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The Sensible Psychology Dictionary Psychiatric Diagnoses in Plain English

Body dysmorphic disorder

DSM Classification

(The psychiatry bible)

Body dysmorphic disorder

Diagnostic criteria

A. Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person’s concern is markedly excessive.

B. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

C. The preoccupation is not better accounted for by another mental disorder (e.g. dissatisfaction with body shape and size in Anorexia Nervosa).

Sensible Psychology Definition

Believing that one is an unacceptable freak on account of the inherently repellent nature of some perceived physical imperfection.

Body dysmorphia is more extreme than the average ‘poor body image’.

For instance, you might feel that your nose isn’t perfect when you think about it. But if you don’t think about it much, and it doesn’t stop you doing anything in life, then it’s not a problem.

A woman who feels she’s a bit fat and isn’t too keen on wearing a bikini at the beach might be over-estimating her obesity (or how bad it looks to others), but unless this concern really interferes with her day to day life it is just ‘poor body image’ rather than full blown body dysmorphia.

The DSM description of BDD is accurate in relation to excess and intensity:

  • An excessive preoccupation or ‘obsession’ with a perceived imperfection or defect. Sometimes the focus for BDD may seem obscure to others, such as skin tone, or the shape of ears or feet. The person’s worry and certainty that the perceived physical defect is real can seem delusional to others. Sometimes the anxiety and worry over the perceived defect can contribute to the onset of a depressive episode. The sufferer may continually check their reflection in mirrors or obsessively avoid catching sight of themselves. They may begin to compulsively use plastic surgery procedures.
  • A preoccupation that is so intense that it starts to dictate what the sufferer thinks and feels for much of their day; preventing them from doing the things they would otherwise enjoy. The individual may feel they are so horribly hideous that they can’t possibly inflict their ‘ugly’ face and/or body on other people. There may be some overlap with bulimia nervosa and anorexia nervosa.

Body dysmorphia v a fulfilling life

A major problem with body dysmorphic disorder (and, in fact, with every acute or chronic emotional problem) is that it grabs your attention and focus and doesn’t let go too easily. This means that the all mysteries and wonders of life can be going on all around you, but you don’t partake. It’s like travelling through an amazing landscape full of fascinating people and breath-taking scenery while focusing so exclusively on how your car looks that you don’t even notice what’s around you.

Body dysmorphia is depressing:

  • it encourages worry – and negative introspective rumination, if it doesn’t generate real solutions, ultimately saps energy and motivation (1)
  • it undermines quality of life because it blocks fulfilment of emotional needs for
    • loving and intimate relationships (it’s hard to focus on someone else when you are so focussed on your own emotionality)
    • connection to community and a wider group (the BDD sufferer may stop going out all together)
    • feelings of safety and security
    • feelings of status and self esteem
    • feelings of achievement and meaning
    • and so on.

Body dysmorphia may, in part, be caused by not getting these primal emotional needs met but also, in turn, it stops them getting met.

What causes body dysmorphia?

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No single clearly identifiablecause for body dysmorphia has yet been identified. There may be different contributory causes for different folk. For some, it might be innately personality driven (for example, perfectionism may be correlated with a vulnerability to BDD). This doesn’t mean that it can’t be helped. For others, early family or peer group conditioning may have ‘programmed’ them to feel that something was ‘not right’ about themselves. Body dysmorphia may begin in adolescence, when preoccupation with one’s own appearance (and acceptability) can take over as hormones kick in.

The need for a ‘scapegoat’

If we come to feel that we are somehow basically ‘defective’ or ‘faulty’ we will naturally look for an explanation for why we have fallen short. Because there is often nothing concrete or definite behind such a learned sense of ‘not being good enough’, we might focus all this feeling on a perceived physical inadequacy or defect – because this is something we can see/touch.

This is not to say that this is clearly the definitive cause for body dysmorphia, but we have observed that focusing all kinds of nebulous dissatisfactions with the self on some physical attribute can function as a sort of ‘coping mechanism’ – albeit one that generates plenty problems of its own.

It’s almost as if the perception of ‘unsightly’ dark circles under the eyes, or a ‘crooked’ turn of the mouth, or ‘inward sloping chest’, or whatever it might be, becomes a ‘scapegoat’ for more indistinct feelings of self criticism. Of course, sometimes a defect may be real enough, although the focus on it becomes out of all proportion. Many people experiencing BDD are considered highly attractive by others, who may have little sympathy with what seems like ‘self obsession’.

It can also be argued that the widespread pumping out of idealized images of ‘perfect’ looking people by the media also contributes to conditions like BDD.

Treatment for body dysmorphia

Body dysmorphia is often treated with Cognitive Behavioural Therapy (CBT) which focuses on helping people examine what they think and do with a view to changing their unhealthy habits of mind and behaviour. If depression is involved, anti-depressants (see Drugs and medications) may also be prescribed.

The sensible psychology approach

Human beings are not just ‘rational’ or ‘cognitive’ or ‘behavioural’, but ascertaining how people think and behave is nonetheless vital in the treatment of psychological disturbance. People also have unconscious drives and often don’t consciously know why they behave and feel as they do.

Trying to ‘argue’ someone out of a delusional belief rarely works. Many people will have already tried – and failed – to convince the sufferer that they ‘look fine’ or that there is ‘nothing wrong with your appearance’. People tend to cling more strongly to their beliefs (even if those beliefs are clearly harming them and woefully inaccurate) when they feel others are directly challenging them.

So instead of challenging the delusion directly, we find it is more effective to focus on identifying any human emotional and physical needs that are not being appropriately met and working with the sufferer to devise better ways to meet these needs.

Body dysmorphic disorder also narrows and ‘locks’ the attention of the person experiencing it and to this extent is inherently ‘hypnotic’ as they focus on the troubling imperfection to the exclusion of every other consideration. Hypnosis can be used therapeutically to ‘unlock’ this focus and direct it towards healthier concerns – moving the sufferer from a negative to a positive trance state.

It is vital to work with a BDD sufferer to develop the awareness that the dysmorphia is not ‘who they are’, part of their identity at a core level, but rather a ‘grafted on’ pattern that they have been experiencing (no matter for how long).

Hypnosis can be used not only to calm and relax the sufferer but also to help them put their physical preoccupation or ‘obsession’ into its proper place as just a small part and not the major focus of their one precious life.

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Mark Tyrrell

About Mark Tyrrell

Psychology is my passion. I've been a psychotherapist trainer since 1998, specializing in brief, solution focused approaches. I now teach practitioners all over the world via our online courses.

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Notes:

  1. See the entry for Major depressive episode.

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