Being self-conscious about one's looks may be a problem, but it's not a psychiatric condition — unless it takes the distressing and sometimes disabling form of body dysmorphic disorder. People who have this disorder are preoccupied with what they regard as defects in their bodies or faces. In about half of the cases, this concern reaches delusional proportions. Others with the disorder know that their worries are irrational, but this only makes them feel ashamed and causes them to suffer in secret.
Since BDD patients often try to hide their problem, experts believe it is much more common than most people realize. The rate of BDD in the general population is about 2%. That includes cases seen by general practitioners and psychiatrists, as well as up to 15% of patients in dermatology and cosmetic surgery clinics.
BDD is no small problem. Looks become the key to self-esteem, with a compulsion to examine the perceived defect, or try to repair or hide it. BDD patients may endlessly seek reassurance or avoid others, with inevitable effects on their work and personal relationships. Almost half develop alcohol or drug problems. Sometimes the torment ends in suicide.
Men and women are affected equally, but in men BDD often takes the special form of "muscle dysmorphia." These men can never be muscular enough. No matter how much they work out, they feel puny. They are often anxious and depressed, compulsive about workouts and diet. They are prone to eating disorders and may abuse anabolic steroids.
Up to half of people with BDD seek cosmetic surgery or dermatology treatment, and often they feel worse rather than better afterward. The disappointment may bring depression, suicidal thoughts, or a desire for revenge on the doctor. Some sue and a few become violent.
Both temperament and culture contribute to the risk of BDD. People with the disorder often have aesthetic interests; a surprisingly high proportion are artists or designers. The culture reflected in our mass media and advertising emphasizes physical perfection and promotes a favorable view of cosmetic surgery. A survey showed that American men are more dissatisfied with their bodies than men in Taiwan, where advertising rarely presents images of near-naked males.
The American Psychiatric Association classifies body dysmorphic disorder as a somatoform disorder, that is, one in which psychological problems take the form of physical symptoms. In that respect, it resembles hypochondriasis. But BDD may also look like obsessive-compulsive disorder — obsessive worrying, constant grooming, repeatedly checking mirrors. When the main concerns are weight and diet, BDD is more like an eating disorder. A person with BDD who refuses to leave home could be said to have social anxiety disorder. And some practitioners regard it as a variant of depression. BDD may turn out to be not one disorder but several with different causes.
BDD is difficult to treat. The first step is recognizing the problem; screening with a short questionnaire may help. Many patients have trouble understanding that there is nothing wrong with their bodies or admitting that they might have a mental disorder. Education about BDD may overcome their resistance to being referred for mental health treatment. It's especially important to avoid unnecessary procedures, such as cosmetic surgery. A few studies have shown that SSRIs like fluoxetine (Prozac and others) can be useful when taken at high doses for at least two months. Adding a low dose of an antipsychotic drug such as risperidone or olanzapine has not been proved effective in BDD, but theoretically should help patients with actual delusions. Cognitive behavior therapy is helpful for the milder (non-delusional) forms of the illness. Above all, people with BDD must be persuaded to think less about their appearance and concentrate on the underlying psychological problems.
September 2005 Update