Body Dysmorphic Disorder: Causes and Treatment

Rosen's cognitive behavioral therapy is currently considered the best approach for body dysmorphic disorder.
Body Dysmorphic Disorder: Causes and Treatment

Last update: 29 March, 2021

Body dysmorphic disorder (BDD), or body dysmorphia, is a psychological disorder. It’s when a person believes that some part of their body or appearance is physically and intolerably flawed. In fact, this idea ends up being a major concern for them, and the anxiety that it generates has a huge impact on their life.

Previous versions of the DSM classified this condition among the somatoform disorders. However, the DSM-5 included it in obsessive-compulsive and related disorders. This change is partly due to the compulsive nature of the disorder, coupled with the obsessive ideas regarding physical appearance.

Body dysmorphic disorder

This disorder makes a person believe they have a physical defect. Therefore, to feel less anxious, they perform a number of rituals. These might be repeatedly looking in the mirror, trying to disguise their supposed defect in some way, or even undergoing multiple cosmetic or surgical treatments.

The disorder usually occurs in adolescence, when physical appearance issues among peers tend to become more important, influencing both self-concept and self-esteem. It affects men and women equally. However, some studies suggest there’s a slightly higher prevalence in women.

These symptoms are quite common in patients who visit dermatologists frequently. The most usual “defects” tend to be acne, rosacea, wrinkles, etc. In addition, problems with their hair can be quite common (alopecia).

Rosen’s cognitive behavioral therapy is currently considered the most effective in the treatment of this disorder. This therapy combines strategies aimed at changing dysfunctional assumptions about physical appearance, along with those aimed at modifying compulsions.

A man looking in the mirror.

The causes of body dysmorphic disorder

As with all psychological disorders, body dysmorphic disorder has a multicausal etiology. Family circumstances are usually quite relevant. For example, if the patient’s grown up with the idea that physical appearance is overly important, they’re more likely to suffer from this disorder.

Another circumstance that may cause this condition is if a child has been bullied at school or college.

Furthermore, if a person has a real physical defect, even if it’s mild, they may have a tendency to magnify the problem. Thus, they may start to revolve their whole life around it, thus triggering body dysmorphic disorder

Having low self-esteem based on external, modifiable, and temporary characteristics, such as physical appearance, make a person much more likely to fall into the trap of body dysmorphic disorder. Treatment needs to ascertain how the patient is actually maintaining this disorder to end the vicious cycle. This is the most important aspect of the cognitive-behavioral treatment of this condition.

Rosen’s cognitive-behavior therapy for body dysmorphic disorder

Before starting therapy, the therapist fully analyzes the symptoms of body dysmorphic disorder, along with the patient’s complaints about their appearance. They use the BDDQ, a proven questionnaire that’s also sensitive to any changes after treatment.

Once the therapist evaluates the patient, they should be able to understand the purpose of the treatment. This purpose doesn’t involve changing their appearance, but their perception of it. In other words, their own body image.

Body image

Body image is a subjective psychological construct that’s completely independent of actual appearance. The therapist explains to the patient that correcting a flaw or trying to improve their appearance won’t always result in self-image changes. Furthermore, that it’ll be possible for them to feel better about their appearance without actually changing it. Finally, that other people tend to perceive them in a very different way from how they perceive themselves.

The therapist doesn’t need to convince the patient that their flaw is imaginary. In fact, it’s better to avoid any confrontation regarding this belief altogether. Instead, they tend to focus on what’s happened to cause the patient so much anxiety. They might suggest the patient to write a brief history about their appearance from childhood to adolescence. They also might suggest certain self-reporting measures, like keeping a diary. This facilitates the cognitive restructuring of the patient’s dysfunctional ideas about their appearance.

It’s really important to discourage any negative language concerning their bodies. For example, “My face is so fat that you can’t even see my cheekbones”. Instead, they’re encouraged to be more objective and unbiased and to make sensible assessments that don’t carry the emotional burden of self-criticism. In fact, the therapist encourages the patient to make new neutral assessments of their appearance. Furthermore, they have to practice them while looking at themselves in the mirror.

A woman with her head in her hands.

Ongoing therapy

As with other behavioral techniques, a person with body dysmorphic disorder has to expose themselves to their own body in the privacy of their own home. They can make a hierarchy of their body parts, arranged from the least to the most distressing for them. They have to gradually expose themselves to each part until they don’t feel much discomfort.

The patient should gradually increase this exposure until they can look at their reflection in shop windows or changing rooms. Finally, they’ll be comfortable enough to go public. For example, they might wear clothes they never would’ve even considered before or go to the beach in a swimsuit they used to avoid putting on.

Cognitive behavioral therapy for body dysmorphic disorder should be completed with response prevention. This might involve the patient going out in public without any makeup, for example. Or, not searching for constant reassurance from others close to them. In addition, they need to learn to accept compliments. For example, if someone says they’re pretty, they’ll accept the comment instead of rejecting it.

Furthermore, they have to tolerate the idea that it’s impossible for the image they portray to be pleasing to absolutely everyone. Finally, they have to accept the fact that their image will never exactly conform to the perfect one in their minds.

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  • Vallejo, P, M.A. (2016). Manual de Terapia de Conducta. Editorial Dykinson-Psicología. Tomo I.