On a typical day, Eve* would wake up and start prodding at her body while still in bed. She would avoid catching sight of herself while showering, or while trying to find an outfit to best hide her body.
“The day would usually be spent at work thinking about what to eat or not to eat and worrying about how I appeared to others, making sure I was holding in my stomach or standing or sitting behind something. I would check myself in every reflective surface I passed during my entire waking moments: shop windows, bathrooms, cars, mirrors.”
She would then go home alone to cook, which she dreaded, eating as quickly as possible to get it out of the way. She would then spend about an hour looking at her body, pinching and squeezing it.
“I would usually go to bed sad and angry about my appearance, hating it – wishing I would morph into another body and [thinking] my life would be so much easier.”
For Eve, body dysmorphic disorder (BDD) has been a shadow attached to every thought since childhood. She was often praised for being “pretty” as a child, but the compliments became backhanded as she got older, with suggestions from boys at school, and later men, that she would be more attractive if she were thinner.
“Then I went through puberty and I felt like I changed, like I became a kind of monster.”
Convinced there was something wrong with most of her body – particularly her stomach, thighs and bottom – she embarked on extreme exercise regimes in a bid to change her naturally “hourglass” shape. At 16, Eve became bulimic.
She was driven by “shame, self-loathing and wishful thinking – if I can just change this, I can do all the things I want”.
Now in her 50s, Eve says she had a couple of relationships, but the disorder ultimately led her to push people away; over the years she socialised less to avoid the anxiety of being looked at.
“It’s a hard one because I really longed for connection … but if people told me I was beautiful, I’d think there was something wrong with them: ‘Why would you find me attractive when I’m so revolting?’
“I believed I’d never allow myself to be intimate again as my body was too repulsive, and if a partner saw me naked, they would reject me. I resigned myself to a life of being single.”
What Eve didn’t know then was that no amount of exercise, or even surgery, could change what she saw.
Extreme body dissatisfaction
Although BDD is becoming better known, experts say it is often still confused with poor self-esteem or narcissism, sometimes with devastating results. The disorder involves preoccupation with perceived – but nonexistent or minor – flaws, causing enormous distress and varying repetitive behaviours to hide or “fix” the flaw.
Eighty per cent of sufferers consider suicide and roughly a quarter attempt it.
It is widely cited as affecting about 2% of the general population, making it more prevalent than anorexia and schizophrenia combined. Experts say the true figure could be higher – and rising.
Susan Rossell, an internationally recognised BDD expert, is running a survey to understand its extent in Australia.
“Those prevalence figures are very old and based on [data from] other countries,” says Rossell, a professor of cognitive neuropsychiatry at Swinburne University.
“We’ve noticed a general trend over the last 10 years of an increase in people reporting extreme body image dissatisfaction leading to BDD. But particularly during the pandemic, a range of things there to support us with our everyday lives – we know now are quite triggering for people who have a potential to develop BDD.”
An example is “the Zoom effect”. Rossell and colleagues found one-third of 335 adult surveyed who used video calls during the pandemic reported new concerns about their appearance; they also expressed greater interest in seeking aesthetic procedures.
Dr Katharine Phillips, a professor of psychiatry at New York-Presbyterian and Weill Cornell Medical Center in the US, notes genetics and the environment contribute to BDD’s development.
Phillips says the last nationally representative US prevalence survey, conducted in 2015, found it to be higher than in any previous study – at 2.9%.
“But I suspect BDD is becoming more common, perhaps because of widespread use of image-centric social media, which can promote unrealistic beauty standards, enables morphing of one’s appearance and can encourage people to compare themselves with very attractive people such as celebrities.”
‘We had no treatments’
During her medical residency, Phillips became interested in some severely ill patients – they could not work or socialise and some had attempted suicide because they believed they were so ugly. She had never heard of BDD, nor had her supervisors.
“It had fallen through the cracks of modern-day psychiatry,” Phillips says.
“Even though BDD had been described for more than 100 years, the field knew almost nothing about the disorder … We had no scales or assessments to diagnose it or assess its severity and we had no treatments. So I started on a quest to learn these things.”
BDD was first mentioned in the widely used Diagnostic and Statistical Manual of Mental Disorders in 1980. Phillips, whose research influenced diagnostic criteria and descriptions in several later editions, says recognition has improved compared with when she began research in the 1990s, but more is needed.
“BDD has been much less studied than many other severe psychiatric disorders and we need more research studies on virtually every aspect of the disorder. We especially need data from diverse populations and in children and adolescents.
“It tends to be considered less important than other severe mental disorders, even though it’s more highly associated with suicidal ideation and suicide attempts than most other serious mental illnesses.”
It often occurs alongside other mental health issues, but many sufferers avoid discussing their symptoms out of shame.
Studies by Rossell and colleagues including David Castle, a psychiatrist and professor of psychiatry at the University of Tasmania, show changes in brain structure and connectivity among BDD patients.
Castle says while obsessive-compulsive disorder (OCD) and BDD both involve obsessional thinking and ritualised behaviours, BDD is distinct in important ways.
“Most people with OCD recognise their concerns are excessive, but in BDD, about half … have delusional convictions about their perceived ugliness: they completely believe it.”
There are also differences in visual processing: BDD sufferers tend to misinterpret facial expressions, being more likely to rate the expressions of onlookers as contemptuous or angry.
Rossell says unlike the brains of healthy people, which switch between looking at fine detail and at the big picture, the brains of people with BDD get stuck in detail mode. If anyone stares at one part of their appearance for a long time, it becomes distorted – which is thought to be at play in BDD.
The Melbourne-based clinical psychologist Dr Toni Pikoos says about three-quarters of BDD sufferers seek cosmetic or dermatology procedures. But, she says, these are unlikely to help and often present increased risks to patients and providers.
“They can be vulnerable consumers. Often they’re quite desperate, so they’re willing to pay the money to feel better … Unfortunately in up to 90% of cases of people with BDD, they don’t experience any change in their symptoms afterwards.”
Pikoos often sees clients who were initially satisfied with a cosmetic surgery, but months or years later feel the “flaw” has come back or become worse.
“They can become quite depressed and fixated on that area of their appearance, which can sometimes lead to getting really angry at the surgeon … There’s a [US] statistic that 29% of people with BDD have complained or taken out litigation against their cosmetic practitioner.”
Following an inquiry into the cosmetic industry, in July 2023 Australia’s medical regulator, Ahpra, tightened guidelines for doctors providing cosmetic procedures, with further changes expected for providers of non-surgical procedures – including nurses, dentists and Chinese medicine practitioners.
The changes require doctors performing cosmetic surgery or prescribing cosmetic injectables (such as the botulinum toxin and dermal fillers) to screen patients for BDD and refer at-risk patients for external assessment.
Pikoos, who co-founded an organisation to help cosmetic practitioners with psychological assessments and consulted on the Ahpra review, says there has been an uptick in referrals for assessment since July, some of which have needed further treatment or support.
Access to treatment
BDD symptoms are unlikely to improve without targeted treatment, Castle says: usually involving high doses of SSRI antidepressants combined with cognitive behaviour therapy focusing on avoidance and safety behaviours, including work with mirrors.
“You can change people’s lives completely. The tragedy is, often people are coming to us very late and having gone through a lot of cosmetic procedures.”
Rossell estimates there is a dozen mental health professionals in Australia trained to treat BDD, many of whom she trained, but laments that there is no specialist focus.
BDD is not a searchable issue in the Royal Australian and New Zealand Royal College of Psychiatrists (RANZCP) or the Australian Psychological Society (APS) clinician directories, although APS includes body image as a subcategory of “personal” issues. Rossell says improving searchability is “crucial”.
She is concerned patients – and those who want to refer them – struggle to find the existing specialists and she urges any practitioners with experience in BDD to notify RANZCP and APS, since they rely on information provided by practitioners.
The RANZCP president, Dr Elizabeth Moore, says research shows the disorder is poorly understood and that prevalence could be higher due to underdiagnosis.
“Amongst health professionals, there are concerns around missing symptoms associated with BDD in patients, or misdiagnosing BDD patients for depression, social anxiety or OCD.”
Eve estimates she saw 10 psychologists or psychiatrists before being diagnosed with BDD three years ago. She has been receiving specialist treatment for almost a year, which has been transformative.
“I wake up feeling positive and the focus on my physical appearance has become less intense.”
It is also bittersweet.
“It’s almost surreal to have someone who understands it. It’s validating, but it also made me a little angry that it had taken so long to get help and that I’ve spent most of my life grappling with it myself – the shame and stigma and being dismissed.”
However, she believes this progress is the reason she is now in a supportive relationship – marking the first time she has told a romantic partner about her BDD.
“Things have changed drastically … and I am in love. I have opened myself up to the most caring and understanding person I have ever met.”
Eve is now studying psychology, with plans to specialise in the treatment of BDD.
*Name has been changed.
• Prof Susan Rossell invites anyone with concerns about body dysmorphic disorder to contact her at Swinburne University’s Centre for Mental Health at firstname.lastname@example.org.
• In Australia, the crisis support service Lifeline is 13 11 14. In the UK and Ireland, Samaritans can be contacted on freephone 116 123, or email email@example.com or firstname.lastname@example.org. In the US, you can call or text the National Suicide Prevention Lifeline on 988, chat on 988lifeline.org, or text HOME to 741741 to connect with a crisis counsellor. Other international helplines can be found at befrienders.org