UNC Health Care
man looking in a mirror, reflection different than actual appearance

Do You Have Body Dysmorphia?

We all have days when we look in the mirror and think we look terrible. No one is perfect, so if we look closely enough, we can find blemishes, imperfections or features that aren’t completely symmetrical. We’re human beings, after all, not statues. And every day we’re fed impossible standards of what society considers physically beautiful.

When we feel that we look unappealing, most of us sigh or make a joke to ourselves and move along. But for some people, concerns about perceived defects or deformities can be all-consuming.

Body dysmorphia, or body dysmorphic disorder (BDD), is a condition in which obsessive thoughts about presumed physical defects cause a great deal of distress, take up significant time and adversely affect a person’s life.

People with BDD “may suffer in silence because it’s embarrassing to them,” says Jonathan Abramowitz, PhD, professor of psychology and neuroscience at the University of North Carolina. People with BDD are not alone; an estimated 1 percent of the population suffers from clinically severe body dysmorphia.

The Difference Between Body Dysmorphic Disorder and a Bad Day

Diagnosing BDD is subjective, Dr. Abramowitz says: “There’s not a blood test or anything like that.” To determine whether concerns about physical appearance go beyond normal, Dr. Abramowitz considers the person’s presumed defect. If it’s imagined, very slight or totally normal, such as male pattern baldness, and yet the person is so concerned about it that it interferes with his or her normal functioning, Dr. Abramowitz starts to suspect BDD.

People with BDD might avoid social situations or take extreme measures such as undergoing multiple plastic surgeries to conceal the presumed defect or deformity; they may wear lots of makeup or a hat to conceal the problem.

Diagnosis is “very much a judgment call, but we know [BDD] when we see it because the person is spending excessive time checking the mirror,” Dr. Abramowitz says. “Every shiny surface they walk by, they’re looking to check out the presumed defect.”

For both men and women, “facial features and hair are primary areas of concern,” Dr. Abramowitz says. Men may also be concerned with their muscularity, while women might obsess over breasts and genitals.

People with BDD spend “a lot of time thinking about how much better life would be if they looked different, to the point that they’re not able to function well anymore,” Dr. Abramowitz says. But it’s a mistake to think that life suddenly becomes perfect just because you’re happy with your looks. In fact, he says, “most people with BDD who undergo surgery to try to fix their perceived physical defect end up feeling just as unhappy as they were before.”

Risk Factors for Body Dysmorphic Disorder

There isn’t one underlying cause of BDD, but people who develop it tend to be younger. “We see it begin to occur in teens to early 20s,” Dr. Abramowitz says, “when they start to become concerned with social stuff.” A tendency for anxiety and for obsessive-compulsive behavior are also risk factors.

BDD is closely related to obsessive-compulsive disorder, a psychological condition characterized by intrusive thoughts and compulsive acts performed to reduce anxiety.

“Here the obsessions are internal questions like ‘Can people notice this?’ or ‘What are people going to think about my nose or my ears?’” Dr. Abramowitz says. While classic OCD might involve rituals like checking locks and washing hands, with BDD, “people spend a lot of time checking mirrors, thinking about and trying to do something about their presumed defect.”

Treatments for People with Body Dysmorphic Disorder

Not all treatments for BDD are recommended, Dr. Abramowitz says. For example, he does not encourage plastic surgery for people trying to “correct” their presumed defect.

“We find that strategy doesn’t work, or it might work temporarily until the person finds something else to be concerned about,” Dr. Abramowitz says. “We’ve seen people in our clinic who have had multiple plastic surgeries and are still upset, so we try to talk people out of doing that.”

Some people with BDD get relief from selective serotonin reuptake inhibitors like Zoloft, Paxil and Prozac, but Dr. Abramowitz doesn’t recommend those either: “We don’t have very strong evidence that they work better than a placebo.”

What does he recommend? Therapy that teaches skills for coping with negative thoughts about your appearance.

“You don’t run out of a prescription for skills,” Dr. Abramowitz says. “We find that therapy empowers the person more.”

Psychological treatments help people with BDD learn that it’s normal to feel insecure about how you look from time to time. Therapy teaches people that, fortunately, others are not as dialed in on the concerns you have about your appearance. “People aren’t thinking about [the presumed defect] the way that you are, and you’re not being judged in the way that you think that you are,” Dr. Abramowitz says.

Therapeutic approaches include:

  • Cognitive behavioral therapy: This is the treatment of choice for BDD, Dr. Abramowitz says. In cognitive behavioral therapy, patients learn to identify maladaptive ways of thinking that lead to anxiety about appearance. Jumping to conclusions and “mind reading” are two common cognitive mistakes people with BDD tend to make.

Here’s an example: “If I walk past someone in the hall and I say hello, and the other person kind of mutters under their breath, ‘hi,’ instead of giving me a big smile and all that, I might assume ‘oh, that person doesn’t like me because they think my ears are too big for my face,’” Dr. Abramowitz says.

People with BDD often erroneously think they understand what’s inside other people’s heads. They make incorrect and distressing assumptions about the thoughts, experiences and judgments of others.

“They have some key cognitive biases, or thinking errors,” Dr. Abramowitz says. “In cognitive behavioral therapy, we teach them to turn that around.”

Dr. Abramowitz teaches patients to look for evidence instead of making assumptions. An important step toward recovery, he says, is “being able to learn and collect evidence that people are not just systematically responding negatively to you because of the presumed defect that you have.”

  • Exposure: Patients with BDD will often predict that everyone in a social situation is going to dial in on their perceived defect—a feature that is probably normal to begin with—and “run screaming.”

In exposure therapy, patients test those predictions. When people don’t run screaming and instead talk to the patients normally, they get real-life evidence that their fearful predictions are not realistic, Dr. Abramowitz says.

“What we do is we help people to go into social situations with their presumed defect exposed,” Dr. Abramowitz says. For example, if the receding hairline is the presumed defect, the patients would go into a social situation without a hat. They would see that no one treats them differently.

“Some people might also have this idea that ‘well, OK, so they’re not laughing at me, but they’re thinking that I look ugly, and I can’t live with that,’ but the truth is actually that no one knows what anyone else is thinking about us,” Dr. Abramowitz says. “We’re all in the same boat in that regard. And so we help the person learn how to live with that uncertainty. We teach them that they can actually manage through life quite OK without doing anything about their appearance.”

  • Response prevention: People with BDD exhibit “compensatory behaviors” (such as checking mirrors) because of their anxiety about their appearance. “Response prevention means not doing the compensatory behavior,” Dr. Abramowitz says. So, if you’re always checking mirrors to see how your ears or teeth look, Dr. Abramowitz wants you not to do that. “I want to reduce the amount of time, attention and preoccupation they’re spending on the defect.”

Dr. Abramowitz wants patients to be able to say, “I didn’t check, and I’m doing OK. I can manage that uncertainty even though I don’t have a perfect mental picture of what I look like.”


Do you need someone to talk to about body dysmorphia issues? Reach out to your doctor or find one here.