place to start. Your GP can provide an assessment and diagnosis, and help you access appropriate treatment. If you’re worried about going to your GP, you might find it helpful to read our pages on seeking help for a mental health problem.
If you are diagnosed with BDD, your GP should offer you treatment options according to the National Institute of Health and Care Excellence (NICE) guidelines. What you are offered may depend on the severity of your symptoms, but ideally you should be given CBT before you are prescribed any medication.
The NICE guidelines on the treatment of BDD recommend:
- cognitive behavioural therapy (CBT) – with self-help materials such as books or computer programs, via telephone, or via a series of sessions with a therapist in a one-to-one or group setting
- medication – either on its own or combined with CBT
- specialist services for BDD, if other treatments do not work.
As it is not uncommon for any of us to worry about our appearance, the signs of BDD can be missed by professionals.
If you feel your GP does not recognise your symptoms and you are not getting the treatment you need, you may find it useful to get an advocate to support you.
Cognitive behavioural therapy (CBT)
CBT is a form of talking therapy that aims to identify connections between your thoughts, feelings and behaviours. It can also help you to develop practical skills to manage them. CBT can be delivered one-to-one or in a group.
For BDD, the aim of CBT is to address the key features of BDD to gradually make you feel less anxious about your body, focusing on:
- improving your general attitude to body image and physical appearance
- your concerns about your perceived physical flaw(s)
- reducing your need to carry out unhelpful behaviour.
CBT is available through the NHS. Your GP should be able to refer you for CBT. In England, you may be able to refer yourself via the Improving Access to Psychological Therapies (IAPT) programme.
There is a useful tool on the NHS website which can help you find which psychological therapy services are available in your local area, or you can try searching on the NHS’s general health services search tool (both England only).
NHS waiting lists for CBT can be long, so you may decide to see a therapist privately if you are able to. Accredited CBT therapists can be found through the British Association for Behavioural and Cognitive Psychotherapies (BABCP). See our page for tips on finding a private therapist.
Exposure and response prevention in CBT
A behavioural element of CBT – known as exposure and response prevention (ERP) – is recommended for BDD. This technique makes you confront your obsessions so you become used to dealing with them. This means:
- facing situations where you would normally think obsessively about the part of your appearance that concerns you, to help you cope better with these situations over time
- developing techniques to help you avoid carrying out compulsive behaviours (such as mirror checking) when you would normally want to.
This technique needs to be carefully managed to avoid causing additional anxiety and distress, so it is important that you understand the treatment fully and feel comfortable with your therapist.
Medication
You may be prescribed antidepressants, either on their own or in combination with CBT, if:
- CBT is not successful in treating your BDD
- your BDD is causing you moderate to severe impairment.
The type of antidepressant prescribed will usually be a serotonin-specific reuptake inhibitor (SSRI). This can help to reduce obsessive thoughts and behaviours.
SSRIs can cause unpleasant side effects so it is a good idea to discuss this with your GP. You can also take a look at our information on what you should do before you start taking medication.
If a first course of SSRIs and more intensive CBT is not effective, the next step is to try a different SSRI or another antidepressant called clomipramine.
Specialist services
If initial treatment is not helpful, your GP can refer you for specialist help. This could be through community-based mental health and social care, where you will be given a more thorough assessment by the community mental health team (CMHT). Your CMHT will develop a potential care plan with you, which may include support from a service that specialises in BDD.
Access to specialist services is limited across the country and you may need to travel outside your local area. Waiting times for specialist services can also be very long.
What other treatments are available?
Everyone is different and the treatments recommended by the NICE guidelines don’t always work for everyone.
You may find different treatments or self-care techniques beneficial, either on their own or alongside other treatments.
The Body Dysmorphic Disorder Foundation provides further information about treatments for BDD on its website.
What can I do to help myself?
Treatment of BDD often includes a combination of strategies, including self-help. Below are some ideas you could try to help you manage your BDD:
Use self-help materials
Many people find self-help materials, such as books or computer programs, useful in managing their BDD. Self-help materials are often based on the principles of cognitive behavioural therapy (CBT), which have been shown to be particularly effective in treating BDD. Making small steps to accept but challenge your worries can reduce your compulsive behaviours.
You may decide to use self-help materials alongside professional help, or you may use them to develop your own coping strategies. BDD Foundation, OCD-UK and OCD Action have self-help resources for BDD on their websites.
Several CBT programmes are available for free via computer or via prescription from your GP. See the NHS website for more information on these.
“Yoga and Pilates, a food diary, To Do lists, music and books – it’s largely about having a routine that enables looking forward and steps of progress but also allows time to just be.”
Practise Self-care
Taking time to look after yourself, such as eating well and doing something you enjoy, can help to support your recovery and improve your quality of life. Take a look at our information on managing anxiety and improving your wellbeing for further guidance.
“Dyeing my hair bright colours helps. It distracts me a little from everything else.”
Try Support Groups
You might find it beneficial to speak with others who have BDD and understand what you are going through.
Support groups and peer support offer an opportunity to meet other people who also have BDD. Hearing about how other people have coped with similar feelings and experiences can be helpful and make you feel less isolated. You can find details of support groups for BDD on the following websites:
- Body Dysmorphic Disorder Foundation
- OCD-UK
- OCD Action.
Alternatively, you can contact Mind’s Infoline or a local Mind to see what support there is in your area.
You can also access peer support online. Communities like Mind’s Side by Side can be a good way of getting support at times when you don’t feel like seeing people face-to-face or if there aren’t any groups nearby.
How can friends and family help?
It can be upsetting and frustrating to see a loved one’s obsessive worries and compulsive behaviours impact their day-to-day life. But there are a number of things you can do to support them:
- Accept their feelings. Friends and family can help a lot just by accepting the feelings of the person with BDD and recognising that they find it difficult to cope with them. While you may not understand their concerns about their appearance, it is important to recognise that these feelings are very real to them. Try to avoid judging them as ‘vain’ or ‘self-obsessed’.
- Offer space to talk. It can be particularly difficult for someone experiencing BDD to acknowledge and speak about their thoughts, especially if they find them embarrassing. But speaking can be a first step in seeking help.
- Help them seek treatment and support. For more information, see our page on how to support someone to seek help.
- Offer support with self-help. If the person with BDD is working to a self-help programme, either on their own or with a therapist, you might be able to support them with this. For example, you could go to treatment sessions with them.
- Give practical support. Offering practical support, such as helping with childcare or household chores, can give them time to attend appointments or use self-help materials.
- Celebrate their successes. Stopping compulsive behaviours can be very difficult and it will take time. Celebrating the small steps, such as spending less time grooming or carrying out fewer repetitions, can help keep your loved one motivated.
“My friends and family are absolutely wonderful. Those closest have taken the time to understand the disorder and as a result they are incredibly mindful of the irrationality it can cause. They support me in every way.”
- Don’t take it personally. It can be particularly difficult if your friend or family member’s BDD means that at times they don’t want to see you or they withdraw from social contact. Try to be aware that this is due to their negative feelings about their appearance rather than anything you are likely to have done.
- Learn their triggers. Some people with BDD find certain situations difficult and find they can provoke more repetitive behaviour. Sometimes these situations cannot be avoided (for example, seeing mirrors in shops or public toilets) but taking steps to gradually build up to the situations with them may help.
- Be consistent. People with BDD may seek reassurance about the way they look. Try not to get drawn into debates about their appearance and encourage others not to do the same.
- Boost their confidence. Encourage them to do the things they enjoy. Offering praise that doesn’t focus on the way they look can also help to raise their self-esteem.
- Get support for yourself. It can be distressing to be close to someone experiencing BDD, particularly if you are caring for them. You might find it useful to talk to other people who are in the same situation as you and to find out more about these complex problems. The Body Dysmorphic Disorder Foundation provides information on BDD for friends and family, as well as support groups for carers.
Useful contacts
Mind’s services
- Mind’s helplines provide information and support by phone and email.
- Local Minds offer face-to-face services across England and Wales. These services include talking therapies, peer support and advocacy.
- Side by Side is our supportive online community for anyone experiencing a mental health problem.
Other organisations
Body Dysmorphic Disorder Foundation
bddfoundation.org
Support and information for people affected by body dysmorphic disorder.
British Association for Behavioural and Cognitive Psychotherapies (BABCP)
babcp.com
Information about cognitive behavioural therapy and related treatments, including details of accredited therapists.
Improving Access to Psychological Therapies (IAPT)
nhs.uk/service-search/find-a-psychological-therapies-service
Information about local NHS therapy and counselling services, which you can often self-refer to (England only).
National Institute for Health and Care Excellence (NICE)
nice.org.uk
Produces guidelines on best practice in healthcare.
NHS Service Finder
nhs.uk/service-search
Searchable database of NHS services in England.
OCD Action
0300 636 5478
ocdaction.org.uk
Information and support for people affected by OCD and hoarding, including online forums and local support groups.
OCD UK
03332 127890
ocduk.org
Charity run by and for people with OCD.