By Katharine A. Phillips, MD
People with BDD intensely dislike one or more aspects of their physical appearance, believing that these body areas look ugly, abnormal, deformed, or disfigured. People with milder BDD may describe the disliked areas as looking “unattractive,” whereas those with more severe BDD may say they look “hideous” or like a monster.
The most commonly disliked body parts for those with BDD are:
- Skin (usually facial skin — for example, perceived scarring, blemishes, or color)
- Hair (for example, perceived balding or too much facial or body hair)
- Nose (for example, size or shape).
Symmetry concerns (for example, uneven eyebrows or hair length) are also common BDD concerns. However, people with BDD can be preoccupied with the appearance of any body area. Some people focus on just one part of their body, whereas others are preoccupied with virtually their entire body.
Nearly all people with BDD spend at least an hour a day in total thinking about the disliked body part/area. People who spend less time than one hour a day probably don’t have BDD. The average is 3 hours to 8 hours a day. Some people find that BDD preoccupations consume their entire day. The appearance preoccupations are usually difficult to resist or control, and very distressing.
Repetitive, Compulsive Behaviors
BDD preoccupations fuel repetitive compulsive behaviors that are intended to fix, hide, inspect, or obtain reassurance about the disliked body parts. On average, these behaviors consume from 3 – 8 hours a day. They are usually difficult to control or stop. These behaviors may be clues that a person has BDD. People who engage in them should be assessed for the possible presence of BDD.
Common repetitive BDD behaviors include the following:
- Camouflaging: Trying to hide or cover up the disliked body areas with things such as a hat, heavy makeup, clothing, hair, sunglasses, one’s hands, or body position. Camouflaging often involves repetitive behaviors, such as repeatedly adjusting one’s clothing to hide disliked body parts or repeatedly applying makeup.
- Comparing: Comparing the disliked features to those of other people.
- Mirror checking: Repeatedly checking the perceived defects in mirrors and other reflecting surfaces, such as windows or a cell phone.
- Excessive grooming: Repeatedly applying makeup, styling or combing hair, plucking hair, or shaving. NOTE: People who pull or pluck out their hair only as a symptom of BDD (in response to appearance concerns) should not receive a diagnosis of trichotillomania (hair-pulling disorder).
- Reassurance seeking/questioning of others: Frequently asking others how they look or if they look okay. Alternatively, some people with BDD repeatedly insist that they look ugly or abnormal.
- Skin picking: Compulsively picking one’s skin to try to make it look better – note that the intent of this skin picking is not to harm oneself. This behavior can cause skin lesions and scarring. It is occasionally life-threatening (for example, when picking into a major artery and losing large amounts of blood). NOTE: People who pick their skin only as a symptom of BDD (in response to appearance concerns) should not receive a diagnosis of excoriation (skin-picking disorder).
- Clothes changing: Frequently changing clothes to try to better hide disliked body areas or find a more flattering outfit.
- Tanning: Excessively tanning to darken skin that is considered too pale or for other reasons (for example, to try to minimize perceived acne).
- Excessive exercising or weight lifting: This behavior is especially common in men with muscle dysmorphia.
- Excessive shopping: Excessively shopping for makeup, other products, or clothes to try to improve the appearance of the disliked body areas.
- Seeking cosmetic surgery, dermatologic treatment, or other cosmetic procedures: These treatments are almost never helpful for BDD concerns and can make them worse.
- Social anxiety and avoidance: Social anxiety and social avoidance are very common in people with BDD, which may cause BDD to be misdiagnosed as social anxiety disorder (social phobia). Social anxiety and avoidance may be caused by fears that other people will see the perceived appearance flaws and look down on, reject, or ridicule the person with BDD because of how they look.
Insight Regarding BDD Beliefs
Most people with BDD are mostly or completely convinced that they look ugly or abnormal, even though other people don’t see them this way. In reality, the perceived defects are actually non-existent or slight (click here for more information about visual processing aberrations in BDD). This mismatch between how people with BDD see themselves and how other people see them can cause friction in relationships, because people with BDD usually don’t believe other people’s reassurance that they really do look “normal.” In addition, about two-thirds of people with BDD have ideas or delusions of reference (i.e., referential thinking); that is, they believe that other people take special notice of the “defective” body areas, talk about them, or make fun of them because of how they look. These beliefs result from a misinterpretation of others’ behavior.
Core Beliefs and Emotions in BDD
Many individuals with BDD report intense feelings of shame and low self-esteem. A deep sense of self-loathing may result in the belief that they are fundamentally inadequate, unacceptable to others, or unlovable, or that they will always be alone because of how they look. Emotions that are common in people with BDD include depression, anxiety, self-consciousness, guilt, frustration/anger, disgust, and grief.