If you've ever made changing your appearance a goal, you’re not alone – around 43 per cent of adults in the UK have set the goal to lose weight. For many, these aims may also extend to more extreme methods of appearance alteration, such as cosmetic procedures or plastic surgeries.
But when does this common, widespread desire for self-improvement or enhancement become something more sinister? For around three per cent of the general population, the drive to fix or change one’s physical appearance becomes a constant – a condition known as body dysmorphic disorder (BDD).
Individuals with BDD see themselves as having serious defects or flaws in their bodies, that to other people would seem slight or potentially even nonexistent.
Take Rebecca*, a 36-year-old woman who strongly believes she looks like a ‘moon-face’ because she can’t help but stare, into the mirror, at acne scars that cover her skin.
Or Tyson*, the 17-year-old who spends hours at the gym each day to build up his muscle mass, because he feels he looks like a ‘toothpick.’
Both Tyson and Rebecca have been reassured countless times by their families, friends and medical professionals that the way they see themselves doesn’t match how they’re perceived by others, but they just don’t believe them. Seeing is believing, right? But what happens when your eyes deceive you?
A long obsession
BDD is not a new condition. It was first described by Italian psychiatrist Enrico Morselli back in 1891, long before we were glued to our TikTok feeds.
He described the ‘dysmorphophobic’ (a former term for BDD) as a person who “in the midst of his daily affairs, in conversations, while reading, at a table, in fact anywhere and at any hour of the day, is suddenly overcome by the fear of a deformity that might have developed in his body.”
It’s believed that BDD is caused by a complex interplay of biopsychosocial factors, including a genetic contribution, differences in brain structure and function, as well as a history of adverse childhood experiences like bullying, abuse or neglect, which can lead an individual to feel ashamed of themself and their body.
This predisposition is often then unmasked or exacerbated by societal pressures on physical appearance. Indeed, research supports the notion that attractive people often gain societal advantages, such as being perceived as more trustworthy, healthy, confident and intelligent.
In turn, this can lead to a greater chance of finding a romantic partner, being hired for a job and even attracting a higher salary.
This often plays on the minds of people with BDD, leaving them feeling like they’re less able to succeed in life. While we can’t ignore that these advantages of beauty exist in our society, the pursuit of beauty at all costs can be damaging to both our physical and mental health.
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Unreal perfection
While BDD predates the development of social media, it has certainly had an influential role in increasing the prevalence and severity of the disorder.
The emphasis on sharing the ‘perfect’ selfie, the use of filters and various methods of augmenting or enhancing an image, and powerful algorithms that ensure users are fed content that they (or their disorder) are most interested in, is a perfect storm for enhancing one’s focus on their appearance.
Frequent social media use and photo editing has been linked to an increased risk of developing BDD, appearance comparison, and interest in undertaking surgical and non-surgical cosmetic procedures.
This relationship occurs in a number of ways. Firstly, our perceptions of attractiveness and beauty are often affected by our ‘visual diet’. When we spend extended periods consuming curated content that showcases the best angles, lighting, makeup and outfit choices, and potentially artificial enhancements through the addition of filters, our perception of beauty can begin to skew towards highly idealised and edited images.
In turn, the viewer feels more pressure to align with this newly formed beauty ideal, and may seek to do so through applying filters themselves, or seeking out cosmetic procedures to better meet this standard.
Unfortunately, the positive effects of the filter on one’s self-image only last as long as the filter is applied and, once removed, or once the individual sees themself in a mirror in the real world, they can feel less attractive or acceptable.
There is also mounting pressure to create a ‘personal brand’ online, which can extend beyond posting the ‘perfect’ picture, to also achieving the most aesthetic feed, the right captions, hashtags and themes. This can contribute to a lack of authenticity, and a growing discrepancy between the ‘online self’ and the ‘real self’.
Some people speak about mounting social anxiety in their day-to-day lives from their social media use. They’re fearful that they might unintentionally ‘catfish’ others who have become accustomed to seeing them a certain way in the online world. Thus, personal brands and polished online personas can contribute to embarrassment and shame around one’s true appearance and personality.
Once a person develops BDD, the disorder is often maintained by unhelpful patterns in thoughts or behaviours.
For example, engaging in excessive behaviours to check, camouflage or change their physical appearance. This can be spending lengthy periods examining oneself in the mirror or taking photos from various angles; covering up with loose clothing, hats, scarves or glasses; and beauty treatments, new hairstyles, and cosmetic procedures.
Many of these are common, everyday behaviours that people engage in for self-expression or enhancement. However, when we take these behaviours to the extreme, they can contribute to a hyperfocus on appearance.
One study compared the mirror-gazing patterns of individuals with and without BDD, and found that even healthy individuals who spent more than 10 minutes looking at themselves in the mirror developed an increased awareness of their ‘flaws’ and heightened distress levels.
People with BDD experienced this heightened distress even when they looked at themselves briefly, for around 25 seconds. These findings support the notion that BDD sufferers display different patterns of visual processing when looking at faces, often focusing on fine details or individual features rather than the big picture.
Similarly, if someone without BDD looks at themselves for long enough, they too begin to see themselves in parts instead of a whole. This is one explanation for why the ‘Zoom effect’ and the sharp increase in video calls during the COVID-19 pandemic led to growing self-image distress for many individuals.
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Extreme measures
In an effort to feel better about themselves, people with BDD often seek out beauty and cosmetic treatments at much higher rates than the general population.
Around 70 per cent of BDD sufferers have sought cosmetic interventions before, and they comprise up to 15 per cent of all patients undertaking cosmetic procedures.
These high rates make sense – for Rebecca, concerned about scars on her face, dermatological treatments like chemical peels and anti-wrinkle injections feel like the obvious solution.
Unfortunately, the research suggests that while most people seeking cosmetic procedures are satisfied with the treatment outcomes, the same is not true for patients with BDD. In up to 91 per cent of cases, they don’t experience any change in their symptoms, meaning they continue to worry about the treated area or engage in methods to hide, check or cover up their ‘flaws’.
Sometimes, the worries shift following a cosmetic procedure. Beforehand, an individual may have been concerned about their ‘hook nose’, which after a rhinoplasty (nose job) develops into a new concern that their nose now looks surgically enhanced, and that others may judge them for having had surgery.
In other cases, BDD symptoms actually deteriorate following a procedure, and can leave a person who was already feeling self-conscious and vulnerable even worse off.
For the cosmetic practitioner, there’s an ethical and professional imperative to identify BDD in their patients before administering a procedure, as there have been cases of people with BDD taking out legal action, making complaints or requesting compensation for procedures that didn’t meet their expectations.
It can be disappointing to learn that cosmetic surgery may not be the solution to an intense and distressing preoccupation with physical appearance. But the good news is that effective, evidence-based treatments exist.
The National Institute for Health and Care Excellence suggests that first-line treatment for BDD should involve cognitive behavioural therapy with exposure and response prevention (CBT-ERP), and the addition of psychiatric medication for moderate to severe cases.
CBT for BDD involves identifying the unhelpful and rigid assumptions and expectations we may place upon ourselves and our appearance (“I must always look presentable when I leave the house”, for example, or “Nobody could ever love me with a nose this size”), and learning new ways of either disengaging from these thoughts, or developing more flexible and helpful thought processes (for example, “I would like to find a partner who is attracted to me for my values, interests and passions – not what my nose looks like”).
The addition of ERP involves gradually exposing the patient to situations, environments or people that may typically be avoided, while at the same time trying not to engage in compulsive behaviours.
For example, Rebecca may work on being able to leave the house without wearing heavy makeup to cover up her skin, by gradually removing a makeup product from her routine each day. Tyson may be working on reducing his workout schedule, or being able to go to the beach with friends without covering himself up with a t-shirt.
These exposure exercises are designed to help the individual learn that what they fear most (being judged or ridiculed for their appearance) might not happen. Through exposure, rather than avoidance, they can begin to live more productive, fulfilling and joyful lives.
Current estimates show that with CBT-ERP, up to 70 per cent of people with BDD experience a significant reduction in their symptoms, rising to 80 per cent when combined with medication.
If you’re reading this and feel like you might be spending a bit too much time worrying about your appearance, there are some things you can try...
How to worry less about your personal appearance
Mirror hygiene
Set some limits around how much time you spend looking at your reflection. Spending more than 10 minutes looking at yourself, when not for a particular purpose, like putting on makeup or shaving, can lead to distress. Don’t avoid the mirror, but try to keep it to an ‘as needed’ basis.
Engage in non-appearance-related interests
BDD is often associated with a hyperfocus on appearance, often at the expense of other activities. By spending time engaging with friends, family and activities you enjoy, your self-esteem broadens and you can identify that your strengths are greater than just your looks.
Social media detoxes
Take a look at your social media and notice how much of the content you’re consuming involves highly edited images, or content promoting fitness, beauty or cosmetic treatments. Unfollow or hide content that makes you feel more self-conscious, or set some limits around when and for how long you engage with social media.
Cut back on reassurance-seeking
Try not to discuss your appearance with others – asking for feedback about your appearance can leave you feeling worse regardless of whether the answer is positive or negative. Focus the conversation on more interesting topics.
Instead of chasing after the perfect body, it could be the time to uncover a broader sense of self-worth that can withstand the inevitable challenges of ageing and development that we’ll all go through – whether we like it or not!
*Names and descriptions do not reflect real clients.
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