Body Dysmorphic Disorder(BDD)

What is BDD?
When does a concern with one's appearance become BDD?
How common is BDD?
When does BDD begin?
How disabling is BDD?
What treatments are available for BDD?
How can service users get help?
Referring treatment refractory patients
Practical advice
Support groups
Current research
Recommended reading
Recommended websites
Questionnaires for clinical use

What Is Body Dysmorphic Disorder?

Body Dysmorphic Disorder (BDD) is defined as a preoccupation with one or more defects in one's appearance for which most people can hardly notice or do not believe to be important. To fulfil the diagnostic criteria it must also either cause significant distress or handicap. The older term for BDD is "dysmorphophobia" which is sometimes still used in the UK. Some people with BDD will acknowledge that they may be blowing things out of all proportion. Others are so firmly convinced about their defect that they are regarded as having a delusion. Whatever the degree of insight into their condition, sufferers usually realise that others believe their appearance to be "normal" and have been told so many times.

When does a concern with one's appearance become BDD?

Many people are concerned to a greater or lesser degree with some aspect of their appearance but to obtain a diagnosis of BDD, the preoccupation must cause significant distress or handicap in at least one area of one's life. For example, someone with BDD may avoid a wide range of social and public situations to prevent themselves from feeling uncomfortable and worrying that people are evaluating them negatively. Alternatively a person may enter such situations but remain very self-conscious. He or she may camouflage themselves excessively to hide their perceived defect by using heavy make up, brushing their hair in a particular way, changing their posture, or wearing heavy clothes. They may spend several hours a day thinking about their perceived defect and asking themselves questions that cannot be answered (for example, "Why was I born this way?", "If only my nose was straighter and smaller") They may feel compelled to repeat frequently certain time consuming behaviours such as:

Checking their appearance in a mirror or reflective surface
Seeking reassurance about their appearance
Checking by feeling one's skin with one's fingers
Cutting or combing their hair to make it "just so"
Picking their skin to make it smooth
Comparing themselves against models in magazines or people in the street

Which are the most common areas of the body involved in BDD?

Most people with BDD are preoccupied with some aspect of their face and many believe they have multiple defects. The most common complaints (in descending order) concern the nose, the hair, the skin, the eyes, the chin, the lips or the overall body build. People with BDD may complain of a lack of symmetry, or feel that something is too big or too small, or that it is out of proportion to the rest of the body. Any part of the body may be involved in BDD including the breasts or genitals.

How common is BDD?

It is not known what proportion of the population suffers from BDD, although it is recognised to be a hidden disorder as many people with BDD are too ashamed to reveal their main problem. One survey has put BDD at about 1 - 1.5% of the population. Mild BDD is probably more common in women and in adolescents.

When does BDD begin?

BDD usually develops in adolescence, a time when people are generally most sensitive about their appearance. However many sufferers leave it for years before seeking help. When they do seek help through mental health professionals, they often present with other symptoms such as depression, social anxiety or obsessive compulsive disorder and do not reveal their real concerns.

How disabling is BDD?

It varies from slight to very severe. Many sufferers are single or divorced which suggests that they find it difficult to form relationships. It can make regular employment or family life impossible. Those who are in regular employment or who have family responsibilities would almost certainly find life more productive and satisfying if they did not have the symptoms. The partners of sufferers of BDD may also become involved and suffer greatly.

How is the illness likely to progress?

Many individuals with BDD have repeatedly sought treatment from dermatologists or cosmetic surgeons with little satisfaction before finally accepting psychiatric or psychological help. Treatment can improve the outcome of the illness for most people. Others may function reasonably well for a time and then relapse. Others may remain chronically ill. Research on outcome without therapy is not known but it is thought the symptoms persist for many years.

What treatments are available for BDD?

There has been very little research on the treatment of BDD. The NICE guidelines on BDD recommend two treatments: cognitive behaviour therapy and serotonergic anti-depressant medication. As yet, there have been no controlled trials to compare different treatments to determine which is the most effective or which treatment best suits which person.

Cognitive behaviour therapy (CBT) helps the person get a full understanding of how the problem works, introduces new ways of looking at it, and teaches the person the necessary skills to understand and overcome their problem. It aims to enable people to become their own therapist when therapy ends.

Treatment should usually involve CBT in the first instance. Cognitive Behaviour Therapy is based on a structured programme of self-help so that a person can learn to change the way they think and act. During therapy individuals learn alternative ways of thinking about their appearance and to refocus their attention away from themselves. They learn to give up comparing their appearance and ruminating. They learn to act against their fears without their camouflage and stop rituals such as checking and excessive grooming. The main side effect of the treatment is the anxiety that occurs in the short term. However the fear gets easier and easier and the anxiety gradually subsides.

Anti-depressant medication: Some people may also need to take anti-depressant medication, which is strongly "serotonergic". The dose may need to be in the high range (similar to the treatment of OCD) and taken daily for at least 12 weeks to determine its effectiveness. The medication may provide either a total cure or no benefit at all. If the drug is effective then a person will need to remain on it for at least a year, often longer as discontinuing the medication may lead to high rate of relapse. It is not known how the medication "works" but it may do so in the absence of depression. Such a drug may be used either alone or in combination with cognitive behaviour therapy, when the risk of relapse may be minimised.

How can a person with BDD get help?

If you are a GP and think your patient is suffering from BDD you should refer him / her to your local Community Mental Health Team (CMHT). This team should assess the service user's needs, and if they are unable to treat him / her locally they should refer the service user direct to our centre.
There are various referral routes to our service, but it does depend on the service user's GP’s registered address and the service agreements our hospital has agreed with the service user's local Primary Care Trust (PCT). Thus local GPs can refer direct to our service. From a very small amount of areas outside South London we can receive a referral direct from a GP. However, for the majority of areas the referral must come to us via the local CMHT to enable us to obtain authorisation to offer an assessment, and/or treatment. In certain cases, once we have received the referral we would have to approach the local PCT on an individual basis to request authorisation to offer your service user our service. This is quite a routine thing to happen, similar to any specialist services that are required on the NHS i.e. the service user starts at their local hospital, but if more specialist expertise is necessary they may be referred on to a more expert specialist in the disorder they have. At our clinic when the referral is received and authorised, our team will discuss this. If the team decides that the service user would be suitable for an assessment, we will write to the service user and the referrer to advise you that your service user has been placed on our waiting list. We will write to your service user again in due course inviting them to contact the Centre so that we can offer them a choice of appointment dates.
It should be noted that specialist services such as ours do have rather lengthy waiting lists, but at this service we do endeavour to offer service users a choice of appointment within 13 weeks of the date of the authorised referral.
Once the service user has accepted an appointment they will be sent out some rather lengthy, but very important questionnaires covering different aspects of BDD, anxiety and depression. It is essential that these are completed prior to the assessment and brought with the service user on the day. We do expect that if for any reason a service user is unable to attend on the day they let us know, preferably in advance. If not we will write to them assuming they no longer require our help, and will discharge them if we receive no reply. If your service user misses the appointment, but requires another, there may be a lengthy delay as they will go back to the end of the list.
The assessment appointment usually takes at least 2 hours; sometimes it can take longer in which case we may need to ask the service user to come back. The service user will be asked very detailed questions about their body image problems and any other problems they may have. It is important that we get a very clear understanding of their problems in order to establish what kind of help they may need. With the service user's consent, we like to audio or videotape our assessments and therapy, which we think is good practice as it means we can be sure we all carry out our assessments and treatment to a high standard. It also means that other members of the BDD team can be involved in discussion about the service user's care. However we recognise that this may be difficult for some patients.
We will not make a decision about what is the best way to proceed on the day. We will consider your service user's case and discuss it with the team, and aim to let you and your service user know within a couple of weeks.
We will write back to the referrer after we have completed the assessment and made decisions about the service user's care. We have a policy whereby if service users wish to be copied in on letters we are happy to do so with their signed consent.
If we feel we are able to help the service user with their problems there is normally a wait of 9 months before we are able to start out-patient therapy. This is due to the high national demand for this service. Alternatively it may be more appropriate to be admitted to our Anxiety Disorders residential unit at the Bethlem royal Hospital.
We would offer suggestions to the referrers about management of the service user's care in the meantime, if this is appropriate.
If, at assessment, we do not feel we are able to help the service user then we tell them the reasons for this and make suggestions as to what would seem more helpful ways for him / her to proceed towards finding help for their problems.

Further information about referrals

Our service does not do psychiatric or psychological assesments for people who are requesting a cosmetic procedure to be funded by their Primary Care Trust as an exceptional case. An example is a woman who is requesting breast augmentation or reduction or a person who has lost a lot of weight and is seeking abdominoplasty or liposuction. Referrals for assessments for cosmetic procedures should be sent to a person's catchment area service or relevant specialist service (e.g eating disorders if they have anorexia nervosa or bulimia.

We take referrals of patients who may have Body Dysmorphic Disorder (that is people who are preoccupied and very distressed by a minor bodily defect or one that is not generally noticeable to others) and who may be interested in a psychological treamtent and/or advice on medication. People with eating disorders with body image problems around their weight and shape should be referred to the eating disorders unit. People who have an eating disorder and who are ALSO preoccupied and distressed with, for example, their face are appropriate to refer to us for an assessment and we may then refer them on to the eating disorders unit, depending on the outcome of the asessment of the main problem.

Another alternative is a referral to our Anxiety Disorders Residential Unit which is based at the Bethlem Royal Hospital. It provides intensive CBT on a residential basis for OCD and BDD sufferers.

For patients whose main preoccupation and distress is with the size or shape of their genitalia, we would advise referral (at least initially) for an assessment to either Dr Martin Baggaley or Professor Bhugra (contact details below).

Dr Martin Baggaley
Sexual and Relationship Problems Clinic
York Clinic
Guy's Hospital
47 Weston Street, London
SE1 3RR
Tel: 020 7 188 7056

Professor Dinesh Bhugra
Couple and Sexual Outpatient Service
Room 56
Outpatient Dept
Maudsley Hospital
Denmark Hill, London
SE5 8AZ
Tel : 020 3228 2371

Practical Advice For Sufferers And Carers

Find out as much as you can about BDD. A good place to start is OCD Action, which is a great place for support, information and advice. It also gives you the opportunity to talk with other people who either have or know of BDD. Remember that you really are not alone with this problem.

If you feel able and ready to start working on the problem there are a variety of self-help books which may help you get started. If this is not an option you may wish to discuss the problem with your GP, and try to get some professional help. There can often be rather long waits on the NHS for therapy however, if you are in a position to do so, you may be able to seek a therapist privately. The British Assocation of Behavioural and Cognitive Psychotherapists are a good source for getting help and advice about finding a suitable therapist. The register of accredited therapists can be found at CBT register or on 0161 797 4484

Are There Support Groups Service Users Can Contact?

There are a growing number of organisations providing support for sufferers of BDD. The most well known are:

The BDD Foundation
www.thebddfoundation.org

OCD Action
www.ocdaction.org.uk

Current Research

At the Centre for Anxiety Disorders & Trauma research into body dysmorphic disorder is ongoing. Most of our research takes the form of studies involving people who have experienced or currently suffer from BDD. Details of future studies will be posted here.

Recommended websites

Questionnaires

Some of the questionnaires used by our clinicians for assessment and treatment of BDD can be found on our questionnaires for clinical use page.