Body Dysmorphic Disorder: What Is It?

Body dysmorphic disorder is a clinical entity that shares some characteristics with OCD. Keep reading to discover more about this disorder.

Written and verified by el psicólogo Gorka Jiménez Pajares.

Last update: 05 March, 2024

All of us have some aspect of our physique that we wish was different. Acne, the size of our chest, a scar, our height, the size of our nose, or the shape of our ears tend to be elements that we’d like to change at some point in our lives. In this regard, people who suffer from body dysmorphic disorder take this concern to a completely maladaptive level, and it can generate serious problems in their day-to-day lives.

Although the perceived physical defect may not be noticeable to others, those with body dysmorphic disorder tend to magnify it. Their worries can even reach a level that could be described as delusional. They can spend up to eight hours a day focusing on the content of their concerns related to their physical appearance in particular.

What is body dysmorphic disorder?

According to the American Psychiatric Association (APA) in its fifth version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), body dysmorphic disorder (BDD) is characterized as “Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others.”

In addition, people with BDD must engage in repetitive behaviors (rituals) in response to their concerns. For this reason, this clinical entity is included in the chapter on “Obsessive-Compulsive and Related Disorders.”

Despite sharing characteristics, it differs from OCD in that, in the case of BDD, the obsessions and compulsions are circumscribed to a real or imagined physical defect, while in OCD, they’re more general and less limited.

Common characteristics of TDC and TOC

Both clinical entities are similar in terms of the presence of obsessions and compulsions.

What’s an obsession?

For the World Health Organization (WHO), obsessions occur in the form of repeated, recurring, and persistent thoughts. They can also take the form of images and even impulses and urges. They’re bothersome, unwanted, and cause anxiety.

What’s a compulsion?

Faced with the appearance of obsessions, people with BDD and OCD try to deal with them in different ways. They may try to ignore them, avoid them, silence them, or neutralize them. These forms of combating obsessions take on the name of compulsions.

Therefore, compulsions consist of behaviors that are also repeated (they can consume up to 8 hours a day) that patients perform in response to their obsessions. In general, they’re very rigid, that is, they must follow a specific pattern: A ritual.

As a result, people with BDD may become extraordinarily shy in responding to delusions of reference. Delusions of reference can be defined as the certainty that those with BDD have that they’re being observed by others who are making judgments about the physical defect that concerns them. For example, “They’re talking about my nose,” “They’ve noticed that I have a small chest,” “They’re staring at me like that because I have so many pimples that I look disgusting,” etc.

What behaviors do people with body dysmorphic disorder carry out?

For professor of psychopathology Amparo Belloch, dysmorphic behaviors could take on up to seven different forms. Through them, people with BDD try to alter their perceived defect in order to place it at levels that they consider acceptable. They also try to prevent the defect from being seen or alter the fact that others can pay attention to it.

Comparison

We all know that comparisons with other people can become important sources of suffering. However, in people who suffer from BDD, this reaches higher levels. In fact, about 90% of patients compare the part or area of their body that they perceive as defective with the same part or area of other people. In this regard, they usually choose individuals who match both their gender and age.

Too much exercise

This is a strategy that’s revealed more intensely in cases of muscle dysmorphia. Muscle dysmorphia is a type of BDD that’s more characteristic of males in which the concern revolves around the perception that their body is too small or not very muscular.

Therefore, to achieve the degree of muscularity that the patient may consider normal, they undergo strenuous exercise routines, which can easily be classified as “excessive” by others.

Mirror Mirror

Mirrors, glass, shiny surfaces, and shop windows are sources of information for people with BDD. The act of continuously looking at reflective surfaces to check on their perceived defect, looking to see if it’s visible or too noticeable, is a factor that can maintain and even aggravate the problem.

The behavior of looking for reflective surfaces in which to see oneself is very common. Approximately 90% of patients perform this action on a daily basis, either briefly or for a prolonged period of time. Among the reasons that guide them to carry out these behaviors, there’s also the hope that their physical defect may be reflected in mirrors differently than how they visualize it in their minds.

In addition, after long periods of evaluating themselves in reflective surfaces, other clinical phenomena may occur, such as dissociative episodes.

Surgery against imperfection

The medical professionals that these people look to the most are dermatologists. Of the total number of patients with BDD, up to 70% have undergone various aesthetic medicine interventions, among which we can highlight aesthetic operations, cosmetological treatments, and dermatological interventions.

In addition, if a medical professional denies them the intervention for reasons of medical ethics or if the individual lacks the financial means to pay for treatment, they may resort to performing the intervention on themselves at home.

The objective they pursue is clear: The modification of their body appearance. Furthermore, if the self-inflicted harm is excessive, they’re certain that medical professionals will accept their case for urgent health reasons.

Concealment of the defect

Lacking the means to alter the physical feature that they perceive as excessively imperfect, people with body dysmorphic disorder try to hide it. For this, they’ll resort to any method to meet this objective. Among the most used means are hats, makeup, postures, or clothing.

Scratching of the skin

This is a behavior of BDD patients that also occurs in OCD. It seems as if the act of scratching the skin, or even picking at it, could erase the defect as if it had never been present. In fact, this behavior has been described in one in three people with BDD.

Avoidance

When previous strategies have had little effect and discomfort persists, BDD patients may choose to isolate themselves. In this regard, avoiding situations that involve social interaction or public exposure is carried out as a strategy to mitigate negatively valenced emotions such as discomfort or anxiety that can arise when they feel observed.

Are there variants of body dysmorphic disorder?

Most of the variants have to do with how this clinical entity is described in different human cultures. In this regard, we can mention a few:

• Muscle dysmorphia. As we’ve mentioned, this is a variant that occurs mostly in the male gender and has to do with the perception of having a small body with few muscles.
• Body dysmorphic disorder by proxy. This variant refers to excessive concern about the imperfection of a physical defect in other people (rather than in ourselves). Despite the fact that their partner, relative, friend, or child may have a normal appearance, people with BDD worry excessively about their physical defects by proxy.
• Olfactory reference syndrome (ORS). This variant refers to the belief and perception of one’s own body odor as repulsive, disgusting, and unworthy. Also, despite trying to camouflage it, people with ORS tend to harbor the belief that others can perceive their unpleasant odor.
• Taijin Kyofusho. This is the Chinese version of the BDD. Despite being conceptualized here, it’s more closely related to social phobia because Taijin Kyofusho is more related to the fear of interpersonal relationships. The key aspect for which it’s considered a variant of BDD is that social relationship anxiety occurs in the context of physical appearance. People with Taijin Kyofusho fear that their physical appearance may offend others.
• Jikoshu-kyofu. This is the Japanese version of the olfactory reference syndrome that we’ve described above.
• Koro. This is a curious variant of Malay-Indonesian culture. In China, it’s called Suoyang and refers to the fear of the retraction of one’s own genitals, that is, the shrinking of the penis, labia, breasts, or nipples. As a result of this recantation, people with this BDD variant believe that their genitalia may eventually disappear.

Among the possible causes of this curious clinical entity, the role that the media and social networks may be playing has been highlighted. In this regard, the messages they transmit in favor of beauty ideals that are difficult to achieve may be playing a relevant role.