Content Warning (CW): In addition to the discussion of body dysmorphia, this article will touch on the topics of trauma, depression, and suicidal ideation.

Body image concerns are unfortunately quite common amongst people of all demographic factors throughout the world. In a global society that places significant value on the appearance of one’s body, it is no wonder that so many of us question our bodies regularly. However, what happens when those concerns are at their most severe? 

Body dysmorphia, a severe type of body image concern, impacts anywhere from 1.8 to 2.4% of the population and is linked with significant negative mental health outcomes (Malcolm et al., 2021). It is particularly important for folks in the fitness world to be knowledgeable about this disorder, as it is common amongst people who seek to change some aspect of their bodies, including through exercise. This article will describe what body dysmorphia is and what you need to know if you or someone you know ever experiences it. 

What is body dysmorphia?

Body dysmorphia, or more accurately Body Dysmorphic Disorder (BDD), is a mental health condition in the Diagnostic and Statistical Manual in which a person perceives that they have some sort of flaw with their body and experiences prolonged preoccupation with this flaw. This imperfection, though very real to the individual, is not visible to others, suggesting a potentially distorted self-perception. The preoccupations with one’s body can center around one or more areas of the body, and the most common concerns are with one’s skin, hair, and/or nose (APA, 2013).  

In addition, folks with BDD tend to have repetitive thoughts or behaviors that are in response to their distorted perception of the self. It is common for folks with BDD to frequently check their appearance in the mirror, groom excessively, seek reassurance from others, and engage in social comparison. Most importantly, this preoccupation and the resulting thoughts and behaviors cause significant distress for the individual and often impairment in their ability to function at work, academic, social, or other arenas of life (APA, 2013). The average age of onset of BDD is 16.7 years of age, with 67.2% of people experiencing the onset of symptoms by 18 years of age (Bjornsson et al., 2014). 

It is also common for people with BDD to experience ideas or delusions of reference which, in the case of BDD, are beliefs that others are overly concerned with their appearance or that others are mocking them for their appearance (APA, 2013). Additionally, there is evidence that people with BDD tend to 1) hyperfocus on minor visual details and overlook the bigger picture (in general, but particularly when it comes to their body), 2) interpret non threatening scenarios as threatening, 3) overestimate attractiveness of others’ faces, and 4) misinterpret neutral emotional expressions as contemptuous and angry (Bjornsson et al., 2022). 

Gender differences in BDD

Research suggests that BDD impacts men and women at the same rates, though some of the ways it manifests tend to be gender-specific. 

Body dysmorphia in women tends to lead to more significant distress (Malcolm et al., 2021) and women tend to engage in more repetitive behaviors like mirror checking or reassurance seeking (Phillips et al., 2006). However, women’s body focus tends to skew more towards the following bodily concerns:

• Body fat (Himanshu et al., 2020)
• Facial hair (Himanshu et al., 2020)
• Legs (Malcolm et al., 2021)

Men with BDD are more likely to be older, single, and live alone (when compared to women). They also are more likely to engage in camouflaging behaviors, which are when they try to hide or cover up their perceived flaws with clothes, makeup, or physical barriers (Phillips et al., 2006). For men, the bodily focus tends to skew toward:

• Muscularity/build (Phillips et al., 2006; Himanshu et al., 2020; Malcolm et al., 2021)
• Height (Himanshu et al., 2020)
• Thinning hair (Himanshu et al., 2020)

It is important to note that there is a paucity of research on the ways BDD might impact people who identify as gender nonconforming or transgender, as bodily concerns among these populations are typically covering experiences with gender dysphoria. While gender dysphoria research is important, this potentially overlooks the experiences of these populations with body dysmorphia. 

Associated disorders and risk

People with body dysmorphia are more likely to have experienced some form of trauma including bullying or childhood abuse or neglect. Dispositionally, people with BDD are more likely to be highly perfectionistic, feel significant shame (in general), and have high levels of negative emotions (Foroughi et al., 2019). 

Though BDD causes significant distress on its own, it is very common for people to experience body dysmorphia alongside other mental health concerns. Major depression, generalized anxiety, and social anxiety are quite common (APA, 2013). Additionally, approximately 32.5% of people with BDD also experience some sort of eating disorder (9% anorexia nervosa, 6.5% bulimia nervosa, and 17.5% eating disorder not otherwise specified; Ruffolo et al., 2006). 

Importantly, BDD is associated with significantly higher rates of suicidal thoughts, attempts, and completion. Approximately 80% of people with BDD experience suicidal thoughts, 25% of people with BDD report having attempted suicide in the past, and the suicide completion rate amongst people with BDD are 45 times greater than the general population (Vashi, 2016). This significant distress and greater risk levels makes BDD incredibly important to understand, diagnose, and treat. 

If you or someone you know is experiencing suicidal ideation (or another type of mental health crisis), call or text 988, the newly established mental health hotline. This service also offers chat features online. If you are experiencing or have experienced the other concerns listed here (trauma, depression, etc.), please seek support from a mental health provider in your local area.

Treatment

Despite this increased risk amongst folks with BDD, the research on treatments is quite limited. The limited research that has been conducted has examined both Cognitive Behavioral Therapy (CBT) and Exposure and Response Prevention (ERP). CBT focuses on the relationship between thoughts, behaviors, and emotions and gives people with BDD insight into how their bodily misperception (thoughts) leads to behaviors and emotions that cause distress in their life. ERP is a form of treatment in which people expose themselves to the anxiety-provoking stimulus (in this case, their perceived flaw) without allowing themselves to engage in the associated repetitive behaviors or thoughts. Together, CBT and ERP have been shown to be effective for treatment of BDD compared with placebo and waitlist control groups (Bjornsson et al., 2022). Note that any treatment for BDD should be done through working with a licensed mental health professional.

There is also promising evidence that self-compassion can reduce the impact of perfectionism and negative emotions on one’s symptoms of body dysmorphia (Foroughi et al., 2019; Related: Managing your inner critic through self-compassion and How to practice and improve your self-compassion). 

With regards to pharmacological (medication) intervention, the bulk of the research indicates that SSRI’s (selective serotonin reuptake inhibitors) — commonly prescribed antidepressants — are most effective for treatment of BDD. Though the FDA has not yet approved SSRI’s in the treatment of BDD, it has been shown to be more effective than placebo in double-blind studies (Bjornsson et al., 2022). 

If you or someone you know is experiencing BDD, be sure to reach out for support from a mental health professional as well as friends, family, and other sources of social support.

References

American Psychiatric Association. (2013). Obsessive Compulsive and Related Disorders. In Diagnostic and statistical manual of mental disorders(5th ed.). 

Bjornsson, A. S., Didie, E. R., & Phillips, K. A. (2022). Body dysmorphic disorder. Dialogues in Clinical Neuroscience, 12(2), 221-232. 

Foroughi, A., Khanjani, S., & Asl, E. M. (2019). Relationship of concern about body dysmorphia with external shame, perfectionism, and negative affect: The mediating role of self-compassion. Iranian Journal of Psychiatry and Behavioral Sciences, 13(2), e80186. 

Himanshu, A. K., Kaur, A., & Singla, G. (2020). Rising dysmorphia among adolescents: A cause for concern. Journal of Family Medicine and Primary Care, 9, 567-570. 

Malcolm, A., Pikoos, T. D., Castle, D. J., & Rossell, S. L. (2021). An update on gender differences in major symptom phenomenology among adults with body dysmorphic disorder. Psychiatry Research, 295, 113619. 

Phillips, K. A., Menard, W., & Fay, C. (2006). Gender similarities and differences in 200 individuals with body dysmorphic disorder. Comprehensive Psychiatry, 47, 77-87. 

Ruffolo, J. S., Phillips, K. A., Menard, W., & Fay, C. (2006). Comorbidity of body dysmorphic disorder and eating disorders: Severity of psychopathology and body image disturbance. International Journal of Eating Disorders, 39(1), 11-19. 

Vashi, N. A. (2016). Obsession with perfection: Body dysmorphia. Clinics in Dermatology, 34(6), 788-791.