A look into body dysmorphia

The dictionary definition of dysmorphia is a condition where a part of the body is a different shape than normal. In psychiatry, dysmorphia means something else – a condition where someone believes that something is wrong with the size or shape of their body or a part of their body incorrectly, and to a degree where it significantly impairs their quality of life.

Body dysmorphia appears as a symptom in multiple categories of mental health conditions. There is one condition that is characterised primarily by intense body dysmorphia – Body Dysmorphic Disorder or BDD.

Body dysmorphia and eating disorders

Body dysmorphia can be a component of anorexia nervosa, atypical anorexia, bulimia and binge eating disorder. Eating disorders and purging disorders are characterised by a person’s self-worth being influenced by body weight and shape, and feeling disturbed by gaining weight. The person believes something is wrong with the size and shape of their body and engages in damaging behaviours to control their body weight. However, body dysmorphia is just one symptom – a greater need for control, emotional numbing, social pressure and stressful environments all play a role.

Body dysmorphia and gender dysphoria

Gender dysphoria is the persistent feeling within a person that the gender they were born with does not reflect the gender they identify with. This can often include dissatisfaction with the body, as it is not congruent with their gender identity. The definition of dysphoria is an unpleasant and distressing mood state – unhappiness, uneasiness, dissatisfaction. Unsurprisingly, dysphoria is a component of many mental health conditions.

Dysphoria is used rather than dysmorphia in the case of gender dysphoria as body dysmorphia usually means extreme distress with the body, or parts of the body, in a way which doesn’t reflect reality. In the case of gender dysphoria, this distress is a component of unease with the person’s born gender identity. Clinicians use the term gender dysphoria rather than body dysphoria to recognise the fact that the person’s dissatisfaction is primarily with their gender, not just with their body.

It is possible for a person with gender dysphoria to experience dysmorphia or to be diagnosed with the condition Body Dysmorphic Disorder, as these two conditions can be distinct but overlapping. There isn’t much research on this, but one study did find that people with gender dysphoria may be more vulnerable to BDD.

Body Dysmorphic Disorder

Unlike the majority of conditions where dysmorphia is a component, Body Dysmorphic Disorder is not an eating disorder – it is a type of Obsessive-Compulsive Disorder. It is characterised by an obsession with minor or imagined perceived flaws in the person’s body. It’s very prevalent in people who seek out multiple cosmetic surgeries and treatments – but sadly, these treatments do not alleviate their symptoms. BDD is extremely distressing to the sufferer, and it has one of the highest levels of suicidal ideation among mental disorders.

BDD causes a person to hone in on one aspect or body part they find particularly distressing, and this fixation interferes with their ability to live life and function. It’s easy to see why surgery can be appealing to someone with BDD – but people with BDD who do get surgery report very low satisfaction rates, and their focus will usually switch to a new aspect or body part. The underlying cause cannot be treated by surgery.

Societal expectations

Mental health conditions do not happen in a vacuum – they are shaped by the society in which a person lives. This is very clear with body dysmorphia.

Women with BDD commonly fixate on body parts which are fetishised, scrutinised and judged in the wider culture, usually breasts, legs and hips, hair, skin, nose and overall body weight. Men with BDD often fixate on genitals, height, body hair, thinning hair or baldness and muscle size.

Diagnostic criteria

The main diagnostic criteria for Body Dysmorphic Disorder are:

• A preoccupation with perceived flaws or defects in physical appearance that are imperceptible or very slight to others
• Repetitive behaviours like mirror-checking, skin-picking, excessive grooming, reassurance-seeking
• The preoccupations cause significant distress
• The preoccupations cannot be better explained by an eating disorder.

The compulsion to engage in repetitive behaviours around appearance is characteristic of obsessive-compulsive disorders, where a person will be driven to repeat behaviours in response to an obsession. This is one reason why Body Dysmorphic Disorder is a subclass of OCD and not an eating disorder.

Treating body dysmorphia

Treating body dysmorphia relies on an accurate diagnosis because it can arise in multiple conditions. If body dysmorphia is a component of an eating disorder, the patient will need eating disorder treatment, like anorexia treatment, binge eating disorder treatment or ARFID rehab. Eating disorder recovery has a focus on normalising eating behaviours, while BDD treatment does not have this focus.

If the dysmorphia is caused by Body Dysmorphic Disorder, there is an established treatment plan. BDD treatment has a lot in common with rumination disorder treatment as prescribed for OCD. Inpatient treatment is generally only recommended in severe cases where the patient is at risk of harming themselves and struggling to keep up with everyday responsibilities. Hospitalisation can reintroduce structure, make sure they keep up with treatment and prevent them from harming themselves.

SSRIs

While a neurochemical basis for BDD has not been established, SSRIs are used as a second-line treatment for BDD. This is because BDD has a lot in common with OCD, social phobias and depression, all of which can be treated with SSRIs. Studies have shown that 53-73% of people prescribed SSRIs for BDD respond positively. Doses are often higher than for other conditions and for a longer time – discontinuing early has a high risk of relapse, so it is important not to stop taking the medication as directed.

CBT

Cognitive Behavioural Therapy (CBT) aims to challenge faulty thought processes and feelings that don’t serve the patient. It teaches how these thoughts and behaviours have a role in maintaining and prolonging problems, gives tools to handle the urge to perform repetitive behaviours and rituals and promotes more flexible ways of thinking. Often, this CBT follows a personalised treatment plan.

We offer a wide range of therapies for various conditions at UKAT, including CBT.