body dysmorphia personal essay

My Journey as a Body Dysmorphic Disorder Advocate

Posted January 18, 2023

By Eva Fisher, PHD

What do you want to accomplish in life? What are your goals, hopes, and dreams?

Therapy and medication enabled me to overcome body dysmorphic disorder (BDD) when I was thirty-six. Since then, my goal has been to raise awareness about this debilitating yet underrecognized body image disorder. I wanted people with body dysmorphic disorder to live a life free from the shame and depression I had experienced for nearly 15 years. But what could I do to help others diagnose themselves and get the treatment they needed?

I knew my personal story was one of many. Millions of men and women suffer from this disorder. Significantly less get the help they need to recover. Everyone’s story is different and important. I wanted to learn how other people were coping with and overcoming BDD. Doing more research on the topic seemed like the best way to accomplish that goal.

My journey from getting a PhD to writing a book about BDD

I decided to combine my desire to get a PhD in communication with my goal of raising awareness about BDD. In 2008, I joined the first cohort of graduate students in the Colorado State University PhD program for public communication and technology. The focus for my dissertation research was analyzing personal disclosure and social support messages posted to an online BDD public forum.

After graduating, I shared my recovery story on the International OCD Foundation website . That was the first step I took to raise awareness about BDD and spread hope that recovery is possible.

In 2020, the global pandemic increased mental stress and anguish for millions of people in the United States and around the world. The pandemic exacerbated symptoms of depression, anxiety, and other mental health disorders, including BDD. As a result, I started an online peer support group for individuals suffering from BDD in spring 2021.

Multiple BDD peer support groups meet via web conferencing in the United States and the United Kingdom. More books are being written by individuals with BDD and by therapists who treat the condition. Organizations such as the International OCD Foundation and the BDD Foundation provide valuable information about diagnosis and treatment.

However, many people still suffer in silence and lack the insight they have BDD. Millions worldwide feel ugly, alone, depressed, and suicidal, unaware they have a treatable mental health condition. I wanted to transform my dissertation into a book so more people could learn about BDD, understand the suffering it causes, and get help from support groups.

Why peer support groups are valuable

Peer support groups offer access to information, advice, and empathy from others who understand. These groups supplement support from family members, friends, partners, and treatment specialists. I gained a deep respect and appreciation for the value of peer support while studying the many messages posted to the BDD forum.

Many participants viewed the BDD forum as a place where they could share their deepest fears with other members and get help. New members often described their symptoms and then asked others if they had BDD or were truly ugly. The answer is not an easy or simple one. People with BDD feel ugly and disfigured even though they often appear normal or attractive to others.

Some members wanted to get a professional diagnosis and treatment but were unwilling to share their appearance concerns outside the forum. Self-stigma and shame prevented them from getting a diagnosis from therapists. Even after people received a clinical BDD diagnosis, they remained skeptical, convinced what they saw in the mirror was real.

Seeking and sharing personal experiences, advice, and support

Members shared their personal experiences with BDD, asked for support, and provided support to others. One person asked other members why believing they were ugly caused them such distress. Answers ranged from fear of being an outcast to feeling unwanted, unlovable, and rejected by others. One forum member replied to the question this way:

I feel like because I’m ugly I have no importance in this world and that I won’t be successful. Yet at the same time, the rational part of me knows that isn’t true. Looks aren’t everything. Ugly or beautiful, everyone is important and beautiful in their own way. I think a lot of people with BDD, including myself just think that in order to be happy, we have to be beautiful. it’s a vicious cycle.

People with BDD have negative thoughts about their appearance and believe if they looked better, their lives would improve. The truth is, only when they overcome BDD can their lives get better.

When I was struggling with body dysmorphic disorder, I believed feeling ugly kept me from being successful and happy. After I self-diagnosed myself with BDD, the stigma of feeling ugly was replaced with the stigma of having a mental health disorder. My desire to get better gave me the courage to seek and find professional treatment. Getting help enabled me to overcome the disorder. I no longer hate my nose and now appreciate the positive aspects of my appearance.

Roger’s global “BDD family” on the BDD support forum

For Roger (the most frequent poster), the BDD forum served as his extended family. He felt a kinship with people who were undergoing similar struggles with the disorder. Roger believed everyone who lived with, was affected by, or sought to overcome the disorder was a member of his global BDD family:

Please do realize you are not alone in this fight. Every person with BDD is a brother and sister in a battle to rid yourself of your own personal bully. It’s a fight you can win but one that is easier with people standing behind you all the way. A common cause that unites all of us from all around the globe into a group of people determined to make a difference. We are the BDD family.

Online peer support groups, such as the BDD forum, can supplement the support provided by family members, face-to-face groups, and clinical treatment specialists. Rather than replacing other forms of support, peer support groups provide additional resources for people whose lives are crippled by this debilitating and underrecognized disorder.

Help and support are available for people with BDD

I have met many therapists, researchers, and advocates at the International OCD Foundation who are committed to helping people with BDD. They are all part of the worldwide BDD community dedicated to supporting people with the disorder, providing effective treatment, and educating others about BDD.

My goal in writing a book was to bring hope and help to people with BDD, their family members, and friends. I want to encourage anyone with BDD that overcoming the disorder is possible. Please reach out to your peers, loved ones, and trained therapists to get the help and support you need to recover.

More information about the Recovery from BDD peer support group is available on the International OCD Foundation BDD site.

More information about my book The BDD Family: Coping with Body Dysmorphic Disorder in a Peer Support Group , is available here: https://feartocourage.com/thebddfamily-book

Please contact me at [email protected] with questions about my journey as a BDD advocate, my peer support groups, and book about coping with BDD.

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What It's Like to Be Transgender and Face Dysphoria and Body Dysmorphia at the Same Time

This piece is part of Allure's coverage of National Eating Disorder Awareness Week .

As someone with a fluctuating self-image and a trans person who feels a simultaneous external demand and internal anxiety to continuously communicate my gender, I’ve never felt at peace with my appearance. Sometimes my desire to be seen can be confusing; I barely have a solid grasp on what I look like, especially to other people. How I feel about myself is nearly always about other people.

Understanding myself through the eyes of others provides a blueprint for me to have control over my self-image. In part, I'm hesitant to admit that maybe the feeling that control eludes me is what it means to have body dysmorphia and gender dysphoria concurrently. Maybe these things are in the driver’s seat more days than I am, and that is a reality I fear confronting.

The Origin Story of My Body Image Issues

Both of my parents grew up poor in Jakarta, Indonesia. With a desire to shift the trajectory of the future for them and their children, they found and worked well-paying jobs. They raised my siblings and me in Jakarta, but in contrast to their childhoods, we were financially well-off. To us, food was more than just food — it signified financial safety, a lack of scarcity and hunger. For my parents, my siblings and I were not just children, we were pockets in which they could invest assurance and safety; a second chance to witness childhoods without want.

My parents worried about us ever going hungry, and by eight years old, I was consuming cod-liver oil supplements daily and eating almost nonstop. Physically, I came to embody abundance because, from my parents’ perspective, I should have never gone hungry. But this physicality was also a symbol of shame, because from everyone else’s perspective, I was merely a fat kid. In my consumption of the safety my parents provided, I was losing some of my agency as societal fatphobia affected me. My complex relationship with my body began early; with every look in the mirror, I asked myself, "Am I to be thankful or remorseful for this body?"

Realizing I Had Body Dysmorphic Disorder

Contrary to what I was told by my environment, I felt indifferent about my body fat. It meant very little to me, though I disliked the way it shaped how people treated me. As a preteen, I don’t recall feeling embarrassed about being fat, but I think that’s one of the survival tactics you develop when you’re subject to harassment as a fatter kid in class and at family gatherings.

Though most of my childhood didn’t revolve around my weight, I recall feeling frustrated — even confused — when I had to look at photographs and footage of myself. In my head, I had a very clear image of what I looked like, and yet it was far from what I saw in pictures and videos of myself. Maybe my weight was part of that gap in perception, but it felt deeper and heavier than size. Body weight can change, and I feared that the dissonance between how I saw myself and how I actually appeared would never go away, even if the body weight did. I recognize this now as body dysmorphic disorder (BDD).

“The main component of BDD in a person is the primary feeling they are not who they are, having displeasure, and being unable to accept oneself physically,” says Emily S. Rosen, a licensed clinical social worker in New York City, trained in modern psychoanalysis and Gestalt psychotherapy . “Sometimes people see themselves differently than they are; like you see something in yourself that might not be there, but it feels like it’s there.”

To work through BDD, Rosen tells Allure , “I believe that if we had more compassion for ourselves , we would have more compassion for each other.”

I have yet to fully embrace that compassion for myself, but coming out as a trans woman and pursuing a medical transition at age 18 was a huge step for me in reclaiming my body. It was monumental for me to say, “No, I’m not a boy, I’m actually a girl,” because I felt like I was taking back my physical narrative. But I soon found that I was unprepared for the additional set of complexities and questions transitioning brought up.

Understanding Gender Dysphoria

Similar to BDD, gender dysphoria (GD) occurs when there is a disparity between one’s gender and the perception of their gender through societal constructs. Transitioning for me was a way to work with my BDD, but not because I was initially dysphoric about my gender. In college, I recognized my appearance less and less as testosterone gradually increased and affected my development, changing physical aspects such as bone structure, face shape, hairline, body hair, and more. I figured if testosterone drove me to perceive myself as masculine in a debilitating way, the only answer was to undo its effects by going on estrogen.

A few weeks after coming out, I scheduled an appointment with a psychotherapist to obtain my approval letters to undergo hormone replacement therapy (HRT), in which the testosterone in my blood would gradually be substituted with a prescribed dosage of testosterone blockers alongside estrogen. As an Internet kid, it wasn’t hard to surf the Web to prepare myself for the questions psychiatrists would ask me before determining whether or not HRT would be a good fit for me.

Shortly after I got my approval letters diagnosing me with gender identity disorder (GID), I met with Carolyn Wolf-Gould, a family physician who, since 2012, has worked at the Gender Wellness Center in Oneonta, New York, a facility that has worked with over 700 trans patients . During our first physical exam, she felt my throat for what was supposed to be an Adam’s apple. When she didn’t feel anything there, she said, with a promising grin, “Ah, you’re going to be just fine.” Before that moment, I’d never thought to have an opinion about my neck's appearance.

I believe she meant to assure me that an Adam’s apple, or lack thereof, was not something for me to be dysphoric about, but this moment taught me something bigger: There is a mold of what a woman should look like, and it was possible for me to fit that mold. Yes, it was comforting that not having an Adam’s apple was one less thing to worry about, but in that moment, I began second-guessing other aspects of my appearance.

After our appointment, I created a routine for myself. To avoid a five-o-clock shadow that I wasn’t even sure was an issue, I began color-correcting my face before applying makeup. I covered myself up with cardigans to assuage the fear that my shoulders were too masculine. I dressed in hyperfeminine clothing because I wanted to minimize the risk of being perceived as anything other a woman.

Because of BDD, I had always had a generally strange perception of myself. When I transitioned, I noted the pressures and expectations of presenting as a woman and eventually developed GD, which gave me an idea about exactly how I wanted to look. I went from wanting to just realistically recognize myself in the mirror to wanting to see myself as a woman, without a doubt.

The Compounding Effects of My Dysmorphia and Dysphoria

Because BDD and GD coexist, I need people in my life to understand the varying capacities of strife they cause me and how the two can compound the effects of each other on a day-to-day basis. Having gender dysphoria has forced me to be more in tune with myself, perhaps too much. When communicating my gender, I am hyper-aware of the way I present myself . Though I wish I didn’t have dysphoria, having some grasp on my appearance lessens the dysmorphia that blurs my perception of self. But on certain days my dysmorphia still gets the better of me, and when I see my reflection, I’m back to a place of confusion. At other times my dysphoria has a strong presence, and the effort to stand in my womanhood feels embarrassing and ineffective.

I don’t need doctors or therapists to validate that I am a girl who has a body, and that my body and gender are never going to be mutually exclusive, be it by my standards or someone else’s. “The number one misunderstanding of gender dysphoria is that it needs a pathological diagnosis of gender identity disorder, or GID, under the Diagnostic and Statistical Manual ( DSM ),” Wolf-Gould tells me. “The reality is that many trans people aren’t dysphoric and still need treatment. Then, how do they get cover[ed] in insurance? Thankfully, now there’s a new diagnosis: ‘gender incongruence,’ which means there’s a mismatch without any overlay of depression or upset-ness.”

I have no blueprint or calendar or meteorology report to predict the things that might impact my day. A few weeks ago, on my way home from school, it rained suddenly. On the sidewalk, I walked by a mother twirling her daughter in the rain. In between the patter of raindrops, I heard the clear joy in the girl’s laughter. I felt it ground me, reminding me of when I lived in Indonesia. I loved the way the beach swallowed my body whole. The ocean water was the only thing that understood my body's changes. I could stand still or swim, and know with full certainty that the water would still envelop every inch of me. I want to know how to live like that on land.

Ridding myself of dysmorphia and dysphoria seems unimaginable, and the shame of being truthful about my body image keeps me in silence. Daily, I am working on breaking that remorse, finding reflection not in images, but in stories.

Read more stories about body image on Allure :

• What I Wish My Doctor Understood About My Eating Disorder
• How I Realized I Have Body Dysmorphic Disorder
• Navigating Beauty Standards as a Trans Woman

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A Day With: Body Dysmorphia

[Editor’s Note: This piece is part of an ongoing series of personal essays on what it’s like to live with a mental health diagnosis. Each piece describes a singular and unique experience. These essays are not meant to be representative of every diagnosis, but to give us a peek into one person's mind so we may be more empathetic to all.]

On Halloween, when I was twelve years old, I ran down the hallway of my junior high school, in a Sailor Mercury costume . I was trying to catch up with my neighbor Jessica, and my blue wig was sliding to one side of my head. Right as I got to the exit, I heard a voice.

“Hey, you with the blue hair. ” When I turned around, I saw that it was Mike. He’d been suspended several times and got into regular fights. “What?” I said. “Come here.” A group of middle schoolers began to crowd around us. I had just gone through a growth spurt and was one of the tallest girls in my school. I had hips and breasts and weight to me. I knew I didn’t look “normal,” but I also didn’t want to show Mike I was afraid. So I walked slowly up to him. Before I knew what was happening, Mike grabbed my wrist and said, “Who wants to see her arms jiggle?” Cue the nervous laughter of dozens of tweens ready for a show. He slapped my underarm and my skin betrayed me. I pulled away, but this time he grabbed me, both hands on my wrist, spun me around and repeated, “Who wants to see her arms jiggle?” He started shaking me as he spun me out. I pushed him away and walked as fast as I could past the softball fields, towards home. I walked the two miles alone, replaying “Who wants to see her arms jiggle?” like a damaged videotape stuck on the same part. At home, I took a look in the mirror. My arms were growing. I felt like I was in a funhouse, and my arms kept expanding. They were so big and so fat, and disgusting. I felt disgusting. I promised myself I would never look like this again. That year, I ran five miles a day, lost thirty pounds, and fainted at school regularly. I was really skinny, but I never felt that way. Not yet a teenager, I experienced what would be my first of three bouts of anorexia bulimia, and began my lifelong recovery from body dysmorphic disorder.

“Body dysmorphic disorder, unlike body image disturbance is when someone is struggling with an over-emphasis on a particular body part as opposed to someone who, say, doesn’t like their body size or type. They fixate on a body part repeatedly to the point where it interferes with their social, emotional, educational, and occupational welfare,” says Andrew Walen, psychotherapist and CEO/founder of the Body Image Therapy Center . Body dysmorphic disorder (BDD) affects 7.5 million Americans a year. According to the International OCD Foundation , “BDD is about as common as obsessive-compulsive disorder and more common than disorders such as anorexia nervosa and schizophrenia.” The mental illness is an anxiety-based disease, and cannot be cured—it can only be treated . It is also different from and not causally linked to eating disorders or anorexia nervosa. Still, BDD shares many commonalities with OCD, including the experience of uncontrollable, obsessive thoughts. When describing his approach to treating patients’ BDD, Walen says, “This is what we would call an imp of the mind, an obsessional bad thought. So the work is to help them understand that they have to expect that these thoughts are going to happen. They have to accept them. They have to practice sitting through it and living with it and going about the act of daily living even though the thought is there because you can’t just undo a thought.” People with BDD may think something like, “I have a horse face,” and Walen works with patients to replace the stigmatizing language with more factual language. So, patients can comment on the shape of their face, because that’s based on fact, instead of judgment. Over time, Walen says that the more often his patients practice this process, the less anxious they become.

So, how is BDD different from having low self-esteem about one’s own body? Scott M. Granet, a psychotherapist and the director of the OCD-BDD Clinic of Northern California, explains that “most people with BDD have a severe problem with depression and really feel that how they look is the link to their happiness [and] overall sense of well-being. I think that if you understand that, you can understand how so many people who have this become suicidal ... it overwhelms their life.” According to a study exploring the suicidality in BDD , 45 to 70 percent of the patients with BDD have reported suffering from suicidal ideation, and 22 to 24 percent of patients with BDD have attempted suicide. What makes BDD particularly dangerous, is that people who suffer from it develop dependencies on obsessive behaviors; they believe these behaviors will provide relief. One such example is “mirror checking,” the ritual of checking a mirror hundreds of times a day to either catch a glimpse of looking good or, as is usually the case, reinforce feelings of negativity surrounding body image. “People with BDD engage in so much mirror checking because on some level they know, even if it’s just one out of 100 times, they may look in the mirror and say to themselves, ‘well, not so bad today’. And that one percent is enough to drive all of that, knowing that there’s that possibility that they may look better at some point. It may help somebody feel better in the moment, but it’s only going to contribute to somebody feeling worse in the long run,” Granet says.

After six years in recovery, my anorexia bulimia and BDD returned when I was 19. I started running five miles a day again. I ate almost exclusively non-fat, low-calorie foods. Anytime I deviated from eating like this, I would make myself throw up. My collarbones looked ready to pop out of my body. All I could see was my stomach; I was fixated on it. I purposely bought shirts that were too long. Every day, I would pull my shirt down, and check the mirror to make sure my stomach was covered. I would check the mirror 5-10 times before I left my apartment to make sure there wasn’t an inch of skin popping out. In the dining hall, when I sat down, I would suck in my stomach and repeatedly pull down my shirt. I purposely went to the bathroom before and after I ate, so I could make sure my stomach hadn’t grown. I’d stare at the women next to me in class and compare my stomach size to theirs. I was sure that if I had a flat stomach, I would be happy again. Years later, when I finally saw my first psychologist, and I told her about my eating disorder, she asked me how often I looked in a mirror. I almost lied to her—the number was over 100. She told me to get rid of all full-length mirrors in my home, and I wasn’t allowed to check any mirror over 10 times a day. Listening to her, it seemed impossible. At first, all I wanted to do was to check a mirror. I thought about it obsessively; after a few months, I noticed that I had naturally reduced mirror checking.

So, how can BDD be treated? Granet informs me that one of the most important steps in cognitive and behavioral therapy is to have his patients experience exposure therapy, which involves exposing a patient to their biggest fears. For example, someone with BDD who thinks their face is hideous might try leaving the house without wearing makeup. Granet says, “Exposure therapy is a very hard thing to do—nobody wants to put themselves into situations that are going to make them feel uncomfortable. But, there is a point to the whole thing, and people will learn that [their appearance] isn’t as important as they think it is [and] this isn’t just a matter of wanting to look a certain way, they feel this way because it’s a psychiatric illness.” Nancy Clark is a sports nutritionist and registered dietician based in Boston. When describing how she approaches working with clients with BDD, she says her first step is to “develop a food plan to help them reach their goals, and also to remind them that there is a possibility that their bodies are good enough the way that they are, and that they’ll never have the perfect body, but maybe they’ll have an excellent body.” Clark encourages clients with BDD to think of food as fuel and to confront body image, or a distorted body image with fact-based evidence: measuring her clients’ body fat, showing photographs of what real athletes look like, etc. “Your body was born excellent, it still is excellent, but it’s your mind that gets you into this mess,” Clark says. “People think that they are their body and they aren’t—they are two separate entities.” Walen likes to use the acronym CARESS when working with his patients to find coping strategies: Communicate Artistically, Release Endorphins, and Self-Soothe. He finds that some patients respond very well to communicating how BDD affects them through creative processes such as songwriting, drawing, storytelling, or photography. As BDD can be heightened by traditional exercise, Walen recommends that patients release endorphins by laughing regularly or engaging in physical touch. He adds that acts of self-care, such as listening to music or meditation can help reduce anxiety in his patients. For me, living with BDD involves refocusing efforts and re-training the mind from what I am most afraid of to what I hold most valuable. It’s a re-examination of the self that goes beyond appearances, and while we can accept some aspects of anxiety, we need not succumb to it. Seven years after my first psychology session, I still don’t have a full-length mirror in my bedroom; although I still live with BDD, when I do catch myself in the mirror and don’t like what I see, I remind myself: what you see is not there . I finally believe that.

*     *     *

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An Essay On Body Dysmorphia & The Quest To Conquering My Insecurities

I think so many women (and men) struggle with the delicate topic of body image, no matter what their shape and size may be, myself included. In an attempt to practice vulnerability, and perhaps a little self-therapy through writing about something so personal, plus the thought of someone reading and relating and knowing they’re not alone, I want to share my headspace around it.

I have gone through phases of extreme dieting and exercise at different stages in my life — I was a teenager of the nineties and the predominant narrative surrounding our impressionable teenage heads were fashion magazines praising the paper thin and our role models were Kate Moss and company. Body image was something I struggled with, and to be honest, sometimes I still do. I think many humans (women especially) can say the same. But, I was also incredibly lazy as a kid / young adult. I hated exerting any energy that wasn’t absolutely necessary. I was the girl who would beg my friend’s parents for rides home after elementary school so I didn’t have to walk. I was the girl that failed middle school phys. ed because I refused to dress-out in our required gym uniform. I was the one who would ditch P.E. class in high school to get coffee and hang out in the senior parking lot. At the time, I could pretty much eat what I wanted without gaining weight. There was about a year and a half, from age 19 to 20, where I put on an extra twenty pounds, due to a comfortable relationship, underage drinking, and too much T-Bird’s pizza soaked in ranch dressing. After a bad breakup and a desire to “show him”, I joined a cardio kick-boxing class and became obsessive about going daily, sometimes taking back-to-back classes. I did this while my diet consisted of McDoubles and Jack-In-The-Box Curly Fries. What I’ll chalk up to youth and a fast metabolism, the weight fell off and my boyfriend and I got back together.

I want to clearly state that my weight loss was not why my ex and I rekindled our relationship — it was love, okay. Within a year I was pregnant with our son. I gained 50 pounds during my first pregnancy. All I craved was fruit salad, .99 cent cheeseburgers, and brownie batter, and all I ate was fruit salad, .99 cent cheeseburgers, and brownie batter — on a regular basis, mind you. Not the most optimal diet for a growing baby, but I was 20 and clueless. About nine months after my son was born, I managed to get back into my pre-pregnancy jeans — “finally,” I thought to myself. 18-months later, we had our daughter (I was 23), and I developed an auto-immune disorder which I learned later to be Graves’ Disease aka hyperthyroidism. I got very, very thin just two weeks after her birth, and could eat as much as I wanted and not move a muscle without ever gaining a pound. I loved it, of course. People made comments on my thinness and I soaked it up. When I hit 26, the Graves’ faded and my body naturally started to fill out. I looked like a woman. It felt foreign to me and I definitely struggled getting used to my newfound curves. I was not fat by any means, but in my head, I needed to lose a few pounds — I needed to get back to where I was. I managed to stay active from chasing two kids around all day and Saturday nights spent dancing until last call with my friends, but I was constantly watching what I ate to get back to that unrealistic goal I was fixated on. I even fell victim to the oh-so tempting gym membership, signed an expensive, year-long contract and I went exactly four times — big, huge waste of money. I was lazy, and would revert to dieting over physical activity every time. This was during the Y2K celebrity slim down era of Nicole Richie and Lindsay Lohan, when True Religion jeans and Juicy Couture velour sweatsuits reigned supreme.

Insecurity is a nasty little fucker. I, at times, would blame my mother for my skewed views towards food and being thin. We essentially grew up together (she was a teen mom and all of 16 when she had me). There was always “body talk”, the latest dieting craze, new aerobics VHS tapes to try, and a fridge stocked with SlimFast shakes. We even dieted together. The short-lived baby food diet is the one that sticks out mostly. We stocked our cabinets with jars of Gerber in an attempt to drop a few pounds. It didn’t work, so don’t bother trying. Of course, there were many factors that contributed to my disordered eating and body dysmorphia: fashion magazines, runway models, and the like. Back then, heroin-chic was glamorized and the thinner you were the more attention and praise you would get. I bought into all of it.

Now, over a decade later, and after trying every diet under the sun and the continual shift between jean sizes, I admit to myself (and to you) that I still struggle with body image. I think I struggle even more with the fact that I CARE at my age. I think we have this idea in our heads that as we get older, these shameful body “issues” will fade away with maturity, adulthood, motherhood… . I don’t think they do. Sure, they may not be as extreme as they have been at different periods in life, but that doesn’t mean that they won’t and don’t sneak back up on you when you least expect it. I still hang onto a pair of jeans that I had when I was a twenty-three-year-old with Graves’. It’s ridiculous. I will never, ever wear them again, which I know, but my brain tells me to keep them for reasons varying from maybe-one-day to a source of unhealthy motivation. I turn 40 later this year, and while my obsession to maintain a certain number on the scale and my desire to get back into that dusty pair of Seven For All Mankind has lessened, that never-quite-rightness still creeps up from time to time. I have learned how to tame the beast for the most part through years of trial and error, but I think these things stick with us and can be an infinite bumpy road well traveled. Hell, I know women in their sixties that still struggle.

I read this quote, which was uncredited, a while back and it has really stuck with me: “Those extra pounds, that place where your body naturally wants to be — that’s your life. That’s your late night pizza with your friends, that Sunday morning bottomless brunch, your favorite ice cream in the whole entire world because you wanted to treat yourself. Those extra pounds are your favorite memories, your unforgettable trips, your celebrations of life. Those extra pounds are your spontaneity, your freedom, your love.” I edited x number of pounds out of this quote — it’s subjective. The message behind the numbers is what counts.

I think it’s important for us to talk about this stuff. I have so much to say and could continue writing on this topic and all of its many variables for days. But for the sake of those reading, I’ll wrap it up with this: I am guilty of feeling the pressures (self-inflicted or not) and succumbing to them. I am guilty of feeling shame when my pants feel too tight and thinking about those things that I ate and shouldn’t have. I am guilty of body comparison, be it via my social media feed or in real life. I am guilty of “eating healthy” in the socially acceptable name of restriction. I am guilty of it all. It is an ongoing, tiring, wrangle within myself. For me, I am trying to practice body acceptance and self-love, more now than ever, because I am the role model for my daughters (and my sons). They see, they learn, they adopt. I am the example. That’s heavy.

Written by: James Kicinski-McCoy

James Kicinski-McCoy is the 40-something Founder and Editor-In-Chief of The Bleu. She likes tequila, picks fights with her husband so she can have the bed to herself, and is trying to figure out that work / life balance.

11 Comments

I resonate so much with all of this. I have battled my weight since childhood and have only been truly skinny a couple of times but the praise you get from losing weight is something you start to crave. I, too, had my first son at 20 and my second, a daughter, at 23. I also have a pair of jeans (citizens of humanity) that I’ve had since I was 18, that I’ll probably never wear again. I’m 32 and on yet another weight loss journey. But one thing is for sure, I do not speak negatively about my body. I really don’t anymore. The reason I started this weight loss journey this time, was because my health was being compromised. I’m doing it for the right reasons…but I’d be lying if that little bit of hope of getting back into those jeans wasn’t still there. I blamed my mom for years, but I’ve realized, she too, is a victim of diet culture. So I’m doing everything I can to raise my daughters (I had a third baby years later) to see that they are SO MUCH MORE than their appearance/weight. I am loving is website. Bravo!

Love this post so much. Thank you for sharing!

I wish all women everywhere could read this x

I too have a pair of Seven for all Mankind jeans collecting dust in my pile of “maybe again” jeans. Thank you for your words.

Yep. I feel ALL of this. And for me, there truly is another layer to this struggle because I don’t feel as healthy as I want to, so I do feel like what and how much I eat plays a role in that. I also have struggled in my distant past with restricting and disordered eating so I have to be careful and examine my choices. At this point I do trust my motivations, but it’s always hard and at 38 i’m still not satisfied with my shape.

SUCKS, lol.

Really great essay. As a young woman who just turned 30, I found it a little (maybe more than a little) disappointing that I still with body image. As you said, there are so many factors at play when it comes to unhealthy messaging around a woman’s shape (the fact that it’s such a focus in general tells us something scary about our cultural values), so I try and not add insult to injury by reprimanding myself for being concerned with the superficial. But, I think for who are aware of how body dysmorphia impedes on some of life’s most basic pleasure, it’s a hard thing to just accept. However, I believe change is possible, and it begins with dialogue were there is a willingness to be vulnerable with EACH OTHER. Our current societal values won’t change unless we change first, and I think that means getting honest about how we think about and treat our bodies. I mean, really honest. One reason I love this essay is that YOU wrote it – a successful, smart, business running wife and mother. You also happen to be objectively beautiful by today’s overarching beauty standards (although, your beauty does emanate through your wit, smile, and kick ass sense of style as well). What this shows me is that amazing, hardworking women who seem to have it all can and do still struggle with body image. This dispels the myth and the added pressure of assuming we can outrun our demons, or perhaps that they will fade with age. For some, I’m sure they do, but for others we need to address it and work on it consistently. I cannot think of a better way to accomplish this then by opening ourselves up to each other, when we are able, in order to share and possibly heal the basis for our insecurities that surround the female body. Again, great essay and I greatly appreciate you using your platform to address this.

Same Same. Although at age 44 I will say I am more concerned with cholesterol lab results than what the scale says. It’s tough and I wish I didn’t daydream over the days my hip bones stuck out and my jeans hung on my frame. I KNOW I’m so much more than my body or appearance and yet that little devil lives on. Thanks for the honesty!

💋 resonating post 2 🍺,wedding 🍰 tasting with a lovely couple and new neighborhood friends. Love the quote and the lovely memories we made tonight. I’ll focus on that more than my tight jeans. Xo

Holly van de Coevering Westley

Thank you James for this refreshingly honest and brave essay. I really appreciate it, it’s not talked about enough. The pressure women and girls feel can be so enormous and endanger healthy self worth. I too grew up believing that heroin chic was The beauty ideal, it’s pretty warping. Self acceptance is a struggle for most women I believe and it’s certainly an ongoing battle for me with health issues thrown in to make it more challenging. Pretty much every woman I have ever known has her own version of it, and the competition between women that keeps it alive can be awful. It’s a fantastic thing that fashion is now opening up in terms of diversity, all different sizes and background of model can be found. I don’t think women compliment each other enough, so this needs to be said, you are so stunning! With your figure I wouldn’t have believed you have the same body image issues, being an ideal already, so thank you for sharing and reassuring me that we can all struggle…

Thanks for sharing this. When I scroll through the blog, I see that all the women that are featured are quite thin, and I think that that tells a different story than what you are sharing in this wonderful essay. When I see a wall of images of women who are all homogeneously thin, it gives me the message that this publication considers one physical type to be ideal. I know it isn’t meant that way, but that’s the effect of seeing the same look over and over. For example, the photo for “The Case For Playing Hooky”. I don’t think imagery like that actually supports your goal of helping women feel good and validated about their bodies. I also hope that the women who are being interviewed and elevated in the blog will show a diversity of backgrounds and body sizes. Thank you so much and I hope this opens up a conversation.

I think the biggest thing that stands out to me about this article is the idea that body issues are not prejudiced. They affect all kinds of women, no matter their size. Being “overweight” my entire life I used to become so bitter about women who were thinner than me who struggled with their body image. As I’ve learned more about how to have compassion for myself and this journey it’s helped me to expand it to others. The comparison game runs DEEP. I’m desperately trying to break old habits and thought patterns that were passed down to me as well from my generation and my mother (who was also a chronic dieter). I love how real this article is and that you don’t try to tie it up with a pretty bow. I too am motivated by my (future) children (not a mother yet) but am trying too to be motivated by myself and the freedom that exists on the other side of body dysmorphia. I’m also into what LS said above which is the idea that we’d love to see even more bodies and women being displayed on this site. I’m really excited to see how Bleu develops and have been enjoying it so far 🙂

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Body Dysmorphia Essay

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Introduction

Causes of the disorder, impacts of the disorder, reference list.

Body dysmorphic disorder is a very common situation in many people where an affected person is so obsessed with appearance that the person always sees some imperfections in body image. Such individuals tend to spend much time in front of the mirror trying to see where and how the fault makes them look.

Many affected people may not realize the disorder as people may think that it is one’s liking to stay in front of the mirror. In most cases, people with this disorder tend to opt for cosmetic surgery to correct the flaws that they think they have. Believe it or not, some people with this order may avoid mirrors as much as possible to avoid seeing the flaws in question.

Other common behaviors in affected people include: over grooming oneself, enquiring on the appearance of the flaw from other people over and over, avoiding social places where there are many people as well as being anxious when around people with the fear that they might see the fault. Body dysmorphic disorder can be relating to a number of eating disorders which involve concerns on one’s body image.

The common areas of concern in this condition are facial features, hair and skin imperfections. The most affected group is the teenagers whose bodies are continually changing in shape and size (Alexandra 2008, p. 1).

Research shows that body dimorphic disorder is caused by both biological and psychological factors with much attention being given to the biological factors involving the brain. From the neurobiological view, unregulated levels of serotonin, which is a chemical neurotransmitter of the brain, results to many of the obsessive disorders that are related to anxiety.

The most vulnerable people are those whose close family members have suffered from depression or anxiety. Psychological factors involve experiences of trauma or emotional imbalance especially if it occurred during one’s childhood. People with low self esteem are equally vulnerable to the disorder especially teenage girls who feel that they do not fit in a certain group of people say in campus or college.

Other cases involve teasing of girls by the boys causing the girls to feel less beautiful. Peers may also affect one’s anxiety, for instance, some teenagers may groom themselves in a certain manner that makes the other age group members to feel less good looking (Ahmed, 2010, p. 1).

Assessments of the neurology functioning have shown that the brain is more involved in causing the disorder. General poor performance by BDD patients has been proven especially on control of body responses towards neurons. Similarly, BDD patients have major problems in memorizing both verbal and non verbal information.

This results from improper organization of one’s memory which consequently results to failure of the frontal-striatal circuits to mediate the executive functioning of the brain. However, proper integration of the brain alone has not completely eliminated the memory dysfunctions.

Research into this matter implicates the hippocampus which is naturally involved not only in memory formation but also in motivation and emotion development. Another structure of the brain involved in BDD is the amygdala whose over activity causes attention misconceptions which result to social anxiety.

Besides proper integration of brain structures which results to failed executive functioning, other regions of the brain that are involved in perception of facial emotions are also involved in development of BDD. Such structures include the inferior frontal cortex, insula and the occipito-temporal cortex (Saxena, and Feusner, 2006, p. 48).

Severe cases of the disorder may lead a person into engaging in certain weird behaviors such as avoiding people even to the extreme of avoiding family members where the individual stays locked into a room. Isolation from society members may as well result leading to avoidance of social gatherings. Some people may also hate themselves to the point of committing suicide.

Many of the people suffering from body dimorphic disorder tend to get depressed to the point of seeking clinical help. In most cases where surgery is involved in an effort to modify one’s body appearance, frustration tends to result because most of them do not get satisfied to their expectations.

Other complications resulting from this disorder are lack of friends and other relationships, abuse of drugs, eating disorders where one tries to keep a certain body size or/and shape (Watkins, 2004, p. 1).

Though the prevalence of the disorder is now low affecting only 2% of a population, researchers believe that it is now rising especially with the development of better diagnosis techniques as well as the increasing desire for people to look good especially now that modernization has been adopted in many countries.

Unlike eating disorders which are more prevalent in women, the body dysmorphic disorder equally affects both males and females although teenagers who suffer most are the girls compared to the boys counterparts (Veale, 2011, p. 1).

The most felt impact of the body dysmorphic disorder is psychological where the person affected gets depressed and may even suffer other depression related disorders especially eating disorders. When such individuals keep themselves locked in the household, they tend to engage in a lot of eating, mostly involving junk food, in order to avoid thinking about their faulty body parts.

These eating behaviors may eventually result to other health problems. Anxiety is another very common effect of the disorder which leads to certain behaviors such as panic or uneasiness.

A person suffering from body dysmorphic disorder is likely to suffer from emotional breakdown may be because of self-esteem which results to inferiority complex. When this happens, such people always find themselves crying whenever they think of the situation. Some may even go to the point of blaming God for not making them perfect (Mayo Clinic staff 2010, p.1).

The social life of an individual is as well affected when one suffers from this disorder. For instance, many such people avoid social gatherings and are always afraid of meeting people. Some may even lack friends because they think that they do not fit in and therefore they cannot be accepted by a certain group of people or classmates.

Occupational functioning may equally be affected when a person suffering from the disorder is reluctant to go to work because the person does not want to be seen with the faulty appearance. Some people may even give fake excuses for not being able to go to work especially when there are visitors at the work place (MedicineNet 1996, p. 1).

Body dysmorphic disorder is a serious illness and should be dealt with immediately when identified to prevent the mentioned complications from occurring. If one suspects certain behaviors form a friend or a family member, it is advisable to inform them in order to seek psychological help as early as possible.

Ahmed, I. (2010). Psychiatric Manifestations of Body Dysmorphic Disorder. Web.

Alexandra. (2008). Body Dysmorphic Disorder: When the Mirror Lies. Web.

Mayo Clinic staff. (2010). Body Dysmorphic Disorder . Web.

Medicine Net. (1996). Body Dysmorphic Disorder (BDD). (1996). Web.

Saxena, S. and Feusner, J. D. (2006). Toward a Neurobiology of Body Dysmorphic Disorder . MBL Communications, pp. 48.

Veale, D. (2011). Body Dysmorphic Disorder – FAQ. Web.

Watkins, C. K. (2004). Body Dysmorphic Disorder . Web.

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I Have Body Dysmorphia, and Here's What I Wish People Understood

Warning: some things discussed in this personal essay may be triggering to those with a history of disordered eating.

By the time I was 3 years old, I had already come to believe that my body was a prison. Growing up as a fat child, I was constantly made to feel lesser than my peers through harmful comments from teachers, classmates, and their parents. It all happened almost instantaneously — I looked in the mirror and hated what I saw, and I refused to look at myself from then on when given the option. It's been 20 years, and I still struggle to look in the mirror or at photos of myself; clothing that hugs my body even a little too closely makes me feel panicked.

What I see in my reflection changes from one day to the next, and sometimes within hours. Suddenly I appear 40 pounds heavier or despise the shape of the pores along my nose, and it immediately shakes my confidence. I've canceled plans because I couldn't bear the thought of someone looking at me, worried that they would fixate on the same tiny piece of my appearance that was currently plaguing me with anxiety.

Body dysmorphia is one of the most commonly misunderstood mental health disorders, and that's what makes having it so isolating. While the effects of the disorder are tedious — there are times when I feel certain people must be staring at my neck or dimpled hands in disgust — people also mistakenly place their very typical insecurities under the same umbrella. I've had friends say, "Ugh, I totally relate to you. I felt so fat yesterday after eating a burrito." Not only is this language harmful, but it also minimizes my disorder. I don't feel fat after eating a burrito. Instead, I constantly feel like my skin is a prison, and I often dream of my soul leaving my body so that I can be free of it.

Body dysmorphia isn't merely a phase that emerges in the insecure years of puberty. It's a lifelong disorder that can have very real consequences. I experienced my first eating disorder in the third grade, and my most recent one just a few months ago. Over the years, I've restricted calories and worked out until I injured myself so severely that I was nearly immobile. None of this was healthy, but even when I did lose weight, I took no satisfaction from it. The disorder made it impossible for me to see the changes in my body. It would simply find another imperfection to fixate on.

Body dysmorphia isn't merely a phase that emerges in the insecure years of puberty. It's a lifelong disorder that can have very real consequences.

Many people also wrongly assume that body dysmorphia only has to do with a person's weight . It doesn't. I've been triggered by bags under my eyes, porous skin, frizzy hair, the broadness of my shoulders, my eyebrows, my breasts, my voice, and more. This disorder takes hold of your whole body and makes you feel as though the world is glaring at the features you dislike most, as though they're sitting under a harsh spotlight.

Body dysmorphia has affected many aspects of my life, including friendships and relationships. Being in a sorority was a constantly triggering experience. Being in a long-term relationship is challenging, too, because I struggle to be intimate with anyone without fearing that they'll hate me. I've even believed at times that people stopped being my friend because of the way I looked, when they hadn't stopped being my friend at all.

I know that I will have this disorder for the rest of my life. While progress can be made , it's a deeply internal, challenging, and emotional process. Progress is not posting a photo of my rolls and captioning it with #curvygirlgoals. It's finding the courage to look at myself in a family photo and maybe someday finally seeing what others do.

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Social Media and Body Dysmorphia

Table of contents.

During the first wave of the Coronavirus pandemic, social media usage increased by 61% 2 . This is a massive spike in an already growing trend, highlighting the need to reflect on its mental health impacts.

It’s already acknowledged that there can be a link between social media and body image. With access to an infinite feed of content, the online realm can change your view on physical reality.

In some cases, social media can contribute to body dysmorphia. In the U.S., it is estimated that about 1 in 50 people struggle with body dysmorphia 1 . However, this number may be greater due to people’s reluctance to talk about their symptoms and receive a diagnosis.

Understanding Positive and Negative Body Image

Your body image is the way you view your physical self in your reflection, in photos, and in your mind 3 . Body image is a culmination of beliefs and feelings about the way you look. Generalizations, experiences, environment, and culture are a few influences that shape it.

It’s an important self-reflection because it affects how you engage with life. This is one of the four aspects of body image known as behavioral body image 4 . For example, if you believe that something is wrong with you, you are likely to have unhealthy behaviors that reflect that belief.

Positive Versus Negative Body Image

Having a positive body image involves a sense of acceptance about the way your body looks and functions 10 . You have a wide range of what you consider “beautiful,” and as such, you can find value in your physical appearance. When you have a positive body image, you view yourself in a relatively stable and positive way.

On social media, a person with a positive body image will engage with posts without it affecting the way they see themselves.

The other side of the spectrum is having a negative body image. This involves judgment, shame, and embarrassment about the way you look.

A person with a poor body image lacks confidence and acceptance of their body, often due to a distorted view of themselves. For example, a person may view their weight, shape, skin clarity and tone, or hair as not being good enough.

Developing a negative body image often comes from comparing yourself to others and to cultural beauty standards. Now that the world spends more time online, this comparison often happens when engaging with social media.

Seeing a feed full of seemingly perfect people can lead to viewing yourself as inadequate. For some, simply logging off or changing who they follow can remedy the issue. For others, it can contribute to something known as body dysmorphia.

Body Dysmorphia

Body dysmorphia, or body dysmorphic disorder (BDD), is a condition where an individual becomes obsessive about a perceived flaw in their appearance. The word perceived is important here, as the issue may be imagined or unnoticeable to others. A person experiencing body dysmorphia becomes self-conscious about their appearance and believes that other people are noticing and judging them 9 .

Body dysmorphia is not to be confused with gender dysmorphia. Gender dysmorphia refers to the distress someone feels when there is a conflict between the gender they were assigned at birth and their own gender identity. Gender dysmorphia involves gender identity , while body dysmorphia involves appearance and attractiveness.

When suffering from body dysmorphia, a person will consistently check on their appearance in the mirror or in photos. This obsessive thought pattern leads to compulsions, which are actions in response to obsessive thoughts.

Experiencing body dysmorphia is more than simply being insecure about a feature of your body. BDD is an obsessive-compulsive cycle that is repetitive and hard to resist making it very similar to obsessive-compulsive disorder (OCD) . The main difference between the two disorders is that people with body dysmorphia focus on appearance as opposed to other issues.

Body Dysmorphia Diagnosis

Body dysmorphia is diagnosed by having an excessive focus on slight or nonexistent flaws, totaling at least one hour a day 7 . For example, a person may fixate on the shape of their nose or the fullness of their lips.

The repetitive compulsions that come from this obsession distinguish it from negative body image. These compulsions don’t bring the individual any joy and can be observable by others.

Body dysmorphia can look like other mental health issues at first, such as social anxiety disorder, eating disorders, and OCD. While other conditions can stem from it, body dysmorphia tends to be the core issue.

Between 5.5 and 9.6 million people in the United States suffer from body dysmorphia 5 . Because it’s a prevalent issue in American culture, it’s important to consider social media’s impact on this condition.

Social media isn’t the only cultural influence on body dysmorphia. For decades, there has been a lack of representation of normal-looking people in modeling, advertisement, and entertainment. Rather than including normal variations in the way people look, visual media mainly shows people who represent unrealistic beauty standards.

Unrealistic beauty standards didn’t start with social media but it has contributed to its continuation. People in this narrow category of beauty standards receive the most likes and attention which can reinforce the cultural illusion that people should look a certain way.

Consequently, the amount of time people spend on social media makes it a major influence on body image and dysmorphia. Social media provides endless content and has become a place where everyone is trying to achieve the “ideal” aesthetic for likes and followers.

To achieve this, people edit and use filters to portray an image of false perfection. Instagram, for example, has countless free filters to alter your appearance. You can also download apps like Photoshop and Lightroom to change your skin texture and body size.

It can be difficult to determine if a person has altered their appearance if you just see them on social media. All you’re seeing is a beautiful, 2-dimensional image of someone’s seemingly perfect aesthetic.

If you see that the way they look is getting them a lot of attention, you may begin to reflect and wonder if you should also change your appearance. This can create a gap between what someone actually looks like versus what they think they should look like.

With body dysmorphia, social media can trigger obsessive thoughts about appearance. Their feed may be full of people looking “perfect”, which can be a constant reminder of their perceived flaws.

This can lead to compulsive actions to try to remediate the issue. This isn’t to say that social media causes body dysmorphia, but rather that it can contribute to this condition.

Signs and Symptoms of Body Dysmorphia

Someone with body dysmorphia will repetitively take action in response to their perceived flaw.

First, they may have thoughts of comparison or may check their reflection in the mirror to assess the perceived flaw. From there, they may perform a variety of behaviors to try to fix the “issue” that they see.

• Some signs and symptoms of BDD include but are not limited to: 6
• Excessive exercising
• Excessive grooming and/or makeup application
• Excessive tanning and/or skin pigmentation modification
• Excessive shopping for clothing and/or accessories
• Frequent outfit changes
• Skin picking
• Hiding or covering up areas of concern

These actions are repetitive and compulsive in an attempt to improve appearance. They can be conscious or subconscious behaviors.

There are also social indicators of body dysmorphia, such as constantly seeking reassurance from peers. Online, this could mean excessively striving for likes or comments on a post.

In some circumstances, a person may develop social anxiety or avoidance due to the fear of their appearance being judged. This could look like missing social gatherings or being absent from work.

When engaging with a post online, a person with body dysmorphia may begin comparing themselves to the “perfection” that they see. This can lead to feelings of inadequacy, which in turn can lead to enacting one or more of these repetitive behaviors.

Compulsions, in and of themselves, take away from a person’s ability to function in a healthy and positive way. Additionally, this cycle can have other mental and physical health consequences.

Risks Associated with Body Dysmorphia

Body dysmorphia can involve or lead to various medical and mental health issues.

It can blend into social anxiety , impairing the individual’s ability to engage with others in social and professional settings.

To try to fix perceived weight issues, a person may develop an eating disorder such as anorexia, bulimia, or orthorexia.

Due to the anxiety and possible isolation involved with body dysmorphia, individuals may also fall into substance abuse, depression, or suicidal thoughts.

One study showed that individuals with body dysmorphic disorder were four times more likely to think about suicide 9 . They were also 2.6 times more likely to attempt suicide than people without the condition.

Body Dysmorphia Treatment

If you or a loved one are experiencing suicidal thoughts, call the National Suicide Prevention Hotline at 800-273-8255 to get help. Otherwise, the first step in treating body dysmorphia is to seek professional diagnosis and support. From there, various therapy and psychiatric methods can be used based on the individual’s needs.

Therapy and Medication

One route of treatment involves talk therapy otherwise known as psychotherapy. A type of psychotherapy generally used to help people with BDD is Cognitive Behavioral Therapy (CBT).

Cognitive behavioral therapy (CBT) addresses the way individuals think, feel, and behave. As such, it can help change the destructive thoughts patterns that lead to obsessions.

In addition to therapy, there are psychiatric medications used to treat body dysmorphia. For example, serotonin reuptake inhibitors (SSRIs) can help treat symptoms 8 .

Mental health struggles, although common, are personal. As such, the treatment of body dysmorphia should be tailored to an individual’s needs.

Supporting Others and Contributing to a Better Environment

If you aren’t experiencing body dysmorphia but are concerned for someone who is, you can take action in a few different ways.

First, you can educate yourself on the issue. That way, you can come from a place of compassion and understanding when speaking with them.

Then, you can support them by being there for them and offering resources for them to get help.

In general, you can also make a difference by being thoughtful about what you post online. While editing photos of yourself can be fun, keep in mind that others may not realize that you’ve altered the way you look. To contribute to a more body-positive digital environment, be authentic about the way you portray yourself.

Even if you don’t suffer from body dysmorphia, social media can have an impact on body image. Be selective about who you follow so that you don’t buy into the idea of aesthetic “perfection”.

Social media can be perceived in a positive light because it can allow you to connect with and learn from others. With that intention in mind, change your feed so that you have more positive experiences.

Build a Positive Body Image

Body dysmorphia is a common disorder that can be exacerbated by the use of social media. This disorder can begin to affect your daily life. With the help of therapy, medication, and support you can find recovery and develop a positive body image.

If you think you’re suffering from body dysmorphia, please contact D’Amore Mental Health to learn more about our program. Our mental health professionals are prepared to answer any questions you may have and help you find the right program for your needs.

• Cleveland Clinic. (2020, October 14). Body dysmorphic disorder: Symptoms, causes, diagnosis, treatments. Cleveland Clinic. Retrieved January 26, 2022, from https://my.clevelandclinic.org/health/diseases/9888-body-dysmorphic-disorder   
• Fullerton, N. (2021, April 29). Instagram vs. Reality: The Pandemic’s Impact on Social Media and Mental Health. Pennmedicine.org. Retrieved January 26, 2022, from https://www.pennmedicine.org/news/news-blog/2021/april/instagram-vs-reality-the-pandemics-impact-on-social-media-and-mental-health#:~:text=The%20impact%20of%20increased%20screen,social%20media%20for%20more%20connectivity
• NEDA. (2018, February 22). Body image. National Eating Disorders Association. Retrieved January 26, 2022, from https://www.nationaleatingdisorders.org/body-image-0
• NEDC. (2021). Body Image. National Eating Disorders Collaboration. Retrieved January 26, 2022, from https://nedc.com.au/eating-disorders/eating-disorders-explained/body-image/
• Philips, K. (2020). Prevalence of BDD. International OCD Foundation. Retrieved January 26, 2022, from https://bdd.iocdf.org/professionals/prevalence/
• Philips, K. (2020). Signs & Symptoms of BDD. International OCD Foundation. Retrieved January 26, 2022, from https://bdd.iocdf.org/professionals/signs-symptoms/
• Philips, K. A. (2020). Diagnosing BDD. International OCD Foundation. Retrieved January 26, 2022, from https://bdd.iocdf.org/professionals/diagnosis/
• Phillips, K. A., & Hollander, E. (2008, March). Treating body dysmorphic disorder with medication: Evidence, misconceptions, and a suggested approach. Body image. Retrieved January 26, 2022, from https://www.ncbi.nlm.nih.gov/labs/pmc/articles/PMC2705931/
• Singh, A. R., & Veale, D. (2019, January). Understanding and Treating Body Dysmorphic Disorder. Indian journal of psychiatry. Retrieved January 26, 2022, from https://www.ncbi.nlm.nih.gov/labs/pmc/articles/PMC6343413/
• White, Y. (2020, October 11). Body image: What is it, and how can I improve it? Medical News Today. Retrieved January 26, 2022, from https://www.medicalnewstoday.com/articles/249190#negative-body-image

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Body Dysmorphic Disorder: Clinical Overview and Relationship to Obsessive-Compulsive Disorder

Information & authors, metrics & citations, view options, definition and core clinical features of bdd, diagnostic criteria for bdd in dsm-5, criterion a., criterion b..

Criteria C and D.

Bdd specifiers in dsm-5 : muscle dysmorphia, insight, and panic attacks, with muscle dysmorphia..

With panic attacks.

Key associated features, epidemiology, age at onset and course of illness, bdd among youths, impairment in psychosocial functioning, suicidality, gender-related aspects of bdd, major depressive disorder, substance use disorders, and other comorbid conditions, a patient with bdd, emerging clues about bdd’s etiology and pathophysiology, genetic factors, neurobiological factors, information-processing biases, psychological and social-environmental factors, evolutionary perspective, bdd’s relationship to ocd and other disorders: similarities and differences.

How to Assess Patients for BDD

How to differentiate bdd from disorders with which it is often confused, excoriation (skin-picking) disorder, trichotillomania (hair-pulling disorder), major depressive disorder, social anxiety disorder, agoraphobia, generalized anxiety disorder, eating disorders, psychotic disorders, gender dysphoria, olfactory reference disorder (olfactory reference syndrome), clearly noticeable physical defects, normal appearance concerns, treatment of bdd, treatment challenges and how to address them, surgical, dermatologic, dental, and other cosmetic treatment, pharmacotherapy, sri efficacy., sri dosing., sri trial duration., sri augmentation and switching., non-sri monotherapy., cbt efficacy studies., components of cbt for bdd., session number and frequency., predictors of therapy response., combined pharmacotherapy and cbt, family therapy, approaches for treatment-refractory bdd, conclusions and future directions, information, published in.

• Obsessive-compulsive disorder
• body dysmorphic disorder

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What Is Body Dysmorphia?

Frequently asked questions.

Body dysmorphic disorder (BDD), also called body dysmorphia , is a mental health condition that involves an overwhelming preoccupation with one’s body and appearance. Someone with BDD may focus excessively on minor physical flaws or worry about perceived flaws that others don’t notice.

NickyLloyd / Getty Images

In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), BDD is listed within the category of obsessive-compulsive and related disorders. This means it involves both obsessions (intrusive, persistent thoughts) and compulsions (actions that someone performs repeatedly in an attempt to reduce anxiety).

Learn more about body dysmorphia, including symptoms, causes, and available treatment options.

Prevalence of Body Dysmorphic Disorder

Estimates suggest that up to 4% of the U.S. population meets the diagnostic criteria for body dysmorphic disorder. It is most common among people age 15–30.

People with body dysmorphia worry excessively about minor or nonexistent flaws in their body and/or face. To "fix" those flaws, they may go to extreme lengths, such as drastically altering their looks with plastic surgery . 

Research suggests that people with BDD often spend three to eight hours a day worrying about their perceived physical imperfections. Any body part may become a target for these worries. However, people with body dysmorphia are most likely to worry about their skin, nose, or hair.  

Common symptoms of body dysmorphia include:

• Extreme preoccupation with physical flaws that are either very minor or imagined
• Spending an excessive amount of time covering perceived flaws with makeup, different outfits, or new hairstyles
• Buying products or getting plastic surgery to alter one's appearance
• Checking the mirror excessively or avoiding mirrors 
• Trying to hide certain body parts with clothing or accessories
• Repetitive behaviors, such as picking at their skin
• Needing constant reassurance from others about physical appearance
• Worrying excessively about appearing "ugly" or unattractive
• Constantly comparing one's looks to others

Someone with body dysmorphia may feel so consumed with thoughts about their looks that they neglect other areas of their life. They may even avoid school, social events, dating, or work out of fear of being judged for their looks. 

When left untreated, BDD can lead to serious negative consequences. Over half of people with BDD are unmarried, and over 20% of people with body dysmorphia are unemployed. Around 20% of people with BDD are so distressed by their appearance that they attempt suicide.

If you think you may have BDD, talk to your healthcare provider. They can refer you to a mental health specialist who can make a diagnosis using the criteria in the DSM-5. If your worries about your looks are focused more on your body weight or size, you may be diagnosed with an eating disorder instead.

To be diagnosed with body dysmorphia, the preoccupation with your appearance must negatively affect your life and/or cause significant emotional distress. Your healthcare provider may also specify whether you have muscle dysmorphia, a type of body dysmorphia that involves worrying about appearing “too small” or not muscular enough.

During the diagnostic process, your mental health specialist may specify whether you have good, fair, or poor insight into your BDD symptoms.

According to the DSM-5 , some people with body dysmorphic disorder have “good” insight, which means they are aware that their beliefs about their body are not true. People with “fair” or “poor” insight aren’t aware that their worries are excessive or not based in reality.

The exact cause of body dysmorphia is unknown. Researchers believe that several factors may contribute to the development of BDD, including:

• Genetics : In some cases, BDD may be inherited. According to twin studies, genetic factors account for about 44% of the variance in body dysmorphic disorder symptoms. 
• Trauma : People with a history of trauma have a higher chance of developing body dysmorphia. Many people with BDD report having been bullied by peers at school, and up to 79% of people with body dysmorphia experienced childhood abuse .
• Personality traits : People with certain personality traits, such as perfectionism and sensitivity to aesthetics, are more likely to develop body dysmorphia.
• Comorbid conditions : Many people with BDD have at least one other mental health condition at the same time. It’s especially common for someone with body dysmorphia to have obsessive-compulsive disorder (OCD), social anxiety disorder (SAD), or an eating disorder, such as anorexia nervosa (AN).

Treatment for body dysmorphia usually involves psychotherapy (talk therapy) and/or medication. Research suggests that the following approaches are effective in treating people with BDD:

• Cognitive behavioral therapy (CBT) : CBT can help people with BDD learn to manage their anxiety and depression, gain insight into their beliefs, and resist the urge to perform compulsive behaviors. 
• Selective serotonin reuptake inhibitors (SSRIs) : Studies indicate that certain antidepressants , such as SSRIs, have been shown to be 53% to 70% effective in treating BDD. Many people with body dysmorphia have to take SSRIs on a long-term basis to reduce their symptoms.

If you have BDD, it’s important to build your self-esteem and reach out to others for support. In addition to seeking professional treatment, here are some ways to cope with the symptoms of body dysmorphia:

• Joining an online or in-person peer support group for people with BDD
• Spending time with loved ones 
• Practicing mindfulness techniques, such as meditation
• Managing stress with relaxation techniques, such as deep breathing exercises
• Writing your thoughts in a journal
• Using positive affirmation statements to build your confidence
• Participating in a new hobby or learning a new skill

If you or a loved one are struggling with body dysmorphic disorder, contact the Substance Abuse and Mental Health Services Administration (SAMHSA) National Helpline at 800-662-4357 for information on support and treatment facilities in your area.

If you are having suicidal thoughts, dial 988 to contact the 988 Suicide & Crisis Lifeline and connect with a trained counselor. If you or a loved one are in immediate danger, call 911 .

Body dysmorphic disorder (BDD), is a mental health disorder that involves an extreme preoccupation with minor or imagined flaws in one’s physical appearance. People with BDD feel overwhelmed by negative thoughts about their body or face. They may spend excessive amounts of time and/or money in attempts to conceal their imperfections or “fix” the way they look. 

Researchers believe that BDD is caused by a combination of genetic and environmental factors. Many people with BDD have been bullied about their looks. A history of trauma, such as child abuse, also increases the likelihood of developing BDD. Treatment for BDD typically involves psychotherapy , medication, or both.

A Word From Verywell

If you worry excessively about your looks, you’re not alone. Body dymorphia is common, especially among young adults. Many people have low self-esteem and body image concerns. Talk to your healthcare provider about your options for treatment, support, and empowerment.

Many people are insecure about their looks. However, people with body dysmorphia are so concerned with certain aspects of their appearance that it interferes with their everyday life.

They may take extreme steps to change or hide particular body parts. They may also avoid going out at all because of their imagined physical flaws.

You may have body dysmorphic disorder if you are excessively preoccupied with minor or imagined flaws in your body and/or face. You may also perform repetitive actions, such as comparing yourself to others or grooming excessively, to address your perceived imperfections. Talk to your healthcare provider if you feel consumed or overwhelmed by negative thoughts about your appearance.

Body dysmorphic disorder is a fairly common mental health condition. According to estimates, between 0.6% to 4% of the population has body dysmorphia. It is even more common among people who get plastic surgery or visit a dermatologist regularly.

Research suggests that both biological and environmental factors contribute to the development of body dysmorphia. A history of trauma, including bullying and/or abuse, significantly increases the likelihood that someone will develop BDD. Twin studies indicate that genetics also plays a role, accounting for up to 44% of BDD cases.

If your friend or family member has body dysmorphic disorder, try to be an empathetic listener. Help to build their self-esteem and confidence by offering support and companionship.

If your loved one is open to professional help, reach out to a healthcare provider or support group. Remember to set boundaries and prioritize self-care to keep your communication healthy and effective.

Johns Hopkins Medicine. Body dysmorphic disorder .

American Psychological Association. Body dysmorphic disorder .

American Psychological Association. Obsessive-compulsive disorder .

Varma A, Rastogi R. Recognizing body dysmorphic disorder (dysmorphophobia) .  J Cutan Aesthet Surg . 2015;8(3):165-168. doi:10.4103/0974-2077.167279

Substance Abuse and Mental Health Services Administration. DSM-5 changes: implications for child serious emotional disturbance; Table 23: DSM-IV to DSM-V body dysmorphic disorder comparison .

Singh AR, Veale D. Understanding and treating body dysmorphic disorder .  Indian J Psychiatry . 2019;61(Suppl 1):S131-S135. doi:10.4103/psychiatry.IndianJPsychiatry_528_18

Krebs G, Fernández de la Cruz L, Mataix-Cols D. Recent advances in understanding and managing body dysmorphic disorder .  Evid Based Ment Health . 2017;20(3):71-75. doi:10.1136/eb-2017-102702

Schieber K, Kollei I, de Zwaan M, Müller A, Martin A. Personality traits as vulnerability factors in body dysmorphic disorder .  Psychiatry Res . 2013;210(1):242-246. doi:10.1016/j.psychres.2013.06.009

Hartmann AS, Staufenbiel T, Bielefeld L, et al. An empirically derived recommendation for the classification of body dysmorphic disorder: findings from structural equation modeling .  PLoS One . 2020;15(6):e0233153. doi:10.1371/journal.pone.0233153

NHS. Body dysmorphic disorder (BDD) .

By Laura Dorwart Dr. Dorwart has a Ph.D. from UC San Diego and is a health journalist interested in mental health, pregnancy, and disability rights.

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• Research article
• Open access
• Published: 15 June 2021

Body dysmorphic disorder and self-esteem: a meta-analysis

• Nora Kuck 1 ,
• Lara Cafitz 1 ,
• Paul-Christian Bürkner 2 ,
• Laura Hoppen 1 ,
• Sabine Wilhelm 3 &
• Ulrike Buhlmann 1  

BMC Psychiatry volume  21 , Article number:  310 ( 2021 ) Cite this article

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Body dysmorphic disorder (BDD) is associated with low self-esteem. The aim of this meta-analysis was to examine the strength of the cross-sectional relationship between BDD symptom severity and global self-esteem in individuals with BDD, mentally healthy controls, community or student samples, and cosmetic surgery patients. Moreover, the role of depressive symptom severity in this relationship and other moderating factors were investigated.

A keyword-based literature search was performed to identify studies in which BDD symptoms and global self-esteem were assessed. Random effects meta-analysis of Fisher’s z-transformed correlations and partial correlations controlling for the influence of depressive symptom severity was conducted. In addition to meta-analysis of the observed effects, we corrected the individual correlations for variance restrictions to address varying ranges of BDD symptom severity across samples.

Twenty-five studies with a total of 6278 participants were included. A moderately negative relationship between BDD symptom severity and global self-esteem was found ( r  = −.42, CI  = [−.48, −.35] for uncorrected correlations, r  = −.45, CI  = [−.51, −.39] for artifact-corrected correlations). A meta-analysis of partial correlations revealed that depressive symptom severity could partly account for the aforementioned relationship ( pr  = −.20, CI  = [−.25, −.15] for uncorrected partial correlations, pr  = −.23, CI  = [−.28, −.17] for artifact-corrected partial correlations). The sample type (e.g., individuals with BDD, mentally healthy controls, or community samples) and diagnosis of BDD appeared to moderate the relationship only before artifact correction of effect sizes, whereas all moderators were non-significant in the meta-analysis of artifact-corrected correlations.

Conclusions

The findings demonstrate that low self-esteem is an important hallmark of BDD beyond the influence of depressive symptoms. It appears that negative evaluation in BDD is not limited to appearance but also extends to other domains of the self. Altogether, our findings emphasize the importance of addressing self-esteem and corresponding core beliefs in prevention and treatment of BDD.

Peer Review reports

Introduction

Body dysmorphic disorder (BDD) is characterized by a preoccupation with perceived appearance defects and repetitive behaviors intended to hide, fix or check them. The perceived flaws are not observable or only appear minimal to others. Affected individuals may excessively check their body areas of concern, seek reassurance, camouflage or groom, compare their own physical appearance to that of others, exercise to the point of injury, or even seek cosmetic surgery [ 1 ]. The symptoms frequently lead to marked impairment in social functioning and reduced quality of life [ 2 ].

In general, BDD is associated with low self-esteem [ 3 ]. Rosenberg defined self-esteem as one’s positive or negative attitudes towards the self. Accordingly, persons may have favourable or unfavourable opinions about themselves and self-esteem is an overall evaluation of one’s value [ 4 ]. Thus, the question arises how strongly the negative evaluation in the domain of physical appearance in BDD is accompanied by general feelings of unworthiness and a low self-esteem. Several studies have investigated self-esteem in BDD (e.g., [ 3 , 5 , 6 ]). The samples comprised clinical samples (e.g., [ 7 ]), combined samples of patients and healthy control participants (e.g., [ 8 ]), non-clinical community (e.g., [ 9 , 10 ]) or student samples (e.g., [ 11 , 12 , 13 ]). Moreover, data on self-esteem and BDD symptoms in cosmetic surgery settings have been collected (e.g., [ 14 , 15 , 16 ]). Altogether, more pronounced BDD symptoms were related to lower self-esteem in these studies. However, the reported effect sizes varied from r  = − .04 to r  = − .52, or d  = 0.66 to d  = 2.26. In addition, various authors assessed BDD symptoms and self-esteem but did not report effect sizes, and so far, no meta-analysis or review has systematically analyzed and integrated these studies.

A frequent comorbid disorder in BDD is major depression [ 17 ]. Summers et al. demonstrated the interconnectedness of BDD symptoms and depressive symptoms in a network analysis of BDD and major depressive disorder [ 18 ]. Elevated levels of depressive symptoms were found in adolescents with high appearance anxiety [ 19 ]. This shows that, regardless of the diagnostic categories, BDD and depressive symptoms tend to co-occur. Moreover, depression is linked to low self-esteem [ 20 ]. Feelings of worthlessness are among the diagnostic criteria for major depression [ 1 ]. According to a meta-analysis by Sowislo and Orth, low self-esteem represents a risk factor for depressive symptoms rather than a consequence [ 21 ]. Still, low self-esteem and depressive symptoms might reciprocally affect each other [ 20 ]. The connection of depressive symptoms to self-esteem and BDD may have consequences for the relationship between BDD symptoms and self-esteem. More precisely, the co-occurrence of BDD symptoms and low self-esteem may either be specific to BDD or may be caused by high levels of comorbid depressive symptoms. In this regard, Cerea et al. already pointed to the relevance of clarifying the relationship between BDD and self-esteem [ 9 ]. So far, only two studies reported partial correlations and suggested that depressive symptoms might contribute to the relationship between BDD symptoms and self-esteem. A study by K. A. Phillips et al. revealed a zero-order correlation of r  = − .38 and a partial correlation of pr  = −.16 [ 3 ]. Bartsch et al. found an uncontrolled correlation of r  = − .48 and a partial correlation of pr  = −.32 [ 22 ]. Besides, several studies measured depressive symptoms alongside with BDD symptoms and self-esteem but did not provide a partial correlation. Analyzing these studies with meta-analytic techniques and gathering corresponding effect sizes can shed light on the role of depressive symptoms.

Another relevant question is whether the strength of the relationship between BDD symptoms and self-esteem varies systematically between different subgroups. On the one hand, low self-esteem might particularly act as a risk factor for BDD in certain groups such as adolescence. Adolescence is a developmental phase in which body image concerns are common [ 23 ]. BDD most frequently begins in this period [ 24 ]. Also, adolescence is characterized by declining self-esteem [ 25 , 26 , 27 ]. Furthermore, decreased self-esteem appears to be strongly related to dysmorphic concern in adolescents [ 28 ]. Thus, if low self-esteem represented a risk factor for BDD, it could have a more severe impact in a vulnerable period such as adolescence. On the other hand, BDD symptoms might result in lower self-esteem in adolescence and young adulthood than in middle and old age. The concept of contingent self-esteem refers to the degree to which self-esteem depends on achievements and feedback in different domains such as appearance, academic success, relationships, or virtue [ 29 ]. A study by Meier et al. suggested that self-esteem might become less contingent on interpersonal conflicts across the life course [ 25 ]. If contingent self-esteem also decreased in other domains, a preoccupation with perceived defects in appearance might have a larger effect on self-esteem in adolescence and young adulthood compared to middle and old age. Further, some studies found that women tend to have more contingent self-esteem than men, particularly in the domain of appearance [ 25 , 30 ]. Hence, BDD symptoms might possibly affect self-esteem more strongly in women than in men. Alternatively, it is possible that the effects of appearance concerns on self-esteem are stronger in individuals with (vs. without) a clinical diagnosis of BDD given that - according to our clinical observation - individuals with clinical BDD build their self-esteem predominantly on how they look. So far, there has been a lack of longitudinal studies on BDD symptoms and self-esteem, and therefore we do not know whether low self-esteem could cause BDD. Also, the current studies did not investigate moderators of the cross-sectional relationship between BDD symptoms and self-esteem. However, meta-analytic studies allow for a closer investigation of systematic variation in effect sizes. Thus, insights on the influence of age, gender, or sample type on the relationship between BDD symptoms and self-esteem can be gained.

In summary, the aims of the current meta-analysis were as follows:

Examine the strength of the cross-sectional relationship between BDD symptom severity and global self-esteem in BDD patients, healthy controls, community or student samples, and cosmetic surgery patients.

Investigate whether the aforementioned relationship between BDD symptom severity and self-esteem persists beyond the influence of depressive symptoms.

Explore potential systematic differences in the magnitude of the correlations regarding participants’ mean age, percentage of females, the sample type (e.g., student sample or BDD patients), the diagnostic method (self-report versus clinician-administered measures of BDD symptoms), and BDD diagnosis (whether BDD was diagnosed by a clinician prior to or during study participation).

Altogether, the three research questions could further our understanding of associated features in BDD and offer valuable insights for the prevention and treatment of BDD.

A preprint of the manuscript was uploaded to psyarxiv ( https://psyarxiv.com/ ). The extracted data used for the meta-analysis are available at our Open Science Framework (OSF) data repository ( https://osf.io/z52fc/ ). A PRISMA checklist concerning the documentation of the meta-analysis can be retrieved in the Appendix (Additional file  1 ) [ 31 ]. The meta-analysis was not pre-registered.

Study selection

Studies were selected if they fulfilled the following eligibility criteria. BDD symptom severity had to be measured with a questionnaire or interview that captures symptoms as described in the fifth or fourth edition of the Diagnostic and Statistical Manual of Mental Disorders , DSM-5 or DSM-IV [ 1 , 32 ]. This comprised detailed measures of BDD symptom severity as well as shorter screening measures for BDD symptoms. Alternatively, categorial diagnostic measures of BDD based on DSM-IV or DSM-5 were also considered. Hence, the Yale-Brown Obsessive Compulsive Scale for Body Dysmorphic Disorder (BDD-YBOCS) [ 33 ], the self-report and clinician-administered versions of the Body Dysmorphic Disorder Examination (BDDE) [ 34 ], the Body Dysmorphic Symptoms Inventory (Fragebogen körperdysmorpher Symptome; FKS) [ 35 ], the Questionario sul Dismorfismo Corporeo (QDC) [ 36 ], the Dysmorphic Concern Questionnaire (DCQ) [ 37 ], the Body Dysmorphic Disorder Questionnaire (BDDQ) [ 38 ], and the Body Dysmorphic Disorder Diagnostic Module (BDD-DM) [ 39 ] were included in this meta-analysis. Measures of body image or body dissatisfaction were excluded. Also, measures which specifically address muscle dysmorphia were not included, as we intended to investigate BDD symptoms in general and because of the overlap between muscle dysmorphia and eating disorders. This meta-analysis relied on the definition and operationalization of self-esteem by Rosenberg [ 4 ]. Thus, self-esteem needed to be assessed via the Rosenberg Self-Esteem Scale (RSES), the most widely used self-report measure for global self-esteem [ 4 ]. For inclusion in the meta-analysis of partial correlations, studies were required to use a questionnaire or interview for the assessment of depressive symptom severity. The Beck Depression Inventory (BDI) [ 40 , 41 , 42 ], the Hamilton Depression Rating Scale (HAMD) [ 43 ], the depression subscale of the Depression Anxiety Stress Scales (DASS) [ 44 ], the depression subscale of the Hospital Anxiety and Depression Scale (HADS) [ 45 ], the depression subscale of the Symptom Checklist-90 (SCL-90) [ 46 ], and the Patient Health Questionnaire-9 Depression module (PHQ-9) [ 47 ] were used in the studies.

Clinical, subclinical, and non-clinical samples were examined. Studies could target BDD patients, mentally healthy control participants, students, community persons, and cosmetic surgery patients. Participants were allowed to have secondary comorbid mental disorders. However, samples with another primary mental disorder (e.g., eating disorders, social anxiety disorder) were excluded. Studies that were recruited according to the presence or absence of a physical condition (e.g., rheumatic arthritis, obesity) were not included in this analysis. Also, samples that were selected according to related factors (e.g., body dissatisfaction) were not considered. No restrictions concerning age or gender of the sample were applied. Studies could be designed as correlational surveys or intervention studies. Since we investigated the cross-sectional relationship, data on all our variables of interest had to be collected at a single measurement point. In the case of more than one measurement point, baseline measures were analyzed. Case studies were omitted. For inclusion, manuscripts were required to be written in English or German.

Several sources were used to identify relevant studies. The databases PubMed , PsycInfo , PsycArticles , Medline , Web of Science , Psyndex , and Dissertation Abstracts International were searched for eligible studies. Furthermore, ongoing trials were found in the http://ClinicalTrials.gov  registry, the Cochrane Central Register of Controlled Trials ( CENTRAL ), the WHO International Clinical Trials Registry Platform ( ICTRP ), and the ISRCTN registry. We also tried to obtain unpublished data by searching OpenGrey ( http://www.opengrey.eu ). The keyword-based literature search was carried out by the second author in April 2017. Subsequently published or registered studies were identified in January 2019, August 2019, and in May 2020. The following search term was applied: (body dysmorphic AND self-esteem) or (dysmorphophobia AND self-esteem) or (dysmorphophobic AND self-esteem) or (body dysmorphic AND self-worth) or (dysmorphophobia AND self-worth) or (dysmorphophobic AND self-worth). The corresponding German search terms were: (körperdysmorphe AND Selbstwert) or (Dysmorphophobie AND Selbstwert) or (dysmorphophobe AND Selbstwert). Additionally, 24 well-known researchers in the field of BDD were contacted for unpublished studies in September 2019.

In a first step, the abstracts of identified studies were screened. The abstract screening of studies which were published after April 2017 was performed by two research assistants. The abstracts were required to suggest that BDD symptoms and self-esteem were captured in the study. Subsequently, a full text assessment was conducted by the second author (or a research assistant for studies with dates of publication after April 2017) according to the eligibility criteria described above.

Data collection

A coding scheme for extraction of relevant data was developed. The coding scheme contained the following information: First, the sample was described with regard to the number of participants (in total and in the subgroups), clinical status, age, sex, education, ethnicity, sample type (e.g., students, cosmetic surgery patients), comorbidities, and other study-specific inclusion criteria (e.g., a certain cut-off on a BDD questionnaire). Second, the assessment of BDD symptom severity was specified. The interview or questionnaire used to examine BDD symptoms, diagnostic criteria, the diagnostic method (self-report vs. clinician-administered), as well as means and standard deviations of the diagnostic measure in the sample were coded. Additionally, the range of BDD symptom severity (e.g., only clinical participants) and whether the study compared two extreme groups (e.g., BDD patients versus healthy controls) were rated. Third, mean and standard deviation of the RSES in the total sample were gathered. Fourth, information on the assessment of depressive symptoms was collected. This included the measure for depressive symptom severity, the applied diagnostic criteria, the diagnostic method, as well as mean and standard deviation of the measure for depressive symptoms. Fifth, the reported effect size data were compiled. Preferably, the correlations between BDD symptom severity and self-esteem, between BDD symptom severity and depressive symptom severity, and between self-esteem and depressive symptom severity were gathered. Additionally, we coded whether the correlation was reported in the study or obtained by the authors afterwards. The type of correlation and the number of participants, for whom the correlation was calculated, were also coded. Alternatively, Cohen’s d for the difference in self-esteem and depressive symptoms of participants with BDD compared to participants without BDD were entered. If Cohen’s d was not reported, the mean and standard deviation of self-esteem and depressive symptom severity, and the number of participants in each comparison group were collected.

Data were coded independently by the first and second author. Interrater agreement was 97% and consensus was achieved after discussion of divergent coding. If studies did not report all data that were needed for the meta-analysis, authors were asked for the missing information. Altogether, 30 authors were contacted (concerning 35 studies) and 17 authors provided the required information (for 20 studies).

The effect sizes in the individual studies might have been subject to bias. We considered the selection of the sample (e.g., clinical BDD patients versus non-clinical students) and the diagnostic method for assessing BDD symptoms (self-report versus clinician-administered) as possible sources of bias. Consequently, these aspects were included in our coding scheme and controlled for in moderator analysis. Furthermore, we dealt with potential selective reporting by contacting all authors of studies which assessed our variables of interest without reporting an effect size for the relationship between BDD symptoms and self-esteem.

Data analysis

Effect sizes for the relationship between BDD symptom severity and self-esteem were calculated in three ways depending on the level of measurement of BDD symptom severity. For the majority of studies ( k  = 21), Fisher’s z transformed Pearson correlations between BDD symptom severity and self-esteem were analyzed. If effect sizes could not be based on a continuous measure of BDD symptom severity, we either used the pointbiseral correlation ( k  = 1) between BDD (coded 1 for BDD and 0 for healthy controls) and self-esteem or Cohen’s d ( k  = 1) which was transformed to Fisher’s z [ 48 , 49 ]. In this case Cohen’s d described the difference in mean self-esteem between participants with BDD compared to participants without BDD. This categorial effect size is not based on the individual values of participants but rather on the group means. Thus, it mirrors the relationship between BDD symptom severity and self-esteem on a less precise group level. Nevertheless, we preferred to integrate these categorial effect sizes in the meta-analysis to achieve an extensive overview of the field and to avoid complete loss of the information. Two studies [ 12 , 50 ] followed an ordinal approach and reported correlations between the number of items endorsed on the BDDQ and self-esteem. As this represents a gain in information compared to mere nominal data, this procedure was applied for studies which used the BDDQ.

If possible, an effect size for the total sample (instead of separate effect sizes for the subgroups) was gathered. Still, samples with varying ranges of BDD symptom severity were examined. In some cases, this may have caused underestimation of the true effect, whereas in others the magnitude of the relationship might have been overestimated [ 51 ]. Restriction of range in samples with reduced variance of BDD symptom severity (e.g., only clinical BDD participants) may have led to underestimation of the true effect. Enhancement of range and corresponding overestimation of effect sizes may have been produced by comparison of extreme groups (BDD patients versus healthy controls). A meta-analysis without artifact correction was conducted to describe the actual observed effects. Additionally, we attempted to correct for the artifacts. Thereby, we intended to achieve an estimate of the effect scaled on the general population without variance restrictions. For this purpose, studies with potentially restricted or enhanced range of BDD symptom severity were identified on the basis of theoretical assumptions concerning the sample. The individual correlations of these studies were adjusted before conducting a meta-analysis using standard corrections for variance restrictions [ 52 ]. For the adjustment, an estimate of the standard deviation of the BDD symptom severity measure in the general population was used and applied to all studies included. If possible, this was drawn from studies with large community samples.

For the calculation of partial correlations between BDD symptom severity and self-esteem controlling for depressive symptom severity, Pearson correlations between BDD symptom severity and depressive symptom severity, as well as between self-esteem and depressive symptom severity were conducted and preprocessed in the same manner as described above. The partial correlations controlling for depressive symptom severity were also Fisher’s z transformed for a subsequent meta-analysis. A meta-analysis of (z-transformed) partial correlations was also conducted with and without artifact correction.

A random effects meta-analysis was chosen to account for heterogeneity in effect sizes across studies. The computation was performed in R [ 53 ] using the metafor package [ 54 ] . For the assessment of effect size variability I 2 and τ were used. A moderator analysis was conducted to examine the influence of participants’ mean age, percentage of females, sample type, diagnostic method, and BDD diagnosis on effect sizes. An alpha level of α = .05 was applied. To visualize a potential publication bias, we created funnel plots.

Study characteristics

The process of study selection with the number of records screened and excluded at each stage is presented in the PRISMA flow diagram in Fig.  1 [ 31 ]. Altogether, 25 studies (and 27 effect sizes) with a total number of 6278 participants were included in the meta-analysis. The mean age was 26.35 with a mean percentage of females of 69.62%. Regarding the sample type, four samples were drawn from individuals with clinical BDD ( n  = 239), three from mentally healthy control participants and individuals with clinical BDD ( n  = 128), and five from cosmetic surgery settings ( n  = 614). Further, nine student samples ( n  = 3463), two community samples ( n  = 423), and three community samples with large proportions of students ( n  = 1310) were analyzed. For nine studies BDD was diagnosed by a clinician either prior to or during study participation. Twelve effect sizes were based on clinician-rated measures of BDD symptoms whereas 14 relied on self-report measures (for one study no precise information was available whether the BDD-YBOCS was administered by a clinician or applied as a self-report questionnaire). Seventeen studies assessed depressive symptoms and could be included in the meta-analysis of partial correlations. Table  1 provides an overview of the study characteristics and effect sizes which were extracted from the studies.

PRISMA flow diagram illustrating the process of study selection

Meta-analysis of zero-order correlations

The meta-analysis of uncorrected zero-order correlations between BDD symptom severity and self-esteem yielded an overall effect size of r  = −.42, CI  = [−.48, −.35]. The Fisher’s z-transformed effect estimates and confidence intervals for the individual studies as well as the Fisher’s z-transformed overall effect size are illustrated in Fig.  2 . With regard to heterogeneity, I 2 amounted to 85.87% and τ was .17, indicating substantial variability of effect sizes.

Forest plot of Fisher’s z-transformed correlations between BDD symptom severity and self-esteem

When correcting for variance restriction and enhancement of BDD symptom severity, a mean weighted correlation of r  = −.45, CI  = [−.51, −.39] was observed. The artifact-corrected Fisher’s z-transformed zero-order correlations and the corresponding overall effect size estimate are visualized in Fig.  3 . The I 2 of 82.38% and τ = .14 implied considerable heterogeneity. The standard deviation estimates for the BDD symptom severity measures which were used for artifact correction can be found in the appendix (Additional file  2 ).

Forest plot of Fisher’s z-transformed correlations between BDD symptom severity and self-esteem (corrected for variance restriction and enhancement of BDD symptom severity)

Meta-analysis of partial correlations

In the meta-analysis of uncorrected partial correlations between BDD symptom severity and self-esteem controlling for depressive symptom severity a mean weighted effect size of pr  = −.20, CI  = [−.25, −.15] was achieved. The forest plot of Fisher’s z-transformed partial correlations and confidence intervals for the individual studies and the total estimate are displayed in Fig.  4 . Investigation of heterogeneity resulted in I 2  = 37.28% and τ = .06.

Forest plot of Fisher’s z-transformed partial correlations between BDD symptom severity and self-esteem controlling for depressive symptom severity

Basing the meta-analysis on the artifact-corrected partial correlations revealed a mean weighted effect size of pr  = −.23, CI  = [−.28, −.17]. Fisher’s z transformed coefficients and confidence intervals are presented in Fig.  5 . This analysis produced an I 2 of 40.33% and τ = .06.

Forest plot of Fisher’s z-transformed partial correlations between BDD symptom severity and self-esteem controlling for depressive symptom severity (corrected for variance restriction and enhancement of BDD symptom severity)

Moderator analysis

The results of the moderator analysis for the meta-analysis of uncorrected zero-order correlations are presented in Table  2 . The mean age of the sample, the percentage of females, and the diagnostic method did not show a significant influence on the magnitude of effect sizes in any of the analyses. The sample type turned out to be a significant moderator in the meta-analysis of uncorrected zero-order correlations ( F (3, 22) = 4.83, p  < .01). The weighted effect size estimates were z  = −.40, CI  = [−.58, −.22] for clinical BDD samples, z  = −.83, CI  = [− 1.06, −.60] for combined samples of mentally healthy control participants and individuals with clinical BDD, z  = −.39, CI  = [−.46, −.32] for student and community samples (which were analyzed as one category in the moderator analysis), and z  = −.40, CI  = [−.54, −.25] for the cosmetic surgery samples. The effect sizes for combined samples of clinical BDD and mentally healthy control participants differed significantly from the clinical BDD samples when contrasted in a dummy-coded moderator analysis (cf., Table 2 ). However, the moderation effect of the sample type was no longer significant for the artifact-corrected zero-order correlations. The weighted effect size estimates for the artifact-corrected zero-order correlations amounted to z  = −.59, CI  = [−.80, −.38] for clinical BDD samples, z  = −.67, CI  = [−.97, −.37] for combined samples of mentally healthy control participants and individuals with clinical BDD, z  = −.46, CI  = [−.55, −.37] for student and community samples, and z  = −.45, CI  = [−.63, −.27] for the cosmetic surgery samples. Regarding the partial correlations, the moderation effect of the sample type was no longer significant. Even more so, effect sizes for the different sample types were very much aligned after artifact correction ( z  = −.24, CI  = [−.45, −.04] for clinical BDD samples, z  = −.27,. CI  = [−.52, −.02] for combined samples of mentally healthy control participants and individuals with clinical BDD, z  = −.23, CI  = [−.30, −.15] for student and community samples, z  = −.21, CI = [−.37, −.05] for the cosmetic surgery samples) compared to the uncorrected weighted partial correlations ( z  = −.16, CI  = [−.36, .03] for clinical BDD samples, z  = −.32, CI  = [−.54, −.11] for combined samples of mentally healthy control participants and individuals with clinical BDD, z  = −.20, CI  = [−.27, −.14] for student and community samples, z  = −.18, CI  = [−.32, −.03] for the cosmetic surgery samples). BDD diagnosis emerged as a significant moderator in the meta-analysis of uncorrected zero-order correlations (cf., Table 2 ). More precisely, studies in which BDD was diagnosed by a clinician prior to or during study participation appeared to have higher negative correlations between BDD symptom severity and self-esteem compared to studies without clinician-rated BDD diagnoses. However, this was no longer significant in all other analyses ( b  = −.118, CI  = [−.278, .043], p  = .144 for corrected zero-order correlations). In an attempt to explore other factors which could explain the heterogeneity of effect sizes, we additionally conducted moderator analysis with the year of publication and examined differences between different measures of BDD symptom severity. None of these analyses had significant explanatory value.

Publication bias

The funnel plots were rather symmetrical and did not point to any publication bias. Single effect sizes were positioned outside of the funnel which was in line with the heterogeneity of effect sizes, in particular with regard to the effect of the sample type. The funnel plots are attached as supplementary information (Additional files 3 , 4 , 5 , 6 ).

We examined the relationship between BDD symptom severity and global self-esteem, while also investigating the role of depressive symptoms and other moderating factors. Regarding our three research questions, the following results were obtained: First, a moderate negative relationship between BDD symptom severity and self-esteem was revealed in meta-analyses of uncorrected and corrected zero-order correlations. Thus, the current state of research suggests that with increasing BDD symptoms self-esteem appears to be lowered. This is in line with previous findings from individual studies suggesting that BDD is often accompanied by low self-esteem (e.g., [ 3 ]). Thus, it appears negative evaluation in BDD is not limited to appearance but also extends to other domains of the self. Our results corroborate the role of appearance as an idealized value and dominating aspect in defining the self. Our results also provide an empirical basis for negative core beliefs (e.g., “I am worthless.”, “If my appearance is defective then I am worthless.”) that are often described as part of cognitive-behavioral models of BDD [ 62 , 63 , 64 ]. Furthermore, our findings are consistent with studies on other disorders that have also found a relationship between self-esteem and psychopathology [ 65 ].

Second, the negative relationship between BDD symptom severity and global self-esteem was only partly explained by depressive symptom severity. The meta-analyses of uncorrected and corrected partial correlations demonstrated that there was still a negative, though smaller, relationship beyond the influence of depressive symptoms. Thus, higher levels of BDD symptoms appear to be associated to lower levels of self-esteem even after controlling for depressive symptoms. This might be interpreted as a connection between appearance concerns and global self-esteem which is maintained after partialling out the distress and impairment due to depressive symptoms. It corresponds to findings on the association between body image or body dissatisfaction and self-esteem (e.g., [ 66 , 67 ]). Moreover, the results could imply that individuals suffering from BDD symptoms and comorbid depressive symptoms might have particularly low self-esteem.

Third, the relationship between BDD symptom severity and self-esteem turned out to be stable across samples with varying mean age of participants and percentage of females. However, it should be noted that the mean age was rather young in most of the samples and the majority of samples consisted of more female than male participants. Consequently, there might have been too less variation to examine potential effects of these two moderators. Further, the overall effect size was robust regardless of the diagnostic method for the assessment of BDD symptom severity. This suggests that self-report and clinician-administered instruments for the assessment of BDD symptoms were equally capable of capturing the effect. With regard to the sample type, the combined samples of individuals with clinical BDD and mentally healthy control participants showed high negative uncorrected correlations compared to moderate negative uncorrected correlations for the other sample types. However, estimates of corrected correlations were more similar across samples types. Particularly for combined samples of individuals with BDD and mentally healthy controls the correlation was reduced after artifact correction, whereas it was noticeably raised in clinical BDD samples. This suggests that the effect of the sample type was caused by variance restriction and enhancement and not by actual differences between the sample types. Regarding the mean weighted partial correlations, effect sizes for the different sample types were very much aligned after artifact correction. The significant effect of the moderator BDD diagnosis on the uncorrected zero-order correlations might suggest that samples which included participants with diagnosed BDD tended to demonstrate higher negative correlations than student or community samples without clinical diagnostics. However, as this effect was much smaller and not significant for the corrected correlations, it is likely that range restriction/enhancement artifacts also contributed to this finding.

We observed substantial variations in effect sizes with regard to the meta-analyses of zero-order correlations. One explanation for this heterogeneity may be the influence of depressive symptom severity on the relationship between BDD symptom severity and self-esteem. The mean weighted partial correlations which were smaller than the mean weighted zero-order correlations and the substantially reduced amount of heterogeneity in the meta-analyses of partial correlations support this explanation. Other moderators that we considered to possibly have an impact on the systematic variation of effect sizes seemed to be not relevant or only in the context of a statistical artifact caused by relative range restrictions/enhancements. Since the included studies did not provide sufficient information on comorbidities, personality disorders, or medication, these variables could not be investigated. Also, we were not able to examine associated factors such as insight. Furthermore, cultural aspects might play a role and could not be controlled for in the analyses. For instance, the study by Ahmadpanah et al. [ 13 ] stands out with a correlation between BDD symptom severity and global self-esteem of only r  = −.04. This study was conducted in an Iranian sample in which according to the authors the face, hair, and body shape are often covered and not visible for others [ 13 ]. Thus, cultural effects need to be considered when trying to understand the relationship between BDD symptoms and self-esteem. Further, the use of social media or bullying experiences might also act as moderators and their impact should be clarified in future studies.

Limitations

The present meta-analysis has several limitations. First, we included studies using detailed clinician-administered measures of BDD symptom severity as well as shorter self-report screening instruments. These are of course not equally valid in assessing BDD symptom severity. For example, self-report measures might fail to differentiate BDD symptoms from preoccupation about actual defects (e.g., acne, scars) or weight-based concerns in the context of an eating disorder. Four of the 14 studies which applied self-report BDD measures tried to control for eating disorders. One of these studies excluded participants with elevated symptoms of an eating disorder [ 56 ], one study assessed comorbidities and reported that none of the participants were suffering from a comorbid eating disorder [ 6 ], one study excluded participants with a past or present eating disorder according to self-report [ 22 ], and one study ruled out the presence of any mental disorder according to self-report [ 11 ]. In order to address this limitation, we investigated the influence of the diagnostic method in moderator analysis. The diagnostic method appeared to have no systematic influence on the magnitude of effect sizes. On the one hand, this could imply that self-report measures were equally capable of capturing the relationship between BDD symptoms and self-esteem. On the other hand, this could signify that a preoccupation with actual appearance defects or weight-based concerns show a similar association with global self-esteem. Since this is the first meta-analysis on BDD and self-esteem we preferred to include all studies assessing BDD symptoms and self-esteem and controlled for the diagnostic method in moderator analysis.

Second, concerning the assessment of global self-esteem, this meta-analysis relied on the Rosenberg Self-esteem Scale [ 4 ] and considered the level of self-esteem only. Thus, we cannot determine whether other definitions and operationalizations of self-esteem demonstrate the same pattern of results. We were not able to examine contingencies and instability of self-esteem and their associations with BDD symptoms, since most of the primary studies did not assess these aspects of self-esteem.

Third, no causal inference can be drawn from our correlational findings. It remains unclear whether low self-esteem represents a vulnerability for BDD or develops as a consequence of the disorder (cf., [ 3 ]). Orth and Robins described different models for linking low self-esteem to depression [ 20 ] and these models might also apply to the relationship between BDD and self-esteem. Apart from unidirectional pathways, reciprocal relations or a common cause (e.g., bullying experiences) of both variables are possible. Moreover, a diathesis-stress model might be appropriate in which only under certain conditions low self-esteem leads to elevated BDD symptoms. Also, if low self-esteem predisposed BDD symptoms, mediating (e.g., social avoidance) and moderating variables (e.g., instability of self-esteem) might have an effect. Schulte et al. investigated the temporal dynamics of insight, affect, and self-esteem in BDD over six consecutive days and found that the cross-lagged effect of state self-esteem on insight was stronger than the effect of insight on state self-esteem [ 68 ]. Altogether, more studies are required to investigate causal directions.

Fourth, we included studies with varying ranges of BDD symptom severity. This may have led to overestimation of effect sizes for extreme group comparisons and underestimation of the effect in clinical samples. We tried to adjust effect sizes using variance corrections. However, in the absence of standard deviation norms for the individual BDD measures in the general population, we used standard deviation estimates from community samples if these were available or had to rely on student samples. Therefore, the results of the meta-analysis of corrected correlations have to be interpreted with caution, and the corrections need to be regarded as an imperfect attempt to deal with the heterogeneous samples.

Fifth, we were only able to exploratively investigate moderators for which sufficient information was provided in the studies. For instance, we could not control for effects of medication, comorbidities, or personality disorders. Hence, moderator analysis should be replicated in the future with a larger number of studies and variability of moderators.

Future directions

Future studies may examine causal directions concerning the relationship between BDD symptom severity and self-esteem. Furthermore, future research may seek to identify subgroups in which BDD symptoms are associated with particularly low self-esteem, as these groups might benefit from self-esteem interventions. In this regard, it could be important to consider different developmental phases and the impact of depressive symptoms. It might also be helpful to examine whether low self-esteem can help to distinguish individuals with BDD from individuals without BDD among cosmetic surgery patients. Moreover, future studies should focus on different aspects of self-esteem. For instance, Buhlmann et al. investigated implicit self-esteem [ 5 , 6 ], whereas B. Phillips et al. examined contingent self-esteem in BDD [ 10 ]. More research on contingencies and stability of self-esteem in BDD is required. With regard to prevention and therapy of BDD, an important step will be to evaluate the specific effects of interventions targeting self-esteem. In their network analysis of BDD and major depressive disorder Summers et al. revealed a high centrality of feelings of worthlessness and discussed implications for treatment such as addressing maladaptive core beliefs about self-worth [ 18 ]. Hence, future work may further try to determine the role of feelings of worthlessness in etiology, maintenance, and treatment of BDD. Furthermore, future trials may compare the effects of interventions intended to boost self-esteem and enhance self-compassion. In particular, focusing on self-compassion may entail certain benefits because it appears to be independent of personal achievements and success and thereby may result in more stable self-evaluations and reduced processes of comparing oneself to others (e.g., in the domain of appearance) [ 69 ]. Higher levels of self-compassion were associated with fewer BDD symptoms in a sample of adolescents [ 70 ]. Veale and Gilbert proposed to improve current treatments for BDD by developing a functional and evolutionary understanding of the BDD symptoms and by learning to relate to oneself and others with compassion and kindness [ 71 ]. These strategies from compassion-focused therapy [ 72 , 73 ] might complement or enhance cognitive approaches.

Altogether, our findings demonstrate that low self-esteem appears to be an important feature in BDD, particularly when not controlling for depressive symptoms. Consequently, addressing self-esteem and corresponding core beliefs is of high importance in the treatment of BDD. This emphasizes the value of cognitive restructuring and interventions such as the self-esteem pie by which one tries to reduce the overidentification with appearance and develop a more balanced basis of one’s self-esteem [ 63 ]. In this regard, a study by Rosen and Reiter found that decreases in BDD symptoms (as measured by the BDDE) after cognitive-behavioral therapy were associated with improvements in self-esteem [ 34 ]. Furthermore, depending on whether low self-esteem acts as a risk factor or as a consequence of BDD, self-esteem interventions might play a crucial role in the prevention of BDD. Low self-esteem during adolescence predicted adult psychopathology in a longitudinal birth cohort development study [ 74 ]. Consequently, BDD prevention programs might benefit from interventions targeted at cognitive and social determinants of low self-esteem (cf., [ 75 ]). This might buffer against the development of a negative bias in evaluating oneself which appears to be present in adolescents with high appearance anxiety [ 19 ]. Taken together, our results show that BDD is characterized by low self-esteem and highlight the importance of interventions targeting low self-esteem.

Availability of data and materials

The extracted data used for the meta-analysis are available at our Open Science Framework (OSF) data repository ( https://osf.io/z52fc/ ).

Abbreviations

• Body dysmorphic disorder

4th edition of the Diagnostic and Statistical Manual of Mental Disorders

5th edition of the Diagnostic and Statistical Manual of Mental Disorders

Yale-Brown Obsessive Compulsive Scale for Body Dysmorphic Disorder

Body Dysmorphic Disorder Examination

Body Dysmorphic Symptoms Inventory (Fragebogen körperdysmorpher Symptome)

Questionario sul Dismorfismo Corporeo

Dysmorphic Concern Questionnaire

Body Dysmorphic Disorder Questionnaire

Body Dysmorphic Disorder Diagnostic Module

Rosenberg Self-Esteem Scale

Beck Depression Inventory

Hamilton Depression Rating Scale

Depression subscale of the Depression Anxiety Stress Scales

Depression subscale of the Hospital Anxiety and Depression Scale

Depression subscale of the Symptom Checklist-90

Patient Health Questionnaire-9 Depression module

Cochrane Central Register of Controlled Trials

WHO International Clinical Trials Registry Platform

Body Dysmorphic Disorder Examination - Self Report

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Acknowledgements

We would like to thank Laura Brockhoff and Martje Kohlhoff for their assistance in literature search and study selection.

The first author was partly supported by a PhD fellowship from the German Academic Scholarship Foundation. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Open Access funding enabled and organized by Projekt DEAL.

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Conceptualization: NK UB. Data Curation: NK LC PCB. Formal Analysis: PCB NK. Funding Acquisition: NK UB. Investigation: NK LC. Methodology: NK UB PCB. Project Administration: NK. Resources: UB. Software: PCB. Supervision: UB. Validation: NK PCB LC. Visualization: PCB NK. Writing – Original Draft: NK. Writing – Review & Editing: NK UB SW PCB LH. The authors read and approved the final manuscript.

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SW is a presenter for the Massachusetts General Hospital Psychiatry Academy in educational programs supported through independent medical education grants from pharmaceutical companies; she has received royalties from Elsevier Publications, Guilford Publications, New Harbinger Publications, Springer, and Oxford University Press. SW has also received speaking honoraria from various academic institutions and foundations, including the International Obsessive Compulsive Disorder Foundation, Tourette Association of America, and Brattleboro Retreat. In addition, she received payment from the Association for Behavioral and Cognitive Therapies for her role as Associate Editor for the Behavior Therapy journal, as well as from John Wiley & Sons, Inc. for her role as Associate Editor on the journal Depression & Anxiety. SW has also received honorarium from One-Mind for her role in PsyberGuide Scientific Advisory Board. SW has received salary support from Novartis and Telefonica Alpha, Inc. All other authors do not have any competing interests.

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PRISMA Checklist.

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Standard deviation estimates for the BDD symptom severity measures used for artifact correction.

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Funnel plot for the meta-analysis of uncorrected zero-order correlations.

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Funnel plot for the meta-analysis of artifact-corrected zero-order correlations.

Additional file 5.

Funnel plot for the meta-analysis of uncorrected partial correlations.

Additional file 6.

Funnel plot for the meta-analysis of artifact-corrected partial correlations.

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Kuck, N., Cafitz, L., Bürkner, PC. et al. Body dysmorphic disorder and self-esteem: a meta-analysis. BMC Psychiatry 21 , 310 (2021). https://doi.org/10.1186/s12888-021-03185-3

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Body Dysmorphic Disorder

Reviewed by Psychology Today Staff

Body dysmorphic disorder is a type of obsessive-compulsive disorder. An individual with body dysmorphic disorder is overly preoccupied with what are perceived as gross imperfections in their appearance and spends an hour or more every day thinking about the way they look. In reality, the imperfections are imagined or only slight and barely noticed by others, if at all. The affected person may be obsessed with certain body parts, particularly related to their face or head, or with their weight or body shape.

The symptoms of body dysmorphic disorder often begin in the early teens or even childhood , and are all related to the person’s appearance.

According to DSM-5 , the symptoms of body dysmorphic disorder include:

• Preoccupation with one or more perceived defects in physical appearance that are not observable to others.
• Performance of repetitive behaviors—such as checking the mirror, excessive grooming, skin picking, reassurance-seeking—or such mental acts as comparing one's appearance with that of others in response to appearance concerns.
• Clinically significant distress or impairment in functioning caused by the preoccupation.

Individuals with body dysmorphic disorder are constantly checking themselves in the mirror, grooming excessively, over-exercising, skin picking, or hair plucking—and comparing themselves to others. In addition to an extreme obsession with their looks, people with body dysmorphic disorder try to hide their perceived flaws by holding their body in certain ways, covering up with make-up or clothing, or trying to improve their imagined defects, sometimes with multiple plastic surgeries or other cosmetic practices.

Even when steps are taken to make improvements, the person is still unhappy with their appearance. The obsession, repetitive behavior, and the constant covering up create stress for the affected individual and can have a negative impact on daily functioning and quality of life. Major depression is common in those with body dysmorphic disorder, as are suicidal thoughts and behavior.

Some of the most common faulty thoughts that afflict individuals with body dysmorphic disorder include that they are ugly, that others are making fun of how they look, how they compare to other people, the importance of their aesthetic appearance, fixation on a tiny, single feature, and how they might make themselves feel safer, such as by avoiding eye contact or camouflaging a real or perceived flaw.

Many do. People with body dysmorphic disorder represent 2.4 percent of the population but 13 percent of cosmetic surgery patients, research suggests. Yet the disorder is one of body image , so cosmetic treatments typically do not solve the patient’s concerns .

Body dysmorphic disorder has a genetic component, because the likelihood of the condition is higher for those who have a first-degree relative with obsessive-compulsive disorder. Environmental factors also come into play: Individuals with body dysmorphic disorder often have a history of child abuse, neglect, or some other childhood trauma and may also have a parent or sibling with an anxiety disorder.

Those with the condition may also have an anxiety disorder, such as obsessive-compulsive disorder or social anxiety , a personality disorder , or issues with substance abuse . Body dysmorphic disorder is not an eating disorder , though both conditions exhibit similarly severe and abnormal body image concerns and self-esteem issues.

About 2.4 percent of adults in the U.S. have body dysmorphic disorder, according to the DSM-5. The prevalence is 2.5 percent among women and 2.2 percent among men.

The most common age of onset is 12 to 13 years old, and the median age of onset is 15, according to the DSM-5. The symptoms typically emerge gradually, and they are similar in children, adolescents, and adults.

Cognitive-behavioral therapy and antidepressant medication —particularly selective serotonin reuptake inhibitors, or SSRIs—are the primary treatments used to relieve symptoms of body dysmorphic disorder. Often, both therapies are employed in combination.

The goal of treatment is to reduce or eliminate obsessive and compulsive behaviors , to foster recognition of triggers, and to improve management of the stress associated with the behavior. In addition, a major goal of therapy is to help patients learn to view themselves in a non-judgmental fashion. To control symptoms and prevent relapse , treatment may continue for years.

A trained mental health professional can diagnose body dysmorphic disorder based on the criteria listed in the DSM-5, such as preoccupation with perceived flaws and repetitive behaviors such as excessive grooming, mirror-checking, and reassurance-seeking. The clinician may also assess the patient’s medical history and family history.

Mirror exposure therapy is a treatment that can accompany cognitive-behavioral therapy. It includes exercises such as observing oneself in the mirror, describing the body in neutral and objective terms, and exploring the emotions that arise. A recent review found that mirror exposure therapy generally reduces stress, negative thoughts, and body dissatisfaction for those with body dysmorphia and eating disorders.

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• Body dysmorphic disorder

Body dysmorphic disorder is a mental health condition in which you can't stop thinking about one or more perceived defects or flaws in your appearance — a flaw that appears minor or can't be seen by others. But you may feel so embarrassed, ashamed and anxious that you may avoid many social situations.

When you have body dysmorphic disorder, you intensely focus on your appearance and body image, repeatedly checking the mirror, grooming or seeking reassurance, sometimes for many hours each day. Your perceived flaw and the repetitive behaviors cause you significant distress and impact your ability to function in your daily life.

You may seek out numerous cosmetic procedures to try to "fix" your perceived flaw. Afterward, you may feel temporary satisfaction or a reduction in your distress, but often the anxiety returns and you may resume searching for other ways to fix your perceived flaw.

Treatment of body dysmorphic disorder may include cognitive behavioral therapy and medication.

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Signs and symptoms of body dysmorphic disorder include:

• Being extremely preoccupied with a perceived flaw in appearance that to others can't be seen or appears minor
• Strong belief that you have a defect in your appearance that makes you ugly or deformed
• Belief that others take special notice of your appearance in a negative way or mock you
• Engaging in behaviors aimed at fixing or hiding the perceived flaw that are difficult to resist or control, such as frequently checking the mirror, grooming or skin picking
• Attempting to hide perceived flaws with styling, makeup or clothes
• Constantly comparing your appearance with others
• Frequently seeking reassurance about your appearance from others
• Having perfectionist tendencies
• Seeking cosmetic procedures with little satisfaction
• Avoiding social situations

Preoccupation with your appearance and excessive thoughts and repetitive behaviors can be unwanted, difficult to control and so time-consuming that they can cause major distress or problems in your social life, work, school or other areas of functioning.

You may excessively focus over one or more parts of your body. The bodily feature that you focus on may change over time. The most common features people tend to fixate about include:

• Face, such as nose, complexion, wrinkles, acne and other blemishes
• Hair, such as appearance, thinning and baldness
• Skin and vein appearance
• Breast size
• Muscle size and tone

A preoccupation with your body build being too small or not muscular enough (muscle dysmorphia) occurs almost exclusively in males.

Insight about body dysmorphic disorder varies. You may recognize that your beliefs about your perceived flaws may be excessive or not be true, or think that they probably are true, or be absolutely convinced that they're true. The more convinced you are of your beliefs, the more distress and disruption you may experience in your life.

When to see a doctor

Shame and embarrassment about your appearance may keep you from seeking treatment for body dysmorphic disorder. But if you have any signs or symptoms, see your health care provider or a mental health professional.

Body dysmorphic disorder usually doesn't get better on its own. If left untreated, it may get worse over time, leading to anxiety, extensive medical bills, severe depression, and even suicidal thoughts and behavior.

If you have suicidal thoughts

Suicidal thoughts and behavior are common with body dysmorphic disorder. If you think you may hurt yourself or attempt suicide, get help right away:

• In the U.S, call 911 or your local emergency number immediately.
• Contact a suicide hotline. In the U.S., call or text 988 to reach the 988 Suicide & Crisis Lifeline , available 24 hours a day, seven days a week. Or use the Lifeline Chat . Services are free and confidential.
• Call your mental health professional.
• Seek help from your primary care provider.
• Reach out to a close friend or loved one.
• Contact a minister, spiritual leader or someone else in your faith community.

It's not known specifically what causes body dysmorphic disorder. Like many other mental health conditions, body dysmorphic disorder may result from a combination of issues, such as a family history of the disorder, negative evaluations or experiences about your body or self-image, and abnormal brain function or abnormal levels of the brain chemical called serotonin.

Risk factors

Body dysmorphic disorder typically starts in the early teenage years and it affects both males and females.

Certain factors seem to increase the risk of developing or triggering body dysmorphic disorder, including:

• Having blood relatives with body dysmorphic disorder or obsessive-compulsive disorder
• Negative life experiences, such as childhood teasing, neglect or abuse
• Certain personality traits, such as perfectionism
• Societal pressure or expectations of beauty
• Having another mental health condition, such as anxiety or depression

Complications

Complications that may be caused by or associated with body dysmorphic disorder include, for example:

• Low self-esteem
• Social isolation
• Major depression or other mood disorders
• Suicidal thoughts or behavior
• Anxiety disorders, including social anxiety disorder (social phobia)
• Obsessive-compulsive disorder
• Eating disorders
• Substance misuse
• Health problems from behaviors such as skin picking
• Physical pain or risk of disfigurement due to repeated surgical interventions

There's no known way to prevent body dysmorphic disorder. However, because body dysmorphic disorder often starts in the early teenage years, identifying the disorder early and starting treatment may be of some benefit.

Long-term maintenance treatment also may help prevent a relapse of body dysmorphic disorder symptoms.

• Body dysmorphic disorder. In: Diagnostic and Statistical Manual of Mental Disorders DSM-5. 5th ed. American Psychiatric Association; 2013. https://dsm.psychiatryonline.org. Accessed Aug. 17, 2021.
• Body dysmorphic disorder (BDD). Office on Women's Health. https://www.womenshealth.gov/mental-health/mental-health-conditions/body-dysmorphic-disorder. Accessed Aug. 18, 2021.
• Body dysmorphic disorder. Merck Manual Professional Version. https://www.merckmanuals.com/professional/psychiatric-disorders/obsessive-compulsive-and-related-disorders/body-dysmorphic-disorder?query=Body%20Dysmorphic%20Disorder#. Accessed Aug. 18, 2021.
• Hong K, et al. Pharmacological treatment of body dysmorphic disorder. Current Neuropharmacology. 2019; doi:10.2174/1570159X16666180426153940.
• Krebs G, et al. Recent advances in understanding and managing body dysmorphic disorder. Evidence Based Mental Health. 2017; doi:10.1136/eb-2017-102702.
• Dong N, et al. Pharmacotherapy in body dysmorphic disorder: Relapse prevention and novel treatments. Expert Opinion on Pharmacotherapy. 2019; doi:10.1080/14656566.2019.1610385.
• Lifeline Chat. National Suicide Prevention Lifeline. https://suicidepreventionlifeline.org/chat/. Accessed Aug. 18, 2021.
• For people with mental health problems. MentalHealth.gov. https://www.mentalhealth.gov/talk/people-mental-health-problems. Accessed Aug. 18, 2021.
• Mental Health: Managing stress. National Alliance on Mental Illness. https://www.nami.org/Your-Journey/Individuals-with-Mental-Illness/Taking-Care-of-Your-Body/Managing-Stress. Accessed Aug. 18, 2021.
• Sawchuk CN (expert opinion). Mayo Clinic. Aug. 30, 2021.

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