by Nikka Paulina Dela Cruz
Body Dysmorphic Disorder (BDD) is a debilitating body image disorder that engrosses the minds of individuals, causing them to believe that they have imperfections in their appearances (Phillips et al., 2010). This common but underreported disorder is distressing for those who suffer from it. The individual is encompassed by the imagined or exaggerated defect in his or her appearance, causing social isolation and anxiety.
In 2008, Lorrin M. Koran, Elias Abujaoude, Michael D. Large, and Richard T. Serpe published a seminal study that involved 2,513 participants, 2,048 of whom qualified as having BDD. The research revealed that the prevalence of BDD in women was approximately 2.5%, and for men, the prevalence was approximately 2.2%, exceeding the prevalence rates of schizophrenia and bipolar disorder.
In a separate study conducted by Callaghan, Lopez, Wong, Northcross, and Anderson (2011), data indicated that among college students in the U.S., the prevalence of BDD was approximately 10% (n=544).
Body Dysmorphic Disorder is underreported, understudied, and under-recognized. Some think that BDD is just an extreme case of “imagined ugliness” (Phillips, 1991, p. 1138), but it is actually quite detrimental to a sufferer’s health and social functioning. Clinicians trivializing or misunderstanding clients’ symptoms may contribute to the lack of clarity regarding the causes and effects of this condition. BDD patients are often notorious for seeking cosmetic alterations to their perceived defects. Studies have shown, however, that cosmetic surgery is not effective in treating BDD patients’ symptoms. This fact alone is another reason clinicians should be sufficiently educated about BDD. Studies have shown that Selective Serotonin Reuptake Inhibitors (SSRIs), Cognitive Behavioral Therapy (CBT), or a combination treatment is effective in treating patients with BDD. Given the prevalence of this condition, the deleterious effects on people experiencing related symptoms, and the lack of training and treatment dedicated to its alleviation, it is important to advocate for education on BDD in the community of social work students and practitioners.
Signs and Symptoms of Body Dysmorphic Disorder
If a client approaches you with problems such as thoughts of having a head that is too small, having a nose that is too big, or having skin that is too pale, it is important to be able to assess whether the individual may be experiencing BDD. Because BDD is under-recognized, under-reported, and under-studied, ways in which it presents differently across groups (for instance, differences across race, ethnicity, sexual orientation, and gender identity) are difficult to ascertain.
However, studies have identified how BDD symptoms may vary by gender. A sign that a woman is suffering from BDD often includes unhappiness with skin, the size of her hips, and her weight. Men usually become concerned with thinning hair, the size of their genitalia, and their physique (Castle, Rossell, & Kyrios, 2006). A sub-category of BDD, mainly associated with men, is Muscle Dysmorphia. This disorder involves the obsession of men wanting to be muscular and to fit into the mold of what is considered “manly” in mainstream U.S. society.
Similar to the way in which patients with Obsessive Compulsive Disorder perform rituals to alleviate their anxiety, BDD patients perform rituals, as well. Some BDD patients’ compulsive behaviors include mirror-checking (repeatedly checking mirrors to reassure themselves that they do not look ugly or flawed), mirror avoidance (avoiding mirrors altogether), reassurance-seeking (seeking reassurance from others to confirm that they do not look ugly or flawed), camouflaging (the act of hiding a perceived defect either through covering it with one’s hair or applying makeup), and skin picking (repeated behavior of touching, rubbing, picking, or pinching of the skin). The urge to perform a ritual is difficult to control for those suffering from BDD.
Patients Who Seek Cosmetic Treatment
Many patients suffering from BDD are obsessed with wanting to correct the perceived defect. As a result, patients seek cosmetic surgeons to “fix” their flaws. According to a recent study, approximately 75% of individuals with BDD seek cosmetic treatment, and around 65% of individuals undergo these procedures (Bjornsson, Didie, & Phillips, 2010). In studies that researched the effects cosmetic surgery had on patients with BDD, researchers revealed that a majority of individuals still felt dissatisfied with their perceived defects after surgery (Phillips, Grant, Siniscalchi, & Albertini, 2001; Veale et al., 1996). As a result, cosmetic surgeons are urged to avoid performing operations on people with BDD.
Cognitive Behavioral Therapy
People who seek a “quick fix” by consulting a cosmetic surgeon will not obtain the results they desire, namely, a BDD-free life. However, an approach that has shown effectiveness in treating patients with BDD is Cognitive Behavioral Therapy. CBT is a proven method for treating people with obsessive thoughts (e.g., obsessive compulsive disorder). CBT is a form of psychotherapy that involves “psychoeducation, identification of problem thoughts, and correction of cognitive errors” (Allen, 2006, p. 74). The efficacy of CBT has been studied by multiple researchers and it has been shown to be effective in eliminating symptoms of BDD. For instance, in a study conducted by Phillips, Didie, Feusner, and Wilhelm (2008), research focused on the case of “Mr. H.,” a man with BDD whose symptoms diminished after 36 weeks of a combined treatment of CBT and Fluoxetine, a selective serotonin reuptake inhibitor (SSRI).
I do not have BDD, and I do not know anyone who has BDD. I am sharing the information I collected about BDD, because it is important to bring awareness to an often unknown disorder that may possibly affect more people than reported.
I have been diagnosed with vitiligo. Michael Jackson, the “King of Pop,” was thought to have been diagnosed with this auto-immune disorder. Patients with vitiligo lose pigment in affected areas of the skin, leaving white patches throughout the body. Vitiligo is not contagious or life-threatening, but it can be psychologically devastating to the patient. Fans of the late singer joked about Jackson’s dramatic skin color alterations. However, for Jackson, maintaining his persona of being a celebrity meant maintaining an image of being “perfect.” Because Jackson’s white patches were spreading throughout the visible parts of his body, Jackson would lose the said persona.
Patients with vitiligo and patients with BDD are similar to one another in the sense that clinicians, as well as society, do not consider their disorders to be significant. BDD and vitiligo are presumed to be disorders in which a sufferer worries about physical features.
When I tell people I have vitiligo, many are confused as to what it is. Skin disorders such as psoriasis or eczema and mental disorders such as Obsessive Compulsive Disorder or Anorexia Nervosa have entered mainstream society and gained acknowledgment. Granted, revealing to people that one may have a disorder of any kind still holds a stigma. However, the aforementioned disorders are well known to people. Being told that their conditions are largely unknown and understudied increases the rate of comorbidity in patients with BDD and vitiligo. For these reasons, I wanted to increase awareness of BDD (and vitiligo).
As Social Workers, Why is it Important to Understand BDD?
We live in a society where physical attributes are considered to be among the most important features of a person. Social workers are needed more than ever to combat this attitude. BDD is often comorbid with other disorders, such as depression, substance use, anxiety, eating disorders (anorexia/bulimia), OCD, mood disorders, personality disorders, and anxiety. With such high rates of comorbidity, people with BDD are known to have low self-esteem and to experience suicidal ideations. Social workers need to advocate for change on the macro level to demonstrate that fitting into the mold of what is considered “perfect” or “beautiful” is unrealistic and dangerous. Many may think that changing the dominant attitudes of society is a daunting task. However, I’m reminded that the late South African President Nelson Mandela once said, “It always seems impossible until it’s done.”
Allen, A. (2006). Cognitive-behavioral treatment of body dysmorphic disorder. Primary Psychiatry, 13 (7), 70-76.
Bjornsson, A.S., Didie, E.R., Phillips, K.A. (2010). Body dismorphic disorder. Dialogues in Clinical Neuroscience, 12 (2), 221-232.
Callaghan, G.M., Lopez, A., Wong, L., Northcross, J., & Anderson, K.R. (2011). Predicting consideration of cosmetic surgery in a college population: A continuum of body image disturbance and the importance of coping strategies. Body Image, 8 (3), 267-274.
Castle, D.J., Rossell, S., & Kyrios, M. (2006). Body dysmorphic disorder. Psychiatry Clinics of North America, 29, 521- 538.
Koran, L.M., Abujaoude, E., Large, M.D., & Serpe, R.T. (2008). The prevalence of body dysmorphic disorder in the United States adult population. CNS Spectrums, 13 (4), 316-322.
Phillips, K. A. (1991). Body dysmorphic disorder: The distress of imagined ugliness. The American Journal Of Psychiatry, 148 (9), 1138-1149.
Phillips, K. A., Grant, J., Siniscalchi, J., & Albertini, R. S. (2001). Surgical and nonpsychiatric medical treatment of patients with body dysmorphic disorder. Psychosomatics: Journal Of Consultation and Liaison Psychiatry, 42 (6), 504-510.
Phillips, K.A., Didie, E.R., Feusner, J, & Wilhelm, S. (2008). Body dysmorphic disorder: Treating an underrecognized disorder. American Journal of Psychiatry, 165 (9) 1111-1118.
Phillips, K.A., Wilhelm, S., Koran, L.M., Didie, E.R., Fallon, B.A., Feusner, J., & Stein, D.J. (2010). Body dysmorphic disorder: Some key issues for dsm-v. Depression and Anxiety, 27, 573-591.
Veale, D., Boocock, A., Gournay, K., Dryden, W., Shah, F., Willson, R., & Walburn, J. (1996). Body dysmorphic disorder: A survey of fifty cases. The British Journal of Psychiatry, 169 (2), 196-201.
Nikka Paulina Dela Cruz is a senior at the College of Staten Island majoring in social work. Her areas of interest include reading, hiking, and spending time with family. In the near future, she wants to obtain a master’s degree.