Body Image: Are you concerned about your appearance?
Are you concerned about your appearance in any way? Why would you ask that question? Unless asked, body image concerns may not be shared or ‘picked up’ by a professional because of embarrassment or shame. Body image concerns are common, particularly for younger people. Are you concerned about your appearance? Is a question often not asked by therapists, yet Body Dysmorphic Disorder (BDD) is something that seriously affects people’s daily lives and ability to reach their full potential. Around 2% of the general population are impacted by Body Dysmorphic Disorder (BDD) and that’s a lot of missed people that could otherwise be meaningfully and effectively helped.
Relevant questions to ask might be:
Do you dislike the way bits of your body look?
Have others told you that you worry about your appearance too much?
Do you check, try to fix, or hide your appearance from others?
Asking these questions might shine a light on the presence of BDD.
To assess impact and severity, you might consider:
What effect does it have on your life?
Does it make it hard to do your work or be with friends?
Body Dysmorphic Disorder (BDD) usually starts in adolescence. It seems to be slightly more common in women but more so in men is a sub type of BDD called Muscle Dysmorphia, which this is a form of BDD where men subjectively think they are puny, too small, too thin, or not muscular enough. Closely related to BDD is Olfactory Reference Syndrome where people perceive their body odour or breath to smell foul. The problem isn’t necessarily an offensive smell, but a worry about a smell.
The DSM-5 which is the standard text for classification of such problems, describes Body Dysmorphic Disorder as follows:
A. Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others.
B. At some point during the course of the problem, the person has performed external repetitive behaviours (e.g. mirror checking, excessive grooming, skin picking, or reassurance seeking) or internal acts (e.g., comparing their appearance with that of others) in response to the appearance concerns.
C. The preoccupations cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The preoccupations are not attributable to another medical condition.
E. The appearance preoccupations are not better accounted for by concerns with body fat or weight in an eating disorder
People who have an eating disorder will have a disturbed eating pattern, which may not be found in BDD.
Body areas of concerns in order of prevalence are typically skin, hair, nose, weight, stomach, eyes, thighs, teeth, legs, bone structure, ugly face, face shape, lips, chin, eyebrows, hips…any part of the body can be of concern and parts shift over time. Concern is often focused on more than one part at any given time.
Typical reactions and ways of managing concerns are camouflaging, comparing with others, checking, skin picking, tanning, use of mirrors or any reflective surface.
BDD can be costly. Around 27% of BDD patients will obtain cometic treatment, which may not fix the problem. It costs time in terms of preoccupation about appearance, and emotional distress. BDD often presents as depression, or as anxiety, but unless the therapist asks the question about appearance, it will get missed, and a chance to effectively treat it missed too. Sometimes BDD is an Achilles heel and flares up in times of stress and the worry of being ‘physically flawed’ is exacerbated by external stressors.
So, what causes BDD? It’s hard to say, but childhood experiences, family, genetics, perfectionism, attention to aesthetics, not being able to see the whole ‘gestalt’ might all be factors. CBT offers an individualised explanation of why BDD developed, what is keeping it going, and an evidence-based treatment to recover.
Most people with BDD are aware of that something is wrong, but what they, and many professionals, may not realise is that it can be treated effectively with specialist CBT.