by Jennifer Greenberg, PsyD and Sabine Wilhelm, PhD
Definition and Overview
Body dysmorphic disorder by proxy (BDDBP) is a variant of BDD in which the primary preoccupation involves perceived imperfections with another person’s appearance. Most people with BDDBP spend more than an hour per day thinking about the perceived defect(s) of their person of concern (POC) and many spent several (e.g., 3-8) hours per day preoccupied by negative beliefs about the POC’s appearance. The preoccupation causes clinically significant distress and often interferes with daily functioning. The severity of BDDBP ranges from mild to extremely severe. Literature on BDDBP is scarce and until recently was limited to case reports. Phillips (2005) described a woman who worried excessively about her daughter’s “crooked” nose and tried “pushing on it to make it straight” (p. 67). Atiullah and Phillips (2001) reported on a 63-year-old male so distressed by the belief he had caused his daughter’s hair to thin that he committed suicide. Recently, Greenberg et al. (2013) systematically evaluated the clinical features of BDDBP in a broader sample. Together, these reports underscore the distressing, impairing, and potentially fatal nature of BDDBP.
Person of Concern
Individuals report preoccupation with a wide array of people, and, in a recent study (Greenberg et al., 2013), on average were concerned with at least five people. The primary person of concern is most often a significant other (e.g., spouse/partner), but may be a parent, child, sibling, or stranger. The POC may also shift over time (e.g. from one significant other to the next in a new relationship, or from a child to a parent).
Body Areas of Concern
Preoccupation can be focused on any body area, but most often involves skin and hair. Common areas of concern include others’ teeth (e.g. crooked, snaggled, blemished), eyebrows (e.g. asymmetrical, uneven, too thick), hair (e.g., unruly, not full enough, thinning/balding), and skin (e.g., acne/scarring, mark or blemish). The concern may also be focused on the POC’s general body shape (e.g. “bottle shaped”) or signs of aging (e.g. wrinkles, sagging, graying hair).
Ritualistic Behaviors
Most people with BDDBP perform repetitive behaviors to alleviate the anxiety and sometimes guilt associated with their preoccupation or to try to improve the POC’s appearance. These include attempts to check, improve, or hide the perceived defect, such as comparing the POC’s appearance to the appearance of others and providing reassurance to the POC about his/her appearance. Some people try to camouflage the perceived flaw by encouraging the POC to wear (or avoid) particular makeup or clothing. The repetitive behaviors can take several hours per day and typically only provide temporary relief. BDDBP behaviors can vary from person to person are not limited to those listed here.
Avoidance
Avoidance is common, especially of social situations or situations that might expose the POC’s flaw. The impact of BDDBP on relationships– particularly that with the POC– is often substantial.
Distress/Impairment
Most people suffering from BDDBP are very distressed by perceived flaws in the POC and describe their preoccupations as “painful” or “tormenting.” Moreover, most individuals experience shame and guilt about their preoccupations. Many worry that having these concerns makes them a “bad partner/ parent /child.” The preoccupations are difficult to control and time consuming. BDDBP is also associated with difficulties in day-to-day functioning. Because of their concerns, people with BDDBP may miss work, school, or social functions, or be less productive. In addition to the often profound impact on the relationship with the POC, BDDBP usually affects friendships, dating, relationships with family members, intimate relationships, and social interactions more generally.
Beliefs
People with BDDBP often believe that other people take special notice of the POC because of the defect they perceive. For example, they may think others stare at the POC or laugh about the POC’s appearance. Often they believe others would reject them or the POC because of perceived imperfections in the POC. These beliefs develop because of a negative self image and are rarely based on accurate observation. Individuals with BDDBP often feel guilt or shame about their preoccupation with the POC’s appearance, and worry that their concerns will hurt the POC and/or damage the relationship.
References
Atiullah, N., & Phillips, K.A. (2001). Fatal body dysmorphic disorder by proxy. Journal of Clinical Psychiatry, 62, 204-205.
Greenberg, J.L., Falkenstein, M., Reuman, L., Fama, J., Marques, L., & Wilhelm, S. (2013). The phenomenology of self-reported body dysmorphic disorder by proxy. Body Image, 10(2), 243-246.
Phillips, K.A. (2005). The broken mirror: Understanding and treating body dysmorphic disorder. New York, NY: Oxford University Press.