When Appearances Matter too Much: Body Dysmorphia

Medical Reviewer

Appearances matter, but for 1 in 100 people they seem to matter too much. Excessive worry about some minor or imagined issue with appearance is called body dysmorphic disorder (BDD) and it's a common mental health problem.

We begin to pay more attention to our appearance during adolescence, so it's not surprising to learn that problems often start during this sensitive time. A lot of time may be spent gazing into the mirror, comparing appearance with friends and celebrities and feeling self-conscious about blemishes, physical development, and facial characteristics. All of this is perfectly normal and most people manage to grow into their skin and accept things for what they are.

For others the situation is more complex. They become distressed and anxious about some perceived physical defect which others find way out of proportion. The focus of attention often relates to one or more features of the face but other parts of the body may also be involved. A great deal of time may be spent checking the mirror and using make up in attempts to hide or diminish the perceived problem. In more extreme cases people may avoid social contact, be unable to establish relationships, or maintain employment. They believe people are staring, talking or laughing about their situation, whereas this simply isn't the case.

BDD is more common in people who suffer with social phobia, generalized anxiety disorder or depression. It also occurs alongside eating disorders and obsessive compulsive disorder (OCD). It is a highly distressing condition associated with very high levels of suicidal thoughts and suicide attempts. One investigation published in the Journal of Clinical Psychiatry, found 78 percent of sufferers experienced lifetime suicidal ideation (thoughts about suicide) and 27.5 percent had made suicide attempts. In fact completed suicide rates may be more than double those of clinical depression and 45 times higher than that of the general United States population, according to Phillips and Menard (2006).

The cause or causes of BDD are not fully understood with explanations ranging from genetic predisposition, to neurotransmitter imbalances in the brain, to physical or emotional neglect. Some similarities exist between OCD and BDD although current thinking suggests the conditions are different. People with BDD often repeatedly check their appearance in the mirror, can't relax unless they have removed and re-applied make up, or positioned hair so that it helps to cover a perceived problem.

The top five concerns of BDD sufferers are skin, hair, nose, weight and stomach. Cosmetic surgery may appear a likely solution to solve some of the problems but research conducted in 2010 by Katherine Phillips, MD, found only two percent of procedures reduced BDD severity. In a survey of 265 cosmetic surgeons, 178 (65 percent) reported treating patients with BDD, yet only one percent of the cases resulted in BDD symptom improvement.

This perhaps underpins the fact that BDD is really an issue of mental health and treatments involving cognitive behavior therapy appear highly effective in most cases. There are also suggestions that low serotonin levels may be implicated in BDD and the combination of selective serotonin reuptake inhibitors such as fluoxetine (Prozac) with cognitive therapies may be the most effective treatment package to date.


Phillips, K.A., Coles, M.E., Menard, W., Yen, S., Fay, C., Weisberg, R.B. Suicidal ideation and suicide attempts in body dysmorphic disorder. Journal of Clinical Psychiatry. 2005 Jun; 66(6): 717-25.

Phillips, K. A.Menard, W.  Suicidality in Body Dysmorphic Disorder: A Prospective Study. American Journal of Psychiatry . 2006 163 (7): 1280-2.