Dr Vanessa Bogle, Chartered Psychologist, BABCP accredited Cognitive and Behavioural Psychotherapist (CBT) and exercise professional dispels the myths about Body Dysmorphic Disorder (BDD)

In the fitness industry, where pressures to conform to beauty, body shape, weight and size ideals exist, fitness professionals should all be familiar with the term Body Dysmorphic Disorder, for the benefit of ourselves and our clients.

We all have times when we feel dissatisfied about some aspect of our appearance. It’s no surprise, as we are constantly bombarded by images of unattainable ideals of how we should look and what we can do to achieve it, coupled with the pressure and expectations we put on ourselves.

This can lead to anxiety and an excessive preoccupation with appearance that causes distress and interferes significantly with day-to-day life.

What is BDD?

BDD is often confused with body dissatisfaction, but it is much more than that.

It is an anxiety disorder characterised by a disabling preoccupation with one or more perceived defects or flaws in physical appearance that are non-existent or appear slight to others.

Any part of the body may be the focus. When the preoccupation is related to the idea that the body is too small or not muscular enough, despite often being unusually muscular and large, it is known as muscle dysmorphia.

Characteristics include spending many hours weight lifting, paying excessive attention to diet, overuse of protein supplements and sometimes anabolic steroid use.

BDD is a problem of body image not appearance; a problem of how you ‘think’ about your appearance rather than your ‘actual’ appearance.

Approximately 25% of people with BDD attempt to take their lives.

What causes BDD?

The cause is unknown, although vulnerability to BDD is thought to be due to a complex interaction of many factors. These include genetic factors (eg, family history of mental illness), social factors (eg, overemphasis placed on appearance/being teased or bullied about appearance in childhood) and psychological factors (eg, personality traits such as perfectionism).

Common behaviours in BDD

BDD causes considerable emotional distress and impairment in day-to-day functioning. At least one hour per day (often much more) will be spent performing time-consuming, ritualistic and repetitive behaviours, which are difficult to control. Behaviours include:

  • Camouflaging (eg, with clothing/posture/hair)
  • Comparing self with others and scrutinising the appearance of others
  • Mirror checking/avoidance
  • Repetitive appearance-related thoughts (eg, “I’m so ugly”, “I’ll never be as big as that guy”, “Everyone’s staring at my thighs”).
  • Exercising/weight lifting excessively
  • Repetitive touching, inspecting and measuring of the perceived flaw(s)
  • Excessive grooming
  • Frequent reassurance seeking or trying to convince others that the perceived flaw(s) exist
  • Believing that others are staring and noticing the perceived flaw(s)
  • Compulsive skin picking/cleaning
  • Seeking cosmetic surgery/dermatological treatment

Treating BDD

Treatment options depend upon severity and include Cognitive Behavioural Therapy (CBT), anti-depressant medication, or a combination of CBT and anti-depressant medication. CBT is the only proven psychological treatment for BDD.

What is CBT?

It is a talking therapy based on the idea that how we think (cognition), how we feel (emotionally and physically) and how we act (behaviour), all interact together.

If unhelpful thinking patterns and interpretations of situations remain unchanged, these patterns in thoughts, feelings and behaviours can become part of a continuous vicious cycle. CBT helps people to develop alternative ways of thinking and behaving with the aim of reducing psychological distress.


It teaches people a range of skills and strategies, so they eventually become their own therapist:

  • Cognitive (thinking) strategies to help people to come to a more balanced perspective regarding their appearance-related thoughts and beliefs, known as cognitive restructuring.
  • Exposure and response prevention (ERP) encourages people to face their fears about their appearance and ride out their anxiety. It involves gradual exposure, without acting out any repetitive behaviours – for instance, mirror checking (response prevention) or decreasing avoidance (eg, by looking at one’s self in the mirror). Repeated exposure results in the anxiety response decreasing.
  • Mindfulness skills to help people to tolerate their thoughts and tendency to over-focus on perceived flaws – for instance, cognitive defusion techniques (letting thoughts come and go without getting caught up in them).
  • Emotional regulation skills as alternative and more helpful ways of coping (talking with a friend, writing in a journal).
  • Perceptual (mirror) retraining to help people to see the ‘bigger picture’ and learn more helpful mirror-related behaviours, resulting in being able to describe the whole body rather than focusing attention on the perceived flaw(s).

CBT is a time-limited active therapy; it is not just about talking through your problems. Practising the skills taught outside of the session is essential.

If you think you may have BDD, discuss your concerns with your GP and consider seeking help from a British Association for Behavioural and Cognitive Psychotherapies (BABCP) accredited CBT Therapist.

There is no health without mental health, so if you or your organisation want to learn more about how to spot the signs and symptoms of poor mental health in your clients/workforce and how to provide help on a first aid basis, just like physical first aid, Mental Health First Aid Training (MHFA) might be for you.

This is an internationally-recognised training course. For more information visit www.innovative-health.uk or email info@innovative-health.uk

Do you want to contribute a guest blog? Read our terms and conditions.