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I expect that many people reading this article will have heard of body dysmorphic disorder, commonly known as BDD or my less favoured media term ‘body dysmorphia’. However, I wonder how many have been able to access or received any specific training on this condition? BDD affects around one in 50 people of all genders (men and women almost equally), making it more common than many other well-known conditions such as anorexia and obsessive compulsive disorder (OCD),¹ however it is far behind these in terms of understanding and research.² It is commonly misunderstood as a form of eating disorder.

I know this only too well, as when I was first in the grips of this debilitating condition no one had any idea what was wrong with me, and I spent many years getting steadily worse before a family friend watched a BBC documentary highlighting the condition. I was finally able to secure a diagnosis and crucially get specialised help. I had been struggling since my early teens but various wellmeaning counsellors hadn’t been able to recognise my symptoms. My story isn’t unique – in fact I was very lucky as most people have to wait 10 to 15 years before receiving a diagnosis.^3,4 Finally receiving therapy with someone who had knowledge of BDD gave me a route through that was quite simply life-saving. Sadly one in four people with BDD will make an attempt on their life, with the suicide rate being 45 times higher than that of the general population.^5Ìý

What is BDD? 

BDD is described in the DSM-5-TR as a ‘preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others’.⁶ The concern with the perceived flaw causes significant distress while impacting daily functioning, such as socialising, schooling or employment. To be considered BDD, the focus of distress should be broader than just a focus on weight and size, which would fall under an eating disorder category. Any aspect of the body can be the focus of preoccupation, and it can be multiple areas, but the most common are the skin, nose and hair. Generally it is some aspect from the neck up. Sometimes restrictive eating can be employed, but the motivation is not to control the weight on the scales, it is with the hope of changing how their perceived flaw looks. For example, restrictive eating might be used to try to clear skin, have a leaner jaw or through a fear of staining the teeth. The key to determining the difference is discovering what is motivating the eating behaviours. Common symptoms for BDD are obsessively worrying about their appearance, long grooming routines, trying to conceal the perceived flaw (make-up, clothing, posture, lighting), compulsive mirror checking (or avoidance), frequent reassurance seeking, avoiding social situations and pursuing dermatological or cosmetic procedures. 

Prior to treatment I had been struggling to leave the house and spending many hours of the day compulsively redoing my make-up and hair in the hope that I could look acceptable to be seen by others. It was torturous – at my worst I was at the mirror for eight hours before finally giving up and getting back into bed. My whole body was aching from standing up the entire time, leaning into the mirror. It was utterly demoralising. Thankfully, through the right kind of therapy, I was able to slowly reduce my obsessive behaviours and start gently facing my fears. I was able to go to university and start full-time work. However, in my late 20s I had a major relapse and ended up housebound for six months. It was from this point that I became focused on understanding my condition, and in the process developed a passion for helping others. This led to my current position as Managing Director of the Body Dysmorphic Disorder Foundation. I also chose to retrain as a therapist, with my MSc research focused on integrative therapeutic approaches to this condition.

Over the past few years I have seen a boom in media coverage of BDD that I believe is fuelling an increase in individuals self-diagnosing and trying to access help. However, there are still so few clinicians who feel confident in how to approach treatment, and I hear time and time again from people who’ve struggled to get the right support on the NHS. 

Therapy Today, May 2025

Related conditions

As you may have picked up from my description of the common symptoms, BDD is considered a related condition to OCD. This has been helpful in getting BDD on the map, but it has also meant that some of the significant differences have been overlooked. Insight is sadly very low, with 70% of those with BDD considered delusional.⁷ This is far higher than those with OCD. This means that often therapists are starting from a very different position to their clients, most of whom will strongly believe that the main problem is their appearance, rather than psychological. Many will seek multiple cosmetic treatments before considering psychological support. There is good reason for this, as for all humans, we believe what we see. Individuals with BDD are literally seeing themselves differently from how others view them. As such, the term ‘delusional’ is, in my opinion, outdated for this condition as it is not a delusional disorder, or due to psychosis (another common misdiagnosis). It is actually due to neurobiological differences with visual processing.⁸ People with BDD have been shown to hyper-focus on detail, struggling to see the ‘big-picture’. Research also shows that they often misread facial expressions, misinterpreting neutral expressions as showing disgust or anger. Therapists with experience in treating OCD often report that when trying to apply the same protocol to BDD they struggle to make the same headway and often have to utilise a range of other techniques, or refer on. 

Laura’s* story 

Prior to private practice I met Laura. She was a very kind and gentle soul. She had struggled with symptoms of BDD since her teens yet had never received any targeted treatment. She had coped through use of marijuana and alcohol to get her through social situations, and even managed to maintain a career. However, her ability to keep going was quickly diminishing, and she was struggling to go into the office or leave her flat. Although she recognised her distress was extreme, she was convinced that there was a significant problem with her face. Within a couple of weeks she had made her first suicide attempt. Luckily this was unsuccessful but it was clear that she needed urgent help. After months of support she received specialised CBT for BDD via the NHS. She made a fantastic recovery, with a new lease on life, a new job and even a new partner. The CBT had seemingly worked a treat. However, unbeknown to many of her loved ones, Laura was still hoping for, and seeking, cosmetic solutions to the concerns she still held around her appearance. Although some of the symptoms of BDD that had been holding her back had diminished, the root concerns around her appearance were still strong. The relatively short course of treatment she received had led to great strides in her recovery but they proved fleeting. At a time when most of those around her felt they could breathe a sigh of relief, little did we know that Laura was falling fast. The cosmetic treatments fuelled and worsened her BDD. I have often wondered if earlier intervention or a longer course of treatment that involved more than CBT would have helped Laura develop more resilience to relapse. Sadly Laura made the desperate decision to take her life before we had the chance to find out, but the experience of knowing her continues to fortify my resolve to support those impacted by this condition.

Shame and identity 

Seventy-nine per cent of people with BDD reported some form of adverse childhood experience (ACE), a higher percentage than OCD.⁹ This could account for the high levels of shame for those with BDD beyond just the shame they experience around how they look.^10,11 A common experience for those with BDD is feeling different, and then somewhere along the way this becomes focused on their physical appearance. Bullying is commonly referenced, but for some it can come from a heightened focus (positive or negative) on their appearance in childhood.¹² There is a sense that they have little value beyond how they look.¹³ BDD symptoms tend to take hold in adolescence, and as a chronic condition tend to get worse over time.¹⁴ These crucial years that most people spend learning who they are, developing values and skills for life are often stolen by the BDD compulsions. Depending on when someone seeks treatment, they may have become very isolated, having struggled to attend school, university or employment. Beyond reducing the overt BDD symptoms of preoccupation and compulsions, the therapist needs to work with the person to develop an identity beyond their appearance.

Arjun’s* story 

Arjun described a happy childhood, and his appearance in his pre-pubescent years was much commented on, being described by family as their ‘gorgeous boy’. Praise centred around his looks rather than other strengths or achievements. His father was very focused on the family being a good reflection of him, and appearance was highly valued. Difficulties started to emerge when Arjun moved to secondary school. He struggled to make friends and was in a predominantly white school. Both of these factors played into the feeling of ‘being different’. Around puberty he also noticed the compliments he had once received about his appearance had stopped, and he even received some teasing from his father. Feelings of shame started to creep in along with thoughts that he wasn’t good enough, and he had intense worries around others negatively judging how he looked. Arjun’s worry fixated around the size of his nose, fearing it was too big and ‘horribly crooked’. He also needed his hair to be styled in a certain way that he felt distracted from his nose. After reaching a point where he was attending school only sporadically, spending hours hiding in his room and struggling to leave the house, his family sought help. It took more than 20 sessions for Arjun to make some headway with his BDD symptoms. It took time for him to entertain the possibility that he was struggling with a mental health condition rather than a physical one. The CBT techniques, including exposure and response prevention (ERP), helped him to reduce his compulsive grooming behaviours and avoidance. However, the shame and feelings of worthlessness persisted for far longer and often led to lapses in symptoms. Through engagement in valued directions, getting involved in other interests such as computer coding, and developing compassion for some of the experiences he had growing up, he was able to cultivate an identity beyond his appearance, and importantly move beyond the shame surrounding feeling different. 

Treatment approaches 

It is important to note that many of the aspects of CBT that have proven effective in the treatment of OCD and social anxiety have also been shown to be helpful for BDD. Useful CBT interventions include ERP, theory A versus theory B, the vicious flower, reducing self-focused attention and looking at thinking processes.¹⁵ However, it often takes significantly longer to get to the point where the client will feel able to engage in ERP, and often they will require far more sessions than individuals with OCD. Practitioners working within the NHS are restricted by tight protocols from NICE guidelines on BDD (due to be updated this year).¹⁶ But for those working in private practice there are a range of other modalities and interventions that can be woven into effective treatment. My research demonstrated that a flexible approach was often crucial to making headway with this tricky condition. Frequently therapists are leaning on third wave CBT approaches such as acceptance and commitment therapy (ACT) to help the client defuse from their intrusive thoughts and utilise their values to face their fears with exposure tasks.^16,17 Compassion-focused therapy (CFT) has been shown to be effective in reducing levels of shame.^18,19 Dialectical behaviour therapy (DBT) can be utilised for those who are particularly high risk in terms of self-harm or suicide, helping the client to better regulate their heightened emotions. Other modalities that are showing promise are internal family systems (IFS) to explain the role that BDD has been playing as a protection mechanism, and EMDR²⁰ or imagery rescripting²¹ for those who have clear traumatic experiences underpinning their BDD. There could also be a place for attachment-based models, considering the prevalence of emotional childhood neglect.²² The crucial consideration is that although CBT has been long proven to be a fundamental component or ‘main dish’ in effective BDD treatment, if you have a client who is struggling to engage or maintain recovery gains don’t be afraid to add in other modalities. Flexibility and the therapeutic relationship are key to the perfect treatment recipe. 

In my case I experienced a major relapse in my late 20s, which left me totally housebound after having made a pretty good recovery around eight years prior. I had a wonderful therapist, and I’d worked hard with my CBT and the homework but something didn’t stick. The BDD symptoms started creeping back until they took over. The distress, anxiety and shame were so overwhelming that I struggled to re-engage in CBT, in particular the ERP. I couldn’t bear to be seen by anyone other than my immediate family. This is a familiar story, with lapses and relapses being relatively common. My experienced therapist had to lean on alternative ways to help me, including encouraging a connection to others in the community. By connecting with others with BDD my isolation and shame reduced, and I developed a core value for helping others that started to supersede my fears around being seen, and I started to re-engage with CBT. A talk by Professor Paul Gilbert on compassionate approaches to body shame was another turning point.²³ A few years later I underwent EMDR therapy to overcome specific experiences from my childhood. 

What I learned, not only through my own experiences but through the countless stories I have heard via the wider BDD community and therapists actively working with this condition, is that BDD is cunning. It has deep roots that need to be weeded out. Compassion, persistence and flexibility are the keys to success, and the good news is that recovery and reclaiming a fulfilling and joyful life from this painful condition are possible. 

* Name and identifiable details have been changed.