What is Body Dysmorphic Disorder?
When Los Angeles bodybuilder and fitness coach Lindsey Marie Greeley was just 17 years old, she competed in her first bodybuilding show. In the weeks leading up to competitions, she stared in the mirror, ‘trapped in her head’, obsessed with the perfect body. She would be devastated by a third place finish and the ‘constructive criticism’ from the jury like ‘You’re still not small enough; you need to lose more weight.”
It wasn’t long before she developed a body dysmorphic disorder (BDD) along with an eating disorder. The condition affects about one in 50 Americans, and not just athletes and bodybuilders, according to the International OCD Foundation.
BDD diagnostic criteria
Some people don’t like (part of) their body, but BDD goes beyond dissatisfaction. According to the psychiatric manual DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th Edition), these are the criteria used to indicate that a patient has BDD:
Preoccupation with non-existent or minor flaws and flaws in appearance
Repetitive or compulsive behavior, such as looking in the mirror often or changing clothes
Clinical significance, meaning that the obsession must cause significant distress or interfere with daily functioning, such as a person’s social life
Differentiation of an eating disorder, which prevents the doctor from actually diagnosing the person with an eating disorder
There are two additional distinctions for diagnosis:
Muscular Dysmorphism: A person is especially concerned about the fact that his physique (muscles) is too small or insufficient. This particular type has been associated with higher suicide rates and a poorer quality of life than other types.
Insight specification: how accurate or inaccurate a patient’s perception of themselves is.
Beth Rosenbaum is a Philadelphia-based licensed clinical social worker and therapist with over 30 years of experience with eating disorders and BDD. She says there can be either a predilection for reaching a certain size or weight, or that people can have a preoccupation with how a certain body part looks. She usually sees women obsessed with their breasts, stomachs and thighs, trying to meet the “societal expectations of perfection for women.” (Here are the ways to achieve body acceptance.)
For men, it’s often the stomach, chest and muscles, abs, biceps, and a concern that they’re not up to a standard either. She also carefully differentiates between BDD and body dissatisfaction, which many Americans struggle with.
The emotional toll can be heavy, with people often thinking hourly about the body parts they hate, interfering with their daily lives and ability to concentrate.
What Causes BDD?
There is not one cause, but a variety of triggers combined with past or current trauma in the patient’s life. Rosenbaum says it’s often a result of underlying emotional issues that need to be addressed. She also sees that most people with eating disorders also suffer from BDD.
Social norms, social media scrolling, and the inaccurate idea that our lives would be better if we were smaller are all to blame, Rosenbaum explains. Mixed messages about society’s expectations don’t help either.
She describes women’s magazines that she says have traditionally told women mostly conflicting messages: “On one side of the cover is the miracle diet next to how to bake the perfect cake. What do we do with that?”
BDD can also be associated with transgender patients who are in transition.
Men who were given female sex at birth can have a hard time with breast development and hips and stomach, and that too can lead to eating disorders, Rosenbaum says. She also sees that other important physical transitions, such as pregnancy and postpartum life, are triggers for BDD. “You could lose all the ‘baby’ weight, but your body proportions have changed,” she says.
(Here’s how to boost your body image.)
Signs of BDD
Your idea of a “mistake” is not realistic
The Diagnostic Handbook distinguishes between people with medical physical problems that are visible to others, and BDD where you focus on minor human flaws that are not noticeable to others.
Samantha DeCaro, an assistant clinical director at The Renfrew Center of Philadelphia, says BDD is a fixation on “perceived” flaws.
“These defects are undetectable, or barely noticeable, to anyone else,” she says. “People with BDD often become obsessed with real or imagined blemishes on their faces, their hair, or the size and shape of a particular body part.”
You avoid social situations
Have you ever canceled an event because you can’t find something that makes you look skinny enough to go out? This is a worrisome sign that may indicate BDD. Psychotherapist Haley Neidich, a licensed social worker with a private online practice, says that people with BDD “can isolate themselves and avoid social situations.”
Rosenbaum says the main distinction helping her diagnose BDD is identifying “how much does this interfere with” [a patient’s] “How much of my thinking time does this take? Is my focus on my body preventing me from doing things I enjoy, like going out with my friends?” All of these may indicate that you are moving from physical dissatisfaction to a more worrisome, obsessive disorder.(This is what happened when a woman began to struggle with body image after weight loss.)
You spend a lot of time staring in the mirror
When bodybuilder Greeley finally hit her lowest point and reached out to a therapist, she was diagnosed with BDD and bulimia. “When you sit in that world staring in the mirror and seeing thousands of [progression] photos for coaches, I’d say, ‘I can’t see my abs, oh God,’ she says. Greeley would spend hours “stalking” other people’s Instagram accounts and comparing her body to theirs. “I didn’t feel skinny enough. It got sick and obsessive,” she says.
You can’t stand your own face
Rosenbaum says the pandemic has exacerbated BDD for many people who spend hours on Zoom conversations staring at their own reflection. She jokes that even she has never “checked her hair” so many times.
“People stare at their distorted image all day long. For most of us, we are bodies from the chest up. We don’t even have bodies,” explains Rosenbaum. This unreasonable amount of time we can now spend staring at our own functions exacerbates the problem. It’s been dubbed the “Zoom Boom” as plastic surgeons see more patients considering plastic surgery in 2020. Recent research from the American Society of Plastic Surgeons reveals that telemedicine calls for plastic surgery are up 64 percent.
DeCaro says we live in a society obsessed with “fat phobia and ageism,” which makes everyone critical of their bodies from time to time, but people with BDD may be constantly concerned about “real or imagined blemishes on their faces” or other body parts. (Here are body positivity quotes to help you love your body.)
You see your body as parts, not as a very healthy being
Do you find yourself hating a specific body part? This can be one of the problems with BDD, because cutting out the body makes us hyper-analyze the flaws of each part, rather than looking at the body as a whole, explains Rosenbaum. One of the strategies she has found helpful with patients is to help them see their bodies as a whole that has a function, and to focus on what your body can do.
“Appreciate what your body does for you. Every aspect of your body. Learn to appreciate what it does and how it serves you so well… so we need to fuel our bodies to give us energy so our brains work. So we can walk and love and be concerned with everything our body does. Often [people with BDD] focus only on the surface,” Rosenbaum says. That deep dive into our perspective on our bodies, and focusing on the importance of perfecting certain parts, is what BDD patients work on in therapy.
Note that BDD is not strictly about weight. BDD can be presented in different ways. For example, it can pretend to be someone who can’t get through their day because they worry about the appearance of their nail bed. Or in people who can’t keep their jobs because they are always on leave due to plastic surgery on their chin.
(Here’s what a body image coach wishes you knew.)
What to do if you think you have BDD?
First determine the severity of the symptoms. Often, BDD happens in conjunction with an eating disorder, which can be more dangerous than BDD on its own.
Neidich says individuals with BDD have been known to follow or complete medical procedures to alter their bodies in an attempt to rid themselves of the obsession, which can be dangerous. “Given the high prevalence of eating disorders in individuals with BDD, it is important to point out that eating disorders are the most deadly mental disorder,” she says.
Behaviors that Rosenbaum says can be more serious, including binge eating and purging, restricting calories, over-exercising, and other typical symptoms of an eating disorder. Seeking therapy is an important step toward overcoming BDD, and it’s a great place to start.
Neidich suggests the following steps, noting that BDD often co-occurs with another condition (comorbidity):
People with comorbid personality disorders may be referred to dialectical behavior therapy (DBT), a type of cognitive-behavioral therapy that helps teach skills to deal with negative emotions.
Those with comorbid post-traumatic stress disorder (PTSD) may be referred to a trauma therapist.
Anyone with obsessive-compulsive disorder (OCD) may be referred to a specialist for cognitive behavioral therapy (CBT) in conjunction with Exposure and Response Prevention, a form of therapy that exposes people to their fears.
Those with comorbid substance use disorders will be encouraged to attend 12-step programs and focus on sobriety.
People with an eating disorder should have a multidisciplinary treatment team.
“As with other mental illnesses, it is possible for people to reach a place in their recovery where they are no longer (or minimally) symptomatic,” Neidich says. “However, individuals with a history of BDD are at high risk of recurrence of the symptoms or other mental illness in the future, especially around a transition period or intense stress in their lives,” she explains.
Greeley can finally handle it, after years of therapy. She says you don’t just wake up and have no more BDD, and that sometimes she still needs to check herself: “It’s okay to have one Oreo. You can have a cheeseburger and it won’t be the end of the world,” she says. She thanks the support of her healthcare team by helping her “learn to love herself again”.
Next, read these best-ever body shaming comebacks.