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Body Dysmorphia: It Ain’t Low Self-Esteem

a woman with body dysmorphia

Body Dysmorphic Disorder (BDD) is a very private condition that could easily be missed by mental health providers. Often, people with BDD do not present for therapy at all because they are more likely to either internalize their distress, engage in avoidance, or seek out services such as plastic surgery. It goes way beyond just "low self-esteem" or everyday misgivings about one's appearance.


BDD is a condition in which a person hyper-fixates on a particular aspect of their appearance: it could be their nose, legs, hair, or any part(s) of their body or face. They identify this body part as flawed and imperfect and develop obsessions and compulsions around this area. For example, someone might have extreme disgust toward the bump in their nose and believe it makes them horribly unattractive to other people. They might engage in behaviors such as avoidance (not taking photos, not going on dates) or more active behaviors such as checking their nose in the mirror or camera constantly or spending hours looking at “ideal” noses of models on Instagram. They might engage in what we would call “mental rituals”: thinking about their nose all throughout the day or mentally comparing their nose to others’. Their fixation on their appearance might lead to excessive grooming, beauty treatments, and even plastic surgery on the area over which they obsess. These symptoms usually cause extreme distress and often lead to either major negative self-talk, social avoidance, or other things that impair the person’s life, as well as loads of time spent thinking about the "flaw."


Body dysmorphia is different from an eating disorder in that it is generally not a fixation on weight or overall body shape (instead, a more specific area of the body) and the compulsive behaviors are less likely to revolve around eating. Of course, there are probably more similarities than differences, but BDD is a distinct disorder that would not fall within the eating disorder category.


I said that “it ain’t low self-esteem” because people might think that BDD is just someone not liking the way they look in the way that many people have been primed to dislike their appearance. This can lead to a "pick yourself up by the boot straps" mentality because everyone has problems with the way they look, right?

A person with BDD, in contrast, could generally have “high self-esteem” and be happy with their intelligence, sense of humor, accomplishments, or other talents or personality traits. They also might be the most attractive person in the room that you would never imagine could have any problems with the way they look.


Untreated BDD can have serious consequences. It is a shame-centric disorder that can be very impairing yet invisible to others. BDD has an extremely high rate of suicidal thinking. It could also cause people to seek out an unnecessary or dangerous surgery, avoid social interactions (which are essential for health), or be stuck in a constant state of disgust toward the self, leading to depression or other mental health concerns.


What I like to tell people seeking treatment is that body dysmorphia is a problem with perception, not appearance. This realization is the first step toward being able to make any changes. As long as you think your nose is the problem, you will try to find solutions for your nose, not your mental health.


Unfortunately, for many, this realization likely occurs after seeking beauty treatments or plastic surgery. “Now, my nose is perfect, but I don’t feel any better! Maybe the problem is really the extra skin on my eyelids...” {Insert new obsessions here!}


The good news is that there is hope! Cognitive-behavioral therapy can be applied to BDD with great success. Once someone learns specific skills, their perception of their appearance will likely shift and they will learn how to live a life that goes toward their values regardless of what their brain is trying to say about a certain “flaw.”


BDD must be treated by someone who has specific, specialty training and not just any mental health provider. Because the disorder and treatment are similar to obsessive-compulsive disorder (OCD), I recommend searching for a provider through the IOCDF (there’s a filter for BDD!). I find it very rewarding to treat BDD and am able to see patients in Georgia and PSYPACT-authorized states.


Here are some additional resources related to BDD:

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