Sunday September 25th 2022

The tragic truth about Body Dismorphic Disorder


Jennifer* believes that she’s one of the most unattractive people on the planet. She points out scars and marks on her face – a few tiny pimples that her counsellor can barely see, even close-up. The pretty 22-year-old admits that she fell asleep in class regularly after staying up all night, picking at her face, making it bleed, becoming hysterical about her imagined ugliness.

As she grew older, Jennifer was too afraid to be in public and quit her job because it involved sitting under bright lighting and near other people. She did her shopping at midnight, when nobody else was around. Eventually, she went on medical disability because she couldn’t face the social nightmare of work.

Nobody’s perfect – even though we’d like to be. The blossoming beauty and cosmetic surgery industries bear testimony to the fact that millions of men and women want to look good. For most of us though, life goes on, despite lumpy thighs or stretch marks. We may be unhappy with our weight, our noses or knobbly knees, but we still have careers, friends and relationships.

For people afflicted with body dismorphic disorder (BDD), however, there is no life beyond the monster in the mirror.

“BDD is a preoccupation with an imagined body defect – for example, a misshapen nose – or a distortion of a real minor defect,” says  medical doctor and psychological therapist Wilme Steenekamp.

“For such a concern to be considered a mental disorder, the concern must cause the patient significant distress or be associated with impairment in the patient’s personal, social or occupational life.

“In other words, they must spend a great amount of time, effort and money on their fixation on this defect. They think or dream about it a lot of the time, watch themselves in every possible reflective surface or hide all mirrors and avoid reflective objects. They may see doctors about possible correction of the defect, become asocial in an attempt to avoid what they perceive as scrutiny of their defect and neglect responsibilities such as work, socialising or caretaking, due to their fixation on the defect.”

Ugly duckling syndrome

BDD was initially called “dysmorpophobia” when it was first classified more than 100 years ago, says Dr Steenekamp. In the 1980s, it was formally identified as a mental disorder and re-named.

Doctors do see many patients who are preoccupied with their appearance, but not to the extent that they “qualify” as true BDD sufferers, according to the psychiatric guidelines outlined in the diagnostic and statistical manual of mental disorders.

Patients with the complete diagnostic criteria for BDD are relatively rare, she says, and are usually found at dermatologists, plastic surgeons and ear-nose-throat specialists, rather than psychologists, because they seek “cures” for their perceived physical defects, rather than treatment for the mental disorder behind the perception.

The most tragic aspect of BDD is that it is “an irrational perception” and clients suffering from it rarely seek help, since they perceive it as being the truth. They are so fixated on the “defect” or “flaw” that they lose track of the rest of their identity.

The three diagnostic criteria for body dismorphic disorder (BDD), as classified by the American Psychiatric Association, are :

  • Preoccupation with imagined defect in appearance. If slight physical anomaly is present, the person’s concern is markedly excessive.
  • Preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  • Preoccupation is not better accounted for by another mental disorder, such as dissatisfaction with body shape and size in anorexia nervosa.


Dying to be perfect

American psychiatrist Katharine Phillips brought BDD to public attention with her groundbreaking book The Broken Mirror (Oxford University Press, 2005), in which she records her work with patients and discusses the causes and treatments of the disorder.

The book is a definitive and heartbreaking journey through the broken lives of patients such as Jennifer, who spent hours pricking her pimples with pins dipped in alcohol, and Melanie*, who admitted that her concern about  her appearance became a 24/7 obsession.

Phillips says that BDD is an under-recognised and under-diagnosed disorder. Studies indicate that it affects millions of people in the United States alone, and around the world.

It’s a serious and devastating illness – so debilitating, that it can even lead to suicide, she warns.

Phillips has suggested that BDD is caused by a chemical imbalance, most likely genetically inherited from family members with obsessive-compulsive disorder or other anxiety disorders.

Sufferers, she posits, have a deficiency in the production of the neurotransmitter serotonin.

“It is not a well-researched or documented condition, mainly because patients seek help from surgeons – who surgically fix the ‘defect’, only for it to be followed by a new ‘defect’ or disappointment in results – not from psychotherapists, who diagnose the condition,” explains Steenekamp.

“Statistics vary. Some say women suffer from the condition slightly more than men, some say men suffer from the condition as much as women do.”

BDD online support group reports that most sufferers first notice the onset of symptoms during adolescence or early adulthood, though there are exceptions to the rule – some cases developing as early as four years old.

The course of the disorder is often chronic, with little chance of complete recovery without specialised treatment.

Psychiatrist Carol Watkins says behaviours associated with BDD include :

  • Skin picking
  • Avoiding mirrors
  • Repeatedly measuring/palpating the defect
  • Frequent glancing in reflective surfaces
  • Repeated requests for reassurance about the defect
  • Elaborate grooming rituals
  • Camouflaging of an aspect of one’s appearance with the hand, hat or make-up
  • Repeated touching of defect
  • Avoidance of social situations where defect might be seen by others
  • Anxiety around other people.

BDD can lead to social isolation, major depression, school dropout and unnecessary surgery, in addition to the danger of suicide.

The disorder is also often associated with OCD, delusional disorder and social phobia, says Watkins, as well as obsessive concern with body odour (bromosis) and parasitosis (concern about infestation with parasites).

Diagnosis can only be made by a trained professional, especially since BDD may be confused with other conditions such as anorexia nervosa, gender identity disorder, a neglected parietal lobe brain lesion or milder body image disturbances that do not meet BDD criteria. These include “benign dissatisfaction” with one’s looks, which affects 30%-40% of Americans, or some intermittent anxiety or depression about one’s appearance.

The curse of Hollywood?

Observers have toyed with the idea that our mass media culture and obsession with youth and beauty may have contributed to BDD.

Experts agree that popular culture and schleb-friendly society might exacerbate the condition, but are quick to dismiss suggestions that these are the cause.

“Could these be the reason for BDD? I couldn’t say that with scientific proof,” says Steenekamp.

“Research has shown an increase in the disorder, but again, it’s debatable whether it’s a true increase, or rather the fact that people – including health practitioners – are more sensitised to it and therefore diagnose and treat it more often.

“I do, however, believe that incidences of BDD have increased immensely and certainly, our modern obsession with youth, beauty and competing is not making people happier.”

The media has been made responsible for everything from anorexia to the number of divorces, says former BDD sufferer and director of BDD Central support group, Britney Brimhall.

“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 make-up chair, I will probably start experiencing a BDD episode.

“But, even without these magazines and movies, I am certain that I would have developed BDD, given…circumstances during my childhood. BDD has been a recorded disorder for over 100 years. That was before TVs, movies (or) magazines with smiling girls on the cover.”

Brimhall points out that BDD really has little to do with looks. In fact, it’s a coping mechanism that uses looks as an excuse.

Though BDD has become a “buzzword” lately, being featured regularly on talk shows and in magazines due to its media appeal, it’s still not well understood or widely acknowledged by therapists, she says.

“Many sufferers are misdiagnosed with depression and do not receive help for the actual problem.”

Seeing the light

Treatment is necessary and should comprise psychotherapy as well as medication, says Steenekamp. Some anti-depressants have been used with reasonable success, but treatment is a long-term process – there are no quick fixes.

Brimhall cites cognitive behavioural therapy as beneficial, since the treatment involves challenging existing beliefs and replacing them with healthier and more rational ones.

Exposure and response prevention is another avenue of possible relief, since this type of therapy deals specifically with changing behaviours and one’s typical response to them.

People with BDD tend to have depression for years, says Brimhall. Medication is therefore a difficult treatment option, considering the length of time that sufferers would need it. She claims that most people with BDD who take selective serotonin reuptake inhibitors (SSRIs), a type of anti-depressant, found that the medication helped for several months only. Thereafter, they had to increase the dosage or swap to a different medication.

Essentially, she says, the medication route is one of trial and error, since it takes time to determine which medications work best for each individual.

A percentage of sufferers are convinced that their problems will be solved by physically correcting the perceived flaw. They seek help from dermatologists and plastic surgeons, but then find that once the flaw has been “fixed”, dissatisfaction and concern moves to another part of the body.

A suspected BDD sufferer should be referred to a psychotherapist immediately, says Steenekamp.

“However, rather than saying ‘you need to see a shrink, you are suffering from a mental condition’, say, ‘you spend so much of your emotional and physical energy to improve yourself physically. Every physical condition has an emotional side to it. Maybe it would be a good idea for you to talk to a good listener about the way that this defect is affecting your life.’”

As Phillips points out, BDD is not rare – only secrecy and shame make it seem so.


Ayrton Beatty, 25, was first diagnosed with BDD last year after spending years being “fixated” by her appearance.

“Being abused and bullied left me with no self-confidence and no feeling of self worth. At first I was told it was just depression, but then I started picking at my skin and punching myself as all I could see was an ugly blur in the mirror.

“I checked my appearance every five minutes to see if there was any difference, and then the picking and hitting would start up again.

“I’m now on meds and have met a counsellor. She says I’m fine – which isn’t true.”


Dr Wilme Steenekamp, medical doctor and psychological therapist, CEO of Feelwell. Visit or email

Britney Brimhall, director of BDD Central ( Founded by Brimhall in 2001, BDD Central is rated one of the most comprehensive online resources on BDD. Maintained by survivors of the disorder, it also receives contributions from the world’s leading BDD experts.

OCD Action. Visit , email , phone 0845 390 6232 / 020 7253 2664

The Broken Mirror, by Katharine Phillips, MD (Oxford University Press, 2005)

Carol Watkins, psychiatrist. Visit

*Patient names and case studies courtesy of Katharine Phillips, MD, author, The Broken Mirror

© Beth Cooper, 2010.