By Jamie Feusner, MD
Whenever Michael looked in the mirror, he saw nothing but baggy eyelids and dark circles under his eyes. He believed they had looked that way since he was born, but it really started to bother him when he entered high school. By that time he was so self-conscious he would skip class on days when he believed he looked particularly ugly. He spent hours each day checking his eyes in mirrors and applying different types of eye creams. He couldn’t stop thinking about them. Michael was so fixated on his appearance that he couldn’t focus in school and his grades suffered. This contributed to his depression, and he became more and more isolated. His friends and family didn’t understand how he felt about his eyes. They told him he looked fine and should just stop thinking about it, but Michael dismissed them as just trying to be nice. He was certain about what he saw. No one seemed to understand.
Michael suffers from body dysmorphic disorder (BDD), a severe psychiatric disorder that causes people to be preoccupied with perceived physical defects and believe they appear disfigured and ugly. They are so troubled by what they perceive that they often spend hours checking themselves in mirrors, avoiding others, or trying to change their appearance, including getting cosmetic procedures (for example, face-lifts or “nose jobs”). They experience significant distress and are unable to function adequately in work, school, or relationships. People with BDD often become depressed, and in many cases suicidal. 
Who Gets BDD
BDD affects 1.7-2.9% of the population2-5, yet is vastly under studied and under recognized. Some evidence suggests it is related to obsessive-compulsive disorder (OCD) because of similarities in symptoms such as having obsessive thoughts and engaging in compulsive behaviors. In addition, BDD and OCD often afflict members of the same family. Some people even suffer from both disorders.
Symptoms of BDD
One of the most conspicuous symptoms of BDD is the distorted perception of one’s own appearance. For example, a person with BDD may believe his nose is crooked, or that he has acne scars all over his face, or that his hair is thinning. Yet no one else notices these “defects.” Moreover, many people with BDD are so firmly convinced that these flaws exist that no one can talk them out of it. In essence, they are often delusional. This seems to be analogous to what people with anorexia nervosa experience when they perceive that they are fat, yet to everyone else they appear to be extremely thin. What could be causing them to experience this? Could there actually be something abnormal in the way their brains are processing visual information that could account for these perceptual distortions? Understanding the brain basis for apparent perceptual distortions perhaps could improve our understanding of BDD and lead to strategies for better treatments.
People with BDD most often are concerned with “defects” on their face and head6. They constantly check their appearance in mirrors, and often scrutinize others people’s faces. They tend to focus primarily on details, usually on their face, and are not able to see the “big picture” that overall they look normal. A previous study of people with BDD that involved drawing and copying complex figures also suggested this was occurring7. Other studies found that they have abnormalities in face processing8,9. Still others found abnormal attention to facial details, evident when a face is upside-down or upright, in those with BDD10,11 and those with high body image concerns12,13. The results of these behavioral studies, in combination with the patterns of symptoms in BDD, raised the question of whether abnormal visual processing in the brain might underlie distorted perceptions.
Comparing the Brain Activity of BDD Sufferers to Non-BDD Sufferers
In the first brain imaging study to investigate this, we used a type of brain scan called functional magnetic resonance imaging (fMRI) to compare the patterns of brain activity in BDD sufferers to that of healthy control participants. In order to test visual processing, we had them view digital photographs of other people’s faces while they were in the brain scanner. In this study, we tested other people’s faces (as opposed to their own) because we did not want them to experience anxiety, depression or shame that they normally experience when viewing their own face. So, by having the task be emotionally-neutral and by using visual stimuli other than their own face, we could determine if there were more general visual processing abnormalities in people with BDD.
Our brains normally process visual details such as edges depicting contours of the nose, eyes, eyelashes, skin blemishes, exact shape of the mouth, etc. with specific visual networks. Likewise, our brains process holistic or “big picture” elements (for example, spatial relationships between facial features such as the relative position of the eyes to the mouth and the general shape of the face) with other specific visual networks. We predicted that people with BDD might have an imbalance in these networks, perhaps using more detailed processing and less holistic processing. Therefore, we digitally altered some of the photographs to create some images that had only low-detail (which look blurred) and others that had only high detail (which look like line-drawings), in addition to normal photos. By doing this, we were able to use these different photo stimuli to probe the activity in different visual networks.
We enrolled 12 adults with BDD and 13 healthy controls in the study. None of the participants were taking any medications nor receiving cognitive-behavioral therapy. The participants viewed digital photographs of faces on goggles while in the fMRI scanner. We instructed them to push a button to match the identity of the faces, to ensure they were attending to them. We later analyzed the data to compare the brain activity of the BDD participants to that of the healthy controls.
The results were striking. People with BDD used primarily the left half of their brain (left hemisphere) to process the high-detail, low-detail, and normal face types. This was in stark contrast to the healthy controls, who used mostly their right hemisphere to process faces (like many other studies have shown). Only when the healthy controls viewed the high-detail faces did they start to use their left hemisphere, which was expected since normally people use their left hemisphere to process details and the right to process holistically. This imbalance would suggest that the brains of people with BDD might be attempting to extract details from all face types, even when they have no details. In addition, they had abnormal activity in the amygdala, a region in the brain that is involved in processing emotion and fear.
This left hemisphere-predominant pattern of visual processing may account for their symptoms of focusing on details at the expense of seeing the big picture. In essence, they may “lose the forest for the trees.” For example, this suggests that the brain of someone with BDD might detect details of their skin such as pores, but cannot adequately perceive that in the context of their overall face, these pores are actually very small and, in fact, barely noticeable. These people may suffer in large part because of this pattern of perception, combined with the fact that they may assume everyone else sees them similarly.
The results from this study were the first to demonstrate that distorted perception in BDD is associated with abnormal brain functioning. The fact that this occurred in people with BDD while they viewed others’ faces, suggests that there may be more general abnormalities in visual processing beyond a self, body image distortion. The amygdala finding also suggests possible abnormalities in emotional processing regions.
Own-Face Processing in Individuals with BDD
In a second study14 we used fMRI again to study own-face processing in BDD. Participants with BDD (17) and healthy controls (16) viewed their own face and the face of another person while being scanned. Abnormally low brain activity was evident in the visual cortex for low-detail images when viewing both their own and others’ faces. This study, similar to the previous one, provides evidence of imbalances in global versus local visual processing. Another interesting finding was that while the BDD group rated the viewing of their face as highly aversive, they did not demonstrate greater amygdala or insula activity while viewing their own face. This, in conjunction with findings from the previous study, could be considered an abnormal lack of reactivity in emotion-processing brain systems.
In addition, abnormally high brain activity in this study was found in frontostriatal systems (orbitofrontal cortex and caudate) among BDD participants when viewing their own face. These brain regions play a major role in generating motivation and coordinating action. The severity of BDD symptoms was correlated with increased frontostriatal activity and activity in the visual cortex. This study provides early evidence of abnormal frontostriatal circuit activity in BDD similar to that of OCD15. This increased activity in orbitofrontal cortex and caudate may be associated with the obsessive thoughts and compulsive behaviors seen in both BDD and OCD. A more recent study found abnormalities in brain connectivity in frontostriatal regions in BDD, which was also associated with obsessive thoughts and compulsive BDD-related behaviors20.
To investigate if individuals with BDD exhibit abnormal visual processing for more general visual stimuli, other than faces or other appearance-related stimuli, we examined visual processing while individuals viewed houses, using fMRI16. BDD participants (14) and healthy controls (14) were scanned while they matched photographs of houses that were normal, or contained only high detail or low detail. The BDD group displayed abnormally low brain activity in the visual cortex and temporal lobe for low detail images. This could again reflect global processing deficiencies and provide evidence for general abnormalities in visual processing beyond those related solely to appearance.
Subsequently, we extended this line of research to explore similarities and differences in visual processing between BDD and anorexia nervosa, another disorder that involves abnormal perception of appearance17. In a study that combined electroencephalogram (EEG) and fMRI data, we found that individuals with BDD and those with anorexia nervosa displayed similar abnormally low brain activity soon after seeing an image (100 and 170 milliseconds) in early visual processing regions and the dorsal visual stream while viewing low detail faces and houses. The BDD group displayed abnormally high brain activity in the temporal lobe while viewing high detail houses. This brain activity was correlated with lower attractiveness ratings of others’ face; the greater the activity, the less attractive they found others’ faces. In addition, analysis of the EEG data from this study found in BDD lower amplitudes of electrophysiological signals from regions likely involved in structural encoding of faces18. These findings support the interpretation that enhanced detail processing in BDD may lead to a greater likelihood of flaw detection, which may contribute to finding others (and perhaps themselves) less attractive. This study, although small, provides early evidence of similar (although not identical) pathological visual processing in BDD and anorexia.
These neuroimaging studies of visual processing, along with behavioral and neuropsychological studies and their clinical symptoms, converge to suggest deficiencies in global and configural visual processing in BDD. In addition, individuals with BDD may also have enhanced detailed processing17,19. Resulting imbalances in global and local processing may contribute to perception in which details are not integrated and contextualized well. This may result in greater visual attention or vigilance to detect “flaws” and reduced ability to perceive that their “flaws” are, generally, very small relative to their whole face or body and therefore unlikely to be noticed by others. In addition, there is evidence of heightened frontostriatal activity, similar to that seen in OCD, which is associated with degree of appearance preoccupations and repetitive behaviors in BDD. Finally, there is early indication of abnormal emotion system (amygdala) activity associated with visual processing. This could be an indication of differences in emotional saliency of certain images, abnormal emotional reactivity to visual stimuli, and/or impaired ability to integrate visual and emotional information.
If future research confirms that abnormal perception is a feature of BDD, it is certainly not the only problem. People also tend to have obsessive thoughts and perform compulsive or avoidant behaviors. In addition, they often overvalue appearance in general, and have a tendency toward depression and social anxiety. Cultural and societal influences most certainly play a part as well.
Nevertheless, abnormal perception may be an important feature of BDD. The IOCDF provided grant funding in the early stages to support this line of brain imaging research into visual perceptual distortions in BDD. The IOCDF also provided funding for the EEG study18,20 that allowed a deeper understanding of when (at what stage) abnormalities in visual processing are occurring. Since then we have also embarked on investigations of other aspects of visual processing and abnormalities in brain structure.
Currently we are investigating the effects on the brain of two different ways of changing how people with BDD view images of their appearance. In addition to the neuroimaging studies, this has also been informed by studies using eye-tracking that have found abnormal patterns in how people with BDD view face images21-23. Our current study represents a first step to developing new add-on treatments that potentially could remediate visual perceptual distortions, and potentially could be extended to other psychiatric disorders that involve distortions of perception such as eating disorders24. We look forward to building on our findings with future discoveries that can provide us with a better understanding of symptoms that result in so much suffering. The ultimate goal is to develop new treatments such as specific perceptual retraining methods, to remediate these abnormal brain processes.
- Phillips KA, Coles ME, Menard W, Yen S, Fay C, Weisberg RB. Suicidal Ideation and Suicide Attempts in Body Dysmorphic Disorder. J Clin Psychiatry. 2005;66(6):717-725.
- Rief W, Buhlmann U, Wilhelm S, Borkenhagen A, Brahler E. The prevalence of body dysmorphic disorder: a population-based survey. Psychol Med. 2006 36(6):877-885.
- Buhlmann U, Glaesmer H, Mewes R, Fama JM, Wilhelm S, Brahler E, Rief W. Updates on the prevalence of body dysmorphic disorder: a population-based survey. Psychiatry Research. 2010;178(1):171-175.
- Koran LM, Abujaoude E, Large MD, Serpe RT. The prevalence of body dysmorphic disorder in the United States adult population. CNS Spectrums. 2008;13(4):316-322.
- Schieber K, Kollei I, de Zwaan M, Martin A. Classification of body dysmorphic disorder – what is the advantage of the new DSM-5 criteria? J Psychosom Res. 2015;78(3):223-227.
- Phillips KA. The Broken Mirror. New York: Oxford University Press; 2005.
- Deckersbach T, Savage C, Phillips K, Wilhelm S, Buhlmann U, Rauch S, Baer L, Jenike M. Characteristics of memory dysfunction in body dysmorphic disorder. J Int Neuropsychol Soc. 2000 6(6):673-681.
- Yaryura-Tobias J, Neziroglu F, Chang R, Lee S, Pinto A, Donohue L. Computerized Perceptual Analysis of Patients with Body Dysmorphic Disorder: A Pilot Study. CNS Spectrums. 2002;7(6):444-446.
- Stangier U, Adam-Schwebe S, Muller T, Wolter M. Discrimination of facial appearance stimuli in body dysmorphic disorder. J Abnorm Psychol. 2008;117(2):435-443.
- Feusner JD, Moller H, Altstein L, Sugar C, Bookheimer S, Yoon J, Hembacher E. Inverted face processing in body dysmorphic disorder. J Psychiatr Res. 2010;44(15):1088-1094.
- Jefferies K, Laws KR, Fineberg NA. Superior face recognition in Body Dysmorphic Disorder. Journal of Obsessive-Compulsive and Related Disorders. 2012;1(3):175-179.
- Beilharz FL, Atkins KJ, Duncum AJ, Mundy ME. Altering Visual Perception Abnormalities: A Marker for Body Image Concern. PloS one. 2016;11(3):e0151933.
- Mundy EM, Sadusky A. Abnormalities in visual processing amongst students with body image concerns. Advances in cognitive psychology / University of Finance and Management in Warsaw. 2014;10(2):39-48.
- Feusner JD, Moody T, Townsend J, McKinley M, Hembacher E, Moller H, Bookheimer S. Abnormalities of visual processing and frontostriatal systems in body dysmorphic disorder. Archives of General Psychiatry. 2010;67(2):197-205.
- Rotge JY, Guehl D, Dilharreguy B, Cuny E, Tignol J, Bioulac B, Allard M, Burbaud P, Aouizerate B. Provocation of obsessive-compulsive symptoms: a quantitative voxel-based meta-analysis of functional neuroimaging studies. J Psychiatry Neurosci. 2008;33(5):405-412.