• BDD was first categorised as a diagnosis in 1987.
• It is underlined by anxiety and is closely associated with obsessive compulsive disorder (OCD).
• It usually starts in adolescence and is often hidden and can be long-lasting.
• BDD may be underdiagnosed due to a variety of factors, including shame and a lack of recognition of the issue.
• A review of 33 studies estimated that 15.04% of plastic surgery patients had BDD, the average age was 34 and 74% were women. For dermatology patients, 12.65% had BDD, the average age was 28 and 76% were women.

Behaviours

BDD involves a focus on one or more perceived defects or flaws in physical appearance that are not observable or appear minimal to others. It consists of a preoccupation that causes significant distress that disrupts social and occupational functioning.

Individuals affected by BDD may:

• Engage in compulsive, time consuming and repetitive behaviours – reassurance seeking, mirror checking, excessive grooming and skin picking which can lead to lesions
• Compare themselves to others in response to appearance concerns
• The appearance related preoccupation is not primarily explained by concerns about weight as can occur in an eating disorder

Skin concerns can emerge for both men and women. For some women it may be their legs, whilst for men it may be their body build and muscle. Men from a sexual minority may be affected by body dysmorphia due to rejection sensitivity and concealing their sexual orientation.

Insight difficulties

A person’s level of insight can change during their experience of BDD. For example, whether they do/not believe what BDD tells them (good/fair insight), whether they they think it’s probably true (poor insight), or whether they are completely convinced the BDD beliefs are true (absent insight/delusional beliefs).

Consequences

It’s essential to understand that for the person, the beliefs about their flaw(s) feel real. In some instances, they may approach a dentist, dermatologist or surgeon to undergo a procedure to rectify the issue or for example, improve social or romantic relationships. Behaviours associated with BDD are often secretive, underlined by shame and those such as mirror checking do not bring short-term relief, but increase self-consciousness, heighten perceptions of defects and in turn, increase distress. Seeking and having surgery or medical procedures may not bring relief for the person.

Self-image amongst those with BDD may relate to early stressful experiences in childhood. BDD is often hidden as people tend not to seek professional help, and those that do, may be reluctant to discuss their difficulties. Some may report misdiagnosis before finding appropriate treatment. BDD often co-exists with other disorders, with depression being the most common. Others include social phobia, obsessive compulsive disorder (OCD) and generalised anxiety disorder.

People with BDD may report significant distress, productivity problems at work or school and in some instances, withdrawal from school or job losses. The person may believe that others are disgusted at a particular aspect of their appearance. Individuals who experience BDD may express a desire to ‘become invisible’. They may prefer colder weather in order to wrap up i.e. camouflage their perceived flaw and also prefer to leave the house after dark. They may hear positive feedback from others and feel it is intended as pity or sarcasm. They may miss out on social cues and information that may moderate their negative self-image. BDD can lead to social avoidance and self-imposed isolation from family, friends and partners due to worry about being viewed negatively by others. This isolation can contribute to additional distress.

A sense of worthlessness can be part of someone’s experience. BDD increases risk of suicide.

Treatment

Treatment barriers can include: shame, low perceived need and a preference for cosmetic and medical treatments.

Treatment can vary from medication to psychological such as cognitive behavioural psychotherapy (CBT), or a combination of medication and therapy.

Research has highlighted:

• Higher psychosocial stress levels than pre-Covid-19
• Not being able to work, people experiencing anxiety about an unpredictable future
• Self-isolation can heighten other issues, including eating disorders, OCD, depression and suicide risk – feeling of hopelessness and worthlessness during pandemic
• The pandemic might lead to thoughts of not being needed or feeling not important since socialising has been restricted and substance use can also increase suicide risk
• Individuals who were living alone, younger, may report higher dysmorphic concerns, engage in more frequent appearance-focused behaviours and greater distress over the closure of beauty services