Introduction

BODY DYSMORPHIC DISORDER

Introduction

Body dysmorphic disorder (BDD) is a potentially devastating and often disabling mental condition that is under recognized and quite often misunderstood by the general public and therapists alike. Inflicting more than possibly 2% of the population, it is not extremely common, yet also not insignificant enough to be ignored. Sufferers display a wide variety of symptoms, recorded since the late 19th century, revolving around obsessive thoughts and compulsive behaviors relating to physical appearance. The term body dysmorphic disorder is somewhat misleading, considering not only the body, but also aspects of the face and extremities, can be the object of dissatisfaction as well. Although BDD has been classified since 1987 in the DSM-IV as a somatoform disorder, researchers believe it may be related to the anxiety disorders, such as obsessive compulsive disorder (OCD); some deem it nothing more than a specific type of OCD obsession. Unfortunately, BDD is considered more difficult to cure than many of its possible relatives, but is nevertheless considered treatable.

Understanding BDDI didn't go to college yesterday. I got up early and started to get ready to go today but I couldn't. I put my makeup on but nothing would go right. I look at my reflection and I feel physically sick. I have huge bags under my eyes and my eyelids are red. My face is all swollen and the skin is terrible. I just collapsed in tears. My mum was angry with me because I didn't go, and I just felt worthless. She said there was nothing wrong with me and I was ruining my life. I don't want to be like this. Yesterday I cut myself all over my arms and my hands, and today it's starting to hurt a bit as the wounds start to heal. I've been crying a lot. I thought maybe things were getting better but I was just kidding myself. Nothing can get better yet. I'm just trapped.(Anonymous, 2002)

The painful and chilling personal account from an anonymous sufferer illustrates just how severe this little understood disorder can be. BDD, which covers a large spectrum of functionality, with some victims being preoccupied with obsessive thoughts and others being completely housebound, has the potential to be seriously devastating and even life threatening; it is much more serious than a general dissatisfaction with appearance or regular self esteem issues. One of the most unfortunate aspects of the disorder is that it mimics ordinary appearance concerns, or even vanity, making non-sufferers assume it is trite and insignificant, when in reality, most do not truly comprehend the severity of the disorder.

Definition of BDD

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What is BDD?BDD, or Body Dysmorphic Disorder, has recently become a buzzword, even though it has been around for quite some time. It was first documented in 1886 by the researcher Morselli, who gave it the initial title Dysmorphophobia. Over the past few years of researching, I was surprised to find that almost every source of information available on BDD has been taken directly from theDSM-IV(basically, the psychologists' bible), which explains the symptoms in clinical terms and offers no solutions. Although the DSM-IV definition is a great way to find out what symptoms are required for a therapist to diagnose BDD, it does not give any information on cures or personal viewpoints from people with the disorder. It makes BDD seem more like a label instead of set of maladaptive behaviors that can be altered. What we need are more personal stories and real life definitions that we can relate to, and leave the technical stuff to the therapists and researchers. Therefore, I will list the criteria found in the DSM-IV, but will also include subjective information on the disorder from the perspective of people that have it.

Diagnostic criteria for 300.7 Body Dysmorphic DisorderA. Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person's concern is markedly excessive.B. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.C. The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in Anorexia Nervosa).*Information from p.468, DSM-IV, 1994, American Psychiatric Association

There you have it, the criteria for diagnosing body dismorphic disorder. It sure seems simple for being such a complex disorder! I should probably mention that it is unadvisable to diagnose yourself with any disorder, as this should be left to highly skilled professionals. Although, I must admit, I did not meet a single therapist, doctor, or psychiatrist who knew what the disorder was until I recommended they check it out in the DSM-IV! So, if you feel that the previous set of criteria aptly describes what you or your somebody you know are going through, please visit with a trained professional, direct them to page 436 in the DSM-IV, and let them officially diagnose you. I must say, I have also heard from several people that have diagnosed themselves with BDD when they obviously don't have any of the true symptoms, so it is probably best to get the opinion of someone trained in the field of psychology.

Definition of BDD

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In my opinion, BDD is not a problem in itself, but rather a set of symptoms masking a more serious problem. Think of a common cold, and the symptoms associated with it-sore throat, stuffy nose, coughing. Although these symptoms may make you miserable for a week or two, they are not the problem, and are actually there to prevent you from becoming more ill. These symptoms come about because your body is trying to protect itself from a foreign substance that shouldn't have been there in the first place. To me, BDD is exactly like these miserable symptoms, connected with the common cold, which try to prevent you from further harm. It is a coping mechanism, created by your subconscious mind.

The problem with this coping mechanism is the fact that we haven't convinced our minds that it is outdated and no longer necessary in our daily lives. We may have needed help from our subconscious minds in the past, but now, it's not needed and it's difficult to convince our minds to let us take back complete control of our actions and thoughts.

You may be wondering why on earth you'd ever have needed a coping mechanism in the first place, especially such a frustrating one. Well, the truth is, there are many different reasons, probably differing from person to person. Your BDD coping mechanism will display itself in a variety of intriguing ways. Although these behaviors seem to be the real problem, and the cause of all your BDD anguish, it is really just a set of actions that are repetitively done to keep you from more significant problems. Even if these obsessive actions related to your coping mechanism were all instantaneously wisped away, you'd find that your problems would actually be multiplied. Most likely, you would not know how to deal with life free of BDD behaviors. That is why it is important to tackle the real problems behind BDD rather than the obsessive behaviors.

People with BDD have a number of actions that help them cope. Most do not understand why they perform these rituals, but partake in them anyhow. It's a very interesting phenomenon, similar, in my opinion, to Tourette's Syndrome. The actions performed during a BDD episode are entirely voluntary, but, involuntary. This may seem like an oxymoron, but the truth is, the victim is entirely in control of his actions, but has differences in opinion between the subconscious and conscious mind. While the victim would like to keep away from performing ritualistic behaviors, they feel compelled to do them, and can do little to prevent them from happening. It's almost like an addiction that can be overcome, yet every inch of your body screams for the addictive agent.

Overall, I believe that BDD is a very predictable response to uncommon life circumstances. It is estimated that around 2% of the population has BDD. In my opinion, these 2% had living circumstances quite similar to one another, but very different from those around them. There are endless combinations of ways that one could have been raised, and there are also several "strains" of BDD. Each case, although similar, is unique. But from personal experiences, and learning from others who are suffering from BDD, all cases seem to be a natural human response to life circumstances that deviate from the average person's.

Common Behaviors

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Below is an explanation of some of the most common behaviors associated with BDD. Some people may display more than others, and to varying degrees, but they tend to be common among those suffering from BDD.

Mirrors: Checking and AvoidanceOne of the most common behaviors displayed by a BDDer is mirror checking. Any mirror will do, along with reflective surfaces such as store windows, although most BDDers will have a handful of favorite mirrors that are in places with, what they consider to be, the most appealing lighting. I've heard more than once that the lighting from late morning until early evening create the greatest amounts of distress. Such light shining in a window seems to de-emphasize facial features, making them appear akin to a human blob. This often causes the highly perfectionistic BDDer to assume his face has morphed into a horrendous monster, whereas most people would just blow it off as the fault of bad lighting. Many BDDers prefer to avoid mirrors during this time of day.

Although BDD is associated with long hours (in the upper single digits) spent in front of the mirror, I've found that over the past few years, I've started spending less time sitting statically in front of one reflective surface, but instead, check only momentarily several times a day. I consider this a great improvement. Many people affected with BDD find that they avoid mirrors altogether, covering them, taking them down, or turning off lights when they approach one. Most of us have a love/hate relationship going on with mirrors, as they can sometimes reflect an image that is better than what we had in our minds. At other times, we are feeling confident, but then see our reflection and fall into deep despair. What must be remembered is the fact that this mirror checking is not the source of pain. Often, a person with BDD can spend time in front of a mirror and feel no associated torment. But, things become a problem when a BDD attack accompanies this mirror checking. A BDD attack is a BDDer's worst enemy. I use this term to describe times when you feel hopeless, ugly, deformed, and suicidal, and it can hit at any time and be triggered by a number of situations. Because the likelihood of a BDD attack often occurs during stressful times, you will find that your other BDD behaviors, such as mirror checking, will most likely increase as well. Therefore, many BDDers find that they associate this self-hatred and hopelessness with mirrors, and the reflection they see staring back at them.

CamerasAnother common BDD complaint deals with photographs. Many a BDDer has avoided intimate family gatherings or other important situations just to prevent themselves from being photographed. They say a picture is worth a thousand words, but to a BDDer, it is only one: disgust. Having your face caught on film creates much distress, as we become paranoid as to who will see it, what they will think, and feel ashamed that anybody would have to look at us. We have no control over who will see the photo, and what will go through their minds when they see it. A photo almost always convinces a BDDer that their image of themselves, in their own mind, is correct, if not worse than they thought. In my opinion, this shows that BDDers do see themselves just as everybody else does. They've just come to despise what they see, and have become extremely perfectionistic, zooming in on even the tiniest details of their appearance. They do not hold these same standards towards others.The interesting thing is, BDDers opinions of themselves in photographs can change from time to time. Sometimes, they will even see a photograph of themselves that they actually like. I have found that I've hated certain photos in the past, to realize that they actually looked decent, to find that I hated them all over again when they were presented to me at a further date! Perhaps this has something to do with what we are focusing on in the picture, as our body part that we are obsessing over changes from day to day. If a certain photo doesn't emphasize this hated feature, then we can view it as a decent photo. If the feature is entirely minimized by having the picture shot at a unique angle, then we might even like the picture. But most BDDers do not want to take a chance being photographed, as looking at one they consider to be bad can bring about a BDD attack. I would say that most of our obsessive behaviors, such as avoiding cameras, are an attempt to keep BDD attacks at bay.

Public SituationsMany BDDers have problems in public situations. Some even have problems meeting with relatives and family members. I know that every time I am at a family gathering, I run to the back of the house and lock the door because I am too afraid of judgment. When seeing my immediate family after a month of being out of contact, I will shake uncontrollably. Most BDDers find that they are very uncomfortable in social situations for several reasons. They first feel strangely inhuman. They have a difficult time truly connecting to other people, and usually feel like an outcast. Their natural body language is often restricted, because they feel stressed that the people around them might observe them and judge them unfavorably. It almost seems narcissistic, feeling so singled out from the rest of the public, yet at the same time, we do not feel that we are separated from society because we are better than anyone else. We feel almost as if we do not exist, and that we are separated from the rest of the human race. It feels as if we, to use the old clich, stick out like a sore thumb. We are scared to say the wrong thing, move the wrong way, smile, or even blush, because we fear that everyone is observing us, noticing how different we are, and we will be scrutinized and judged, and ultimately rejected. Because of this fear, some BDDers will not leave the house during daytime hours, as they feel others will have a better chance of judging them. Others will drop out of school, be unemployed, become agoraphobic, or just simply avoid any situation where people can be found altogether. Some BDDers will be able to hold down a job, and keep a social life, but most are constantly worrying about what others think of them, and believe they come across much less confident than they really are. They harbor feelings of inferiority, and it causes them much distress that is often unseen by outsiders.

Common Behaviors

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Disguise: Makeup, Hair, and ClothesAnother behavior common to BDDers is camouflaging, or concealing, disliked features. If we don't like our face, we'll cover it up with war paint, a.k.a. overabundant makeup application. We usually won't leave the house without this camouflage, and will reapply it several times a day, trying to make sure it is perfect. We will spend a tremendous amount of time trying to "fix" our problems. For instance, if you don't like your nose, you might try to place eyeshadow on the sides, in strategic places, to make it look like the desired shape. The interesting thing is, the problem area on your face can often change from day to day. One week, you are obsessed with your nose being too large, and the next, you might believe it's too small and not understand why you tried to make it look smaller before! Many people with BDD wonder whether their face is changing, or if their mind is just playing tricks, or if they are actually seeing something different than other people see. Most of our family and friends will reassure us that our face has not changed overnight, and this can often cause despair, because we believe that we will forever be stuck with this newly formed, hideous feature!

BDDers with hair concerns may spend hours a day rearranging or brushing their hair, trying to get it in the perfect position, or the perfect texture. Such things as getting a haircut, or washing your hair, can cause you to believe that your hair has been ruined, and you cannot go on living. They can always convince themselves that it's not quite right, and that other people will notice this as well. They become so focused on their hair, that nothing else about them matters, and if the hair is not improved through vigorous efforts, then they feel a sense of impending doom, and may eventually give up on the idea of leaving the house for the day. Sometimes when they finally rearrange their hair to their standards, they will refocus on the whole picture, and realize that they hate the way they look all together, and also give up.

Many people have concerns about the overall proportions of their body, and will try to wear clothes that flatter certain areas, such as the neck, and minimize others, such as the torso. To the BDDer, this all seems like normal behavior while we are camouflauging. It feels very similar to a nonBDDer, getting up for the day, and trying to make themselves presentable and attractive. But, the difference for a BDDer, is they cannot leave the house without their camouflauge, as they feel they would immediately be rejected and humiliated by anybody that saw them. They don't wear makeup, do their hair, and wear nice clothing because they want to look good; they do it because they feel they need it. Very few people, except those who they truly trust, and feel will not reject them, will see them without camouflage. Often, they will not even allow their family or close friends to see them completely natural.

An interesting aspect of this camouflaging behavior, is many BDDers alternate their ideas on what looks acceptable and what doesn't. I've known several BDDers that will wear their hair down for two years, never letting a single hair blow out of place, because they feel they will look ugly if their face is revealed. Then, they suddenly believe that their face is much too long, and long hair only emphasizes this, and will vow never to wear their hair down again. Some will apply heavy face makeup for years, to suddenly decide that they look like a drag-queen, and opt to never wear makeup ever again. Decisions are black and white, and usually very extreme. They also have a tendency to use very negative words to describe themselves. These negatives terms aren't only outwardly stated, but also occur in internal dialogues. It's not uncommon for a BDDer to make such statements as, "I look more deformed than the Elephant Man" or, "how could you be with such a horribly ugly person like me?". None of this is for attention. If they say it, they truly believe it. But, as I mentioned before, their thinking is very black and white, and they can often change opinions on their self worth from hour to hour, sometimes feeling all bad, and at other times feeling good.

Premeditated PositioningI've found that many BDDers often try to sit in a certain, preplanned position. They will usually believe that one side of their body looks more attractive than the other, and will make an effort of putting their best foot forward, so to speak. If they are in a caf, about to sit down with a friend for brunch, they will first try to find a table that is not placed underneath harsh lighting that might emphasize flaws. They will also take into account where other people are sitting, and where their friend will be sitting, and try to find a position that hides their unpreferred side. For instance, if they feel their chin is pointy, they will not want anyone in the caf being able to see them from the side view, and they will not want their friend seeing them looking down. Therefore, the BDDer may choose to sit with of a profile showing to the outsiders and holding their head up high to the friend. Whatever the final decision is, you can always be sure that the calculations will be quite precise, almost bordering on scientific!

Models, Babes, and Porn, Oh My!Oh, now we've come to a fun, common feature, that causes extreme embarrassment among most BDDers, but always gets a laugh when we really think about what we're doing. Thanks to the invention of the internet, many BDDers have optimized their comparing behaviors, and check out babes on the internet! I have not heard if any BDD guys do the same thing, but I've heard it amongst several BDD females. We will search everything from supermodels, to celebrities, to porn (it's the only way to find a naked female body if your BDD concern is your body proportions). We are highly embarrassed that somebody might catch us in the act, and many of us have had a fun time explaining our way out of such situations. We also know that people might make the assumption that we are homosexual. But, this is not the case. We are merely checking out other women, comparing ourselves to them, seeing how we match up. This sometimes leaves us feeling decent, as if we live up to the standards of being a normal human. But, usually, it leaves us feeling quite depressed, thinking we are homely and deformed, and creates the desire for us to continue looking up babes until we find one that makes us feel better again. If we find one that makes us feel better, we usually continue searching anyhow, and most often end up feeling deformed once again. It's an endless cycle. If a BDDer does not have an internet connection, they will be sure to perform this behavior by reading magazines, watching movies, or just checking out people on the streets. Most likely, they will only compare themselves with the people that have made themselves up for several hours and that are in optimal lighting.

Common Behaviors

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Picking, Pulling, and MeasuringOther BDD behaviors that usually happen while we are participating in the mirror checking ritual are skin picking, feature pulling and pushing, and feature measuring. Skin picking can last for hours at a time, and usually is not related to any true skin problems such as acne. Several BDDers who pick at their skin used to have skin problems, but they have subsided since, yet they still feel as if their skin is flawed. They'll spend an inordinate amount of time, picking at tiny or nonexistent bumps on their faces or arms with their fingers, and poke at them with needles, tweezers, or other sharp objects. Sometimes, they will leave themselves with gashing wounds, and be so ashamed and embarrassed, that they will refuse to leave the house the next day. Skin picking can take place at any time during the day, but often, it will last up until the wee hours of the night, when everybody else is asleep. I've also noticed a tendency for BDD girls to always keep their eyebrows well groomed, which could also be related to this desire to pick at things.

I often notice that BDDers pull and push the body parts of their obsession. If they dislike their nose, they may pull or push it, usually not in an effort to physically change it, but instead to see if they would look better had they been born with a different nose. If they find a position of nose that they desire, they will often come up with intricate plans of creating this nose by finding a plastic surgeon, briefing him on the exact details he needs to know in giving you the nose of your dreams. Most BDDers will not trust a surgeon to make the final decision in what would look good. They already have an idea of perfection in their minds, which will of course change over time, making it nearly impossible for a plastic surgeon to work on a BDDer and receive results that both parties are happy with. There is an endless amount of ways to change a face by pushing and pulling, and most BDDers will spend quite a bit of time during their day seeing how they'd look if their features were moved in different positions. Sometimes, they start to feel hopeless if they cannot push or pull their features into positions that look appealing, and will hurt themselves by being overly forceful out of frustration. It's not uncommon to wake up with a sore jaw if you've been experimenting too roughly with positions that would make your facial structure look more appealing.BDDers often measure their features, coming up with complex formulas related to correct human proportions. If they believe their face is long, they may take out a ruler and divide the face into thirds, making sure that the forehead, nose, and chin are all equal in length. If they find that they are equal, they'll assume that their face is not wide enough. If they prove it is wide enough, they'll come to the conclusion that it's lacking in depth. It's always a no win situation, and if they find positive evidence, they'll still be sure to form a negative conclusion. Such measuring sprees often occur after reading a book or magazine article, or watching a TV program about the correct human proportions, and they, for some reason, need to prove to themselves that they do not fit the standard of a normal human being. Once they prove this to themselves, they usually feel extremely depressed, and often experience a BDD attack.

Preoccupied MindMany people with BDD have a hard time relaxing and listening. Whenever they sit down to watch a movie or TV, or partake in a conversation, they start dwelling on their appearance concerns. Many times, this will lead to ritualistic mirror checking behaviors, and the inability to sit still. Sometimes it will be difficult to sleep, or listen in classes, or study if they cannot rid their mind of their BDD thoughts.

PerfectionismMost BDDers seem to have a highly perfectionistic streak in several areas of their lives. If things do not meet up to their expectations, they can become extremely depressed. Most BDDers do not want to compete with anybody, and almost fear the idea of competition, yet find that they put themselves in competition, comparing themselves to everybody, and judging themselves by the strictest standards. Although I've heard from a few BDDers who judge other people as harshly as they judge themselves, I've found that most people with BDD consider every other person in this world attractive. Most even feel that the Elephant Man would be a step up in the looks department. For some reason, people with BDD have come to see themselves entirely different than other people, and believe that they are being judged on a different standard than normal humans. They also believe that others are judging them by the same standards that they're judging themselves, but do not judge anybody else this way.

Common Behaviors

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Need for ReassuranceProbably the number one most complained about behavior from family and friends of a BDDer is the need for reassurance. Nearly every person with BDD will ask those close to them whether or not they look ok. We are not talking about asking once. Or even twice. BDDers will incessantly bring up the topic, asking over and over again, every time they change one thing about their appearance. For instance, if a girl with BDD decides to wash off her lipstick and replaces it with lipliner, she will most likely run to her mother, or anyone else that she trusts that is available, and a conversation very similar to the following will proceed:

Daughter:"Do my lips look ugly?"Mother: "No, they don't look ugly."Daughter:"Are you sure they don't look ugly?"Mother:"Yes, they look fine."Daughter:"So, they don't look great, because if they did, they wouldn't look fine. So, they could look better?"Mother:"No, they look good."Daughter:"You're just saying that because you are my mother and you have to."Mother:"Don't you know how lucky you are?! You could have been born deformed!"Daughter:"Hmm, ok."(most likely, she's already plotted a new idea of what she could do with her lips to try to improve them, and is not listening to her mother anymore).

Daughter exeunt. She runs to bathroom and experiments with other makeup because she feels both ugly, ashamed, and unconvinced that her lips looked fine.

This is really an interesting behavior. It's definitely a no win situation. The problem is, the daughter is not truly worrying about her appearance. She thinks she is. You think she is. But, she could actually care less if she ended up being the next Pamela Anderson, modeling on magazine covers and posing for centerfold spreads. No matter how she looks, if she feels unaccepted, she will not be content. The problem is, most BDDers believe their problem is 100% physical. I've known many BDDers, including myself, that will admit they are the victim of this "imagined ugliness" disorder, but then shake their heads in total denial, claiming, "no, other people have BDD, but I'm just truly ugly!" This causes the BDDer to play a mental game of hot potato. She'll first throw out the idea that she's ugly. Then she remembers it's just imagined ugliness. Which can then turn into the idea that she's actually normal looking, and she doesn't realize how she thought anything different. Then, she becomes the twin of the elephant man that is doomed to a life of lonliness. Then she returns to the idea that she's just unattractive again! The mind can never rest. So no matter what a parent tells their child, the child's mind will still continue to dwell on other thoughts. On the advice page, you will find out the best ways to communicate with somebody going through a BDD episode.

The Bad Gets Worse: Self-Amputation and SuicideSevere cases of BDD can lead to such behaviors as self-amputation and suicide. I think suicidal thoughts are very common to the average BDDer, and a high percentage of them actually commit suicide. I've heard that this number was around 30%. Thoughts of self-amputation are not that unusual either, but it's usually just a fleeting idea that is somewhat between a joke and seriousness. For instance, you dislike your chin, and cover it up with your hand, just to realize you like it better when you can't see it. So, you might run to family members and ask if they think you also would benefit appearance wise from the lack of a chin. After a few rolls of the eyes and sighs, you realize it was a stupid question, but still think that you might be on to something. I think it is very uncommon for a BDDer to actually go through with dismembering a body part, although they might hurt themselves on accident, while performing a ritual. The most common destructive behavior would probably be cutting all their hair off in a desperate attempt to make it look more acceptable, or accidentally picking their skin too much, leading to scarring. Some BDDers seem to have a preoccupation with visiting plastic surgeons and getting multiple surgeries. I've never had the chance to personally talk to one of them that's undergone several surgeries, but I know that many BDDers have either had a consultation with a surgeon, or at least supported the thought of getting surgery, at one time or another, believing it might be the answer to their problems. I do know that I've never heard of a single BDDer that has been satisfied with their plastic surgery, once again showing that BDD most likely has little to do with appearance at all. If you change one part of your appearance, you will most likely find a new aspect to hate.

NegativityBDDers have an extreme tolerance for negativity and negative self-talk. If every person on earth except for one told a BDDer that she was beautiful, and the remaining person said she looked tired, I assure you she would convince you with all her heart that everyone thought she was ugly because she had bags under her eyes. BDDers look for negative evidence to back up their beliefs. If it is not available, they make up evidence. I know that I often put words in random peoples' mouths, saying such things as, "they didn't say bye to me because they thought my nose was too big," even though I didn't know the people, and they said nothing about my nose. The interesting part is, we truly believe what we say, at least until we realize it's ridiculous. But by the time we realize that our thinking is faulty, we've already come up with another strange idea that we believe is 100% true. Most people complain that BDDers are much too pessimistic and that it ruins their days to hear such horrible comments. These are people that only have to be around the BDDer. Think how it must feel to actually believe these comments and have them aimed at your very being. I find that outside of bashing themselves, BDDers are usually very positive people that give everyone else, but themselves, the benefit of the doubt in all situations. If the topic turns to themselves, they will benegative

Common Behaviors

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Dressing DownSomething else that I have found very common with most BDDers is the desire to dress frumpy. The more a BDDer tries to dress up attractively, the more likely he or she will experience a BDD attack. Very often, a BDDer will spend hours applying makeup, and then go out wearing a t-shirt, shorts, and tennis shoes. Also, I noticed that many can have a wonderful body image from the neck down, but have a horrible body image concerning their face, and vice versa. Often they don't care about 95% of their body, and would not even mind if it became severely disfigured, but only concentrate on what they believe is the important part of their appearance. For some BDDers, dressing up and keeping in shape are extremely important though. I've noticed that several males with BDD pay special attention to dressing nicely, but might neglect some other part of their appearance.

The Perfect PersonThe BDDer will often have an idea of who the perfect person is, and it is sometimes a public figure, and at other times, someone they know personally. Sometimes they just know a type of person that they find perfect. Usually, it does not agree with the average human being's standard of beauty, and often, this person has something in common with somebody they admired in childhood that was totally different from themselves. For instance, I went through a phase where I wanted to look like a short, male, Samurai warrior even though I am a female. Another time, I wanted to look like Conan O'Brien. I've heard of many BDDers who have come up with other random wishes like my own. To the BDDer, these desires seem absolutely normal, until they realize that they aren't so normal, which usually will take a few years. Most BDDers cannot understand how another BDDer could want to look like Conan O'Brien, but think it's totally acceptable to want to look like Howard Stern. Usually, they will not look at the whole picture, and realize that it would require a sex change operation to look like the person they admire. Instead, they think about things like the person's facial structure is exactly the opposite of her own, and obsessively think about how they could change their facial structure to match the desired face shape. Often, the self-talk goes as so, "if I looked like him or her, then I would (fill in the blank with anything you think you aren't now: E.g. Be happy, be accepted, wouldn't complain, etc.)." I also found that many BDDers have a celebrity role model, who they think they might look like on good BDD days. This gives them hope that they look like somebody that is accepted. On bad BDD days, they usually have a backup celebrity, that has the reputation of being quite homely and looks nothing like the first celebrity. They will waiver back and forth between thinking they look like the one, and they look like the other, and will sit in the mirror trying to decide which is more true.

We Can Speak Like the DoctorsI've noticed that many BDDers study up on their perceived defect so much, that they will actually be able to use the jargon that doctors, having been to medical school for several years specializing in that feature, would use. A BDDer will often have a difficult time learning new things while their mind is preoccupied thinking about their appearance, but will have no problems picking up very specialized information on their defect at lightning speed!

We are TalentedAn unusually large percentage of people suffering from BDD are quite talented in the arts, whether it be visual arts, design, singing, music, or other forms of self expression.

Common Link in Displayed BehaviorsAll of the previous behaviors probably seem quite different from one another, but if you analyze them closely enough, you'll find that most of them have something in common. They are behaviors that can help the mind dissociate. Each of them can be repeated over and over again, with perfection rarely being achieved, meaning that the task can never be completed. Imagine a husband, that has been working hard all day, to come home to his wife who yells at him for throwing his dirty clothes on the ground, and a houseful of screaming children that are jumping up and down in the background. All he wants is some peace of mind, so he decides to head on outside and do some yard work. This yard work is not done because he has the desire to work even harder after his long day of tedious work, but it's because he wants to get his mind off things that are really bothering him. By mowing the lawn, and clipping leaves, he can worry that things don't look quite perfect instead of worrying about what he'll say to his wife to make her happy, or how he can convince his kids to settle down. The more he wants to avoid going back inside, the more work he'll find to do outside. The more complex issues on a BDDer's mind, the more likely he or she will perform endless rituals.

Causation

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Here, you will find several theories on the causes of BDD. It is not certain what causes the disorder, so everything you read is entirely based on opinions, which have been based on collected evidence. Expect to see more theories posted in the near future. If you would like to submit your own theory to this section, please email it tobddcentral@gmail.com.

Personal TheoryI believe that everyone has gotten BDD in a different way, but there is a common trend in most of our cases. These are the factors that I believe will form a case of BDD:

1. Outside circumstances made you feel different than others as a child. This can be done in several ways. It can be through abuse from parents, with an emphasis on neglect. It can also be caused by siblings, friends, or teachers making you the outcast, scapegoat, or teasing you. In fact, one comment pointing out your differences can be all that it takes. Something else that I've noticed is that a severe case of the skin disease vitiligo can leave a person feeling like an outcast, or different than others. Just having people notice the problem and ask questions about it can make you feel as if you are not human like everyone else.

2. You experienced some sort of severe trauma that left you with such immense feelings that you were unable to express them. This trauma will vary from person to person. Physical, emotional, and sexual abuse are common themes. Death of loved ones, rape, accidents, developing a terminal disease, etc.

3. Most people with BDD hoard their feelings and never let them see the light of day. Many were forbidden to express feelings as children. Others lived in environments where they never learned that it was normal to talk about pain. Some were so embarrassed by their traumas, and felt guilty about them, that they didn't ever tell anyone what happened. BDDers who were abused sometimes have poor social networks, and therefore only talk to their families. If they were the abusers, they are the last people that would be sympathetic to your past trauma. Either way, BDDers are boiling over with angry, traumatic, and shameful feelings that they never expressed, and still don't know how to, and have decided to just put a lid on it! To cope with such agonizing, stressful thoughts, BDDers create a coping mechanism, BDD, to dissociate from the pain. During a BDD attack, BDDers will be closest to feeling the pain of the original trauma. This is what causes suicidal feelings, because it is far too painful to handle.

Brain Chemistry ImbalanceDr. Katharine Phillips has suggested that BDD is caused by a chemical imbalance that was most likely genetically passed on from family members that have OCD or anxiety disorders. She claims that BDDers have a deficiency in production of the neurotransmitter called Serotonin, and recommends that they take certain drugs called Selective Serotonin Reuptake Inhibitors, which are commonly called antidepressants and affect mood and motivation. These drugs, such as Prozac and Luvox, block the uptake of Serotonin from the synaptic space back into the presynaptic axon terminal

Media Influence: To Blame or Not to Blame?How can we talk about BDD without bringing the media into the discussion? Many people nowadays are complaining that the media is responsible for everything from anorexia, to normal self-esteem concerns, to the increase in plastic surgery cases, to the number of divorces. I believe the media aggravates BDD, but by no means causes it. Sure, when I see a magazine cover plastered with an airbrushed model, or a movie with a glamorous actress decked out in the newest hairstyles and outfits after three hours in the makeup chair, I will probably start experiencing a BDD episode. I'll start comparing myself with this idea of perfection, and assume that I do not match up to it. Nobody can match up with it. It's not real. But, even without these magazines and movies, I am certain that I would have developed BDD giving the previous circumstances during my childhood.

BDD has been a recorded disorder for over 100 years. That was before TVs, before movies, and before magazines had pictures of smiling girls on the cover. It was before pin up girls. It was before the supermodel era. It was before the time that women could get plastic surgery and turn themselves into a form that couldn't humanly be possible. BDD has truly little to do with looks. BDD is a coping mechanism that uses looks as an excuse. In fact, it's ludicrous to say, but we may even be lucky to live in a day and age when babes come at a dime a dozen, because it makes our BDD rituals much easier. We would try to perform rituals no matter what era we had lived in, so at least over time, society has created the optimal environment for BDD rituals to flourish. My main concern with this is that when we are performing rituals, we have an easier time avoiding the real problem that lies deeper than our surface ritualistic behaviors related to beauty

Causation

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Childhood Can be RoughI do not believe that this has anything to do with whether a not a person will develop BDD, but it may play a role in our emphasis on appearance and which features we choose to blame our imagined ugliness on. I was born with an underbite, and spent eight years in treatment, which included braces, headgear, rubberbands, retainers, getting teeth pulled, etc. Although nobody ever teased me about this, which is surprising to me, it still added to the feeling of being different and born "wrong". It was often brought to my attention that I had to go through this treatment because I had a "problem" with my teeth and jaw, and even today, I notice that my main BDD concern deals with my jaw and general facial structure. I assume that it is different than other people's and sets me apart as being different. Even though I've been told that my jaw is now in the correct position after years of treatment, I still feel like they could never quite "fix" me and make me like other humans. So if you were overweight, had to wear glasses, went through braces, or had any feature that made you stand out as being different, and could have been considered "wrong" by society, you may have blamed these features specifically when you developed BDD. If you did not have any feature specifically pointed out to you as being wrong, you may develop the sense that you are just overall ugly, and can't quite pinpoint what makes you this way.

Additional TheoriesThe sociocultural context one is born into obviously plays a huge factor, not only in terms of how strongly that culture attempts to dictate it's own ideal but also what that ideal consists of. A genetic component must also play a part in things due to the neurological parallels with obsessive compulsive disorder. Finally there is a complex interplay of psychological variables which I'll attempt to offer my opinions on. I believe that people with BDD, due to unique upbringings, have a different psychosocial reality than everyone else. This in turn affects the social impressions and reactions we make and/or our perceptions of those impressions and reactions, and causes us to have differing social feedback or feel as though we do. Many view the impressions, reactions and feedback in a negative light, whether real or perceived. All of this then either creates or contributes to a feeling that we are different than others and reinforces what seem to be universal feelings of low self-esteem. This also heightens social sensitivity and social impressions, and a link has been established between individuals sensitive to social impressions and being especially influenced by physical attractiveness. For me it's not too difficult to imagine that for someone who lived with the above, and for whom physical attractiveness was such an important variable, the problem they felt existed with their self would be transferred to their body, especially if you add feelings of bodily ineffectiveness to feelings of psychosocial ineffectiveness. All of this is in accordance with both a psychoanalytical perspective, "The mechanism of symptom formation is a simple displacement of the feeling that there is something wrong with the self from the psyche to the soma" and a developmental contextual one, "...body image not only derives from person-social context relations and the individual's cognitive and emotional developments, but also contributes to both of these processes" and "The person's appraisal of his/her body - that is, cognitions and feelings about his/her body are reactions which (1) derive in part from the socializing others' reactions to the person". What I feel must be added to the last quote is that not only do socializing others' reactions play a part but also the individual's perceptions of socialzing others' reactions.

The result of all this is the individual pursuing beauty, a "normal" appearance, or the removal of some perceived flaw in an obsessive-compulsive manner (congruently with the depression, social phobias and other characteristics of the disorder). This pursuit of beauty or a "normal" appearance is not only a pursuit of a psychosocially satisfying body image but also of a psychosocially satisfying self. Or to put it another way, this is another instance of the beauty is good stereotype, with the afflicted individual also unconsciously pursuing the assumed social confidence and adjustment characteristic of that stereotype. However psyschosocial self change is made that much more difficult because the warped body-image ends up continuously reinforcing the aforementioned feelings of being different, simply due to the fact that one's experience of one's body is fundamental to their experience of reality and oneself. Furthermore the neurological underpinnings (which parallel those of obsessive-compulsive disorder) can also make change extremely difficult, because of the inherent qualities of those neurological pathways.

History of BDD

Body dysmorphic disorder has been officially recognized since 1987, receiving a permanent resting place amongst the somatoform disorders in theDSM-III. Disorders placed in this category, such as hypochondriasis, somatization disorder and conversion disorder, generally manifest themselves in physical symptoms; BDD is no exceptionany aspect of bodily appearance (usually unchangeable ones) can be the cause of concern and trigger obsessive/compulsive thoughts and behaviors.

Although BDD has just recently been accepted as an actual diagnosis, it has been lurking around, and recorded, for well over a century. Morsellini, an Italian researcher, coined the term dysmorphophobia to describe BDD as early as 1886. Other sources report that Emil Kraeplin, the father of modern scientific psychiatry, psychopharmacology, and psychiatric genetics, was the first to discover the distressing disorder. Even Sigmund Freud claims to have worked with a sufferer of BDD named Sergei Pankejeff, more aptly nicknamed the wolfman.. This patient was so preoccupied with the appearance of his nose, he was barely able to function outside of his obsessive thoughts. Recognized in Europe for quite some time, where it received its initial title,dysmorphophobiawas eventually renamed body dysmorphic disorder to halt misconceptions of BDD dealing with a behavioral pattern of avoidance.

Comorbidity

Although BDD is categorized as a somatoform disorder in theDSM-IV, many experts believe that it is closely related to the anxiety disorder, OCD, due to its obsessive-compulsive nature and positive response to similar therapy and drug treatments; yet BDD is still considered much more difficult to treat. Unlike OCD, BDD Additionally, only 30% of OCD sufferers have an additional diagnosis of depression compared to 80-90% of people with BDD. Unlike other related disorders, which are centered on feelings of anxiety, BDD is much more likely to be accompanied by feelings of shame, guilt, disgust, self-hatred and depression, which could be contributing factors to the high suicide rates. victims normally do not find satisfaction or relief of anxiety by performing ritualsinstead, it often creates a feeling of great despair and suicidal ideation.

Other disorders which seem to have similarities to BDD are trichtotillomania, or obsessive hair plucking; anorexia nervosaan obsession with body weight; and koro, a disorder more readily observed in Asian cultures, where an individual believes his genitalia is shrinking back into his body, potentially causing imminent death.

BDD is rarely seen as a pure disorder; instead, comorbid disorders are often diagnosedmost commonly, depression and social phobia, or alternately, avoidant personality disorder. It is uncertain whether these additional disorders are created by BDD; it would certainly be plausible for a person who views himself as severely deformed to become depressed and fearful of social interaction in a situation where he may be judged by appearances! Yet, it would also be possible to claim that a chemical imbalance, initially caused by depression, could spur the onset of BDD.

Other frequently seen comorbid disorders, which are not as well documented, are bipolar II disorder, narcissistic personality disorder, dependent personality disorder, and obsessive-compulsive disorder. Its not as uncommon as one might think to see a narcissistic, bipolar BDDer who one day sees and describes himself as an absolute stunning Greek god with no faults, and the next, plummets into a severe and suicidal depression because hes convinced he looks like a homogenous blend of Spock and a sheep.

Prevelance & Gender

Current research suggests that BDD is much more common than once thought; nearly 5 million people in. Although BDD has recently become a buzzword, appearing on a variety of talk shows, magazine articles and radio stations due to its media appeal, it is still not well understood or widely acknowledged by therapists. Many sufferers are misdiagnosed with depression and do not receive help for the actual problem. alone suffer from the potentially disabling disorder, and due to the highly secretive nature and embarrassment of sufferers, many others are most likely plagued as well and have not received a diagnosis.

Unlike eating disorders which are much more prevalent in women, research indicates that BDD is just as commonly seen in women as in men. While the most frequent BDD obsessions regard facial appearance, many women sufferers are also plagued with overall body proportions issues, while some men are preoccupied with the need to be larger and more muscular. This latter phenomenon is referred to, in a groundbreaking book written by Dr. Roberto Oliviandro and Katherine A. Phillips, as the Adonis complex.

Disorder Course

Most sufferers first notice the onset of symptoms during adolescence or early adulthood, but there are exceptions to the rule, with some cases developing as early as four years old and others quite late in life--often after some type of traumatic event. The course of the disorder is often chronic with little chance of complete recovery without specialized treatment. With treatment, the recovery process is often long and prone to relapse, although some treatments, such as cognitive behavioral therapy, exposure and response prevention, and medications are providing promising results. The future for BDD sufferers is hopeful as studies are conducted by researchers as a means of finding continually improved treatment options.

Tips for Sufferers

BDD Attacks ( 8 items )Here is information on BDD Attacks.

Methods for Coping ( 4 items )Here is a list that is continually updated with insider tips for battling your BDD. These techniques may not be a cure to BDD, but have proven to alleviate symptoms in BDDCentral members and bring about a significant decrease in negative aspects of BDD! If you'd like to submit a tip that's helped you battle BDD, please email it to bddcentral@gmail.com.

Advice for Family and Friends ( 1 items )In this section, we will provide advice for those who know someone with BDD. Most people that know a sufferer have no clue as to what they should say or do to help their loved one. They get discouraged, feeling like nothing is having any influence. If you would like to ask any questions, and receive answers from a BDDer perspective, please email them to bddcentral@gmail.com and we'll post our advice.

Suicide Prevention Resources ( 1 items )Some studies say that up to 30% of people with BDD attempt suicide, so this is not a subject to be taken lightly. If you or somebody you know are feeling suicidal, please get help immediately. Here is some information regarding where you can find the help you need.

BDD Glossary

Here, you will find an ever-growing list of terms that are related to body dysmorphic disorder. If you don't understand something on this site, please refer to this list, and hopefully you will find a definition for what you are looking for. Our support group has come up with quite a few original words due to the lack of literature written on BDD at the time of its origin. If you would like any terms added to this list of definitions, please contact us.

BDDAcronym for body dysmorphic disorder

BDDerA person with BDD

BDD AttackWhen a person with BDD is so overwhelmed with feelings of self-hatred, they can no longer function properly. Suicide is often considered at this time. BDD attacks eventually pass, and can be followed by normal functioning, or a BDD episode

BDD EpisodeA BDD episode occurs when a person with BDD is having a day filled with self doubt, comparing themselves to others, and constantly worrying and filled with anxiety

CompulsionsAn irresistible impulse to act, regardless of the rationality of the motivation

DelusionalA false belief strongly held in spite of invalidating evidence, especially as a symptom of mental illness

DysmorphophobiaAn alternate name for BDD. It was the original name of the disorder

Imagined Ugliness SyndromeA nickname sometimes used when referring to BDD

Katharine PhillipsOne of the leading authorities researching BDD. She has also written a book on the disorder called,The Broken MirrorMirror CheckingBehavior often preformed by a person with BDD. They may sit in front of a mirror for a varying length of time, observing features, picking at skin, touching features, etc.

NonBDDerA person that does not have BDD

ObsessionsA compulsive, often unreasonable idea or emotion. People with BDD are usually obsessed with an imperfection in appearance

OCDAcronym for obsessive-compulsive disorder. Many believe that this disorder may be closely linked with BDD

RitualsA detailed method of procedure faithfully or regularly followed. Two common BDD rituals are checking one's reflection in a reflective surface, or skin picking

SSRIAcronym for Selective Serotonin Reuptake Inhibitor. It is a class of drugs, such as fluoxetine or sertraline, that inhibit the uptake of serotonin by neurons of the central nervous system and are primarily used in the treatment of depression and obsessive compulsive disorder, as well as BDD

TrichotillomaniaThe compulsion to tear or pluck out the hair on one's head and face and often to ingest it. Many people with BDD find that they also have trichotillomania