Misperceiving Your Body’s Appearance

Body Dysmorphic Disorder (BDD) is characterized by an intense and distressing preoccupation with one’s physical appearance. It affects between 1% and 9% of the general population^1. People struggling with BDD tend to think of themselves as ugly or deformed, and are often disgusted by themselves. BDD can be a gateway to other severe mental illnesses, particularly substance abuse, major depressive disorder, and suicidal ideation¹. Following onset, 80% of people with BDD experience suicidal thinking, and 25% admit to attempting to take their own life. Despite the severity of BDD, researchers are still uncertain about what BDD is really about. In this post we will dive into what the latest research is uncovering about this debate and how this can help inform treatment courses.

Brain scans reveal that people with BDD see the world differently.

People with BDD focus more on visual details and tend to overemphasize these, which is consistent with clinical observations of BDD patients obsessing about minor details of their own appearance¹. In the brain, people with BDD have altered activation when looking at regular objects, such as houses, which is consistent with research reporting abnormal anatomy, activity, and connectivity of regions that are involved in visual processing². This insight suggests that BDD may involve a disconnect between one’s perception and one’s appearance. These results point to a fault specifically in visual perceptions. Similar to the Rubber-Hand Illusion, in which people over-rely on visual input leading to misperceptions of the rubber hand as their own, people with BDD may use faulty visual perceptions to incorrectly shift their internal sensations about their appearance. People with anorexia nervosa are significantly more susceptible to thinking the rubber hand is theirs, and the brain differences concerning visual processing observed in BDD are similar to those reported in anorexia nervosa. Currently the best option for modifying one’s perceptions of the world is through cognitive behavioral therapy (CBT) which consistently challenges your view of the world. CBT is also a scientifically validated technique for treating obsessive-compulsive disorders (OCD), a mental illness with which BDD has many clinical overlaps.

BDD is now seen as an obsessive-compulsive disorder.

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is one of the primary guidebooks for diagnosing people with mental health challenges. The DSM is updated regularly based on the newest science, and the most recent edition (DSM-5) moved BDD from the Somatoform Disorder section into the Obsessive-Compulsive and Related Disorders, a shift that had been recommended by many researchers³. There is a clear overlap between BDD and OCD behaviorally: In BDD, people spend hours ruminating and obsessing about their physical appearance, try to soothe their anxiety through ‘safety’ behaviors such as mirror-checking, and avoid situations that could shine a light on their physical appearance — for example, social gatherings. This behavioral overlap is reflected in the brain, with studies reporting similar abnormalities in the connection between frontal and striatal brain regions⁴. The striatum is important for performing movements, while areas within the frontal lobe are important for regulating a person’s behavior and thoughts. A lack of frontal regulation can lead to unchecked behaviors, and is hypothesized to drive compulsive behaviors in OCD. Similar to OCD, people with BDD also have heightened anxiety levels and elevated amygdala reactivity. The amygdala is involved in emotion regulation, and increased activity in this region is thought to maintain the compulsive behavioral loop driven by the fronto-striatal circuit. A major goal of OCD treatment is therefore to address their anxiety, a clinical goal that appears to be equally as relevant for people with BDD. Interestingly, there is also a genetic contribution to both OCD and BDD, and some of these genes may overlap, suggesting similarities in disease etiology⁵.

People with BDD can experience delusions similar to psychotic disorders.

BDD resides on a spectrum of no delusions to severe delusions. Some people with BDD understand that their obsession with, and disgust at, their appearance is abnormal, while others are absolutely certain that their body is deformed, disgusting, and requires change. This lack of contact with external reality has led clinicians and researchers to contemplate whether BDD may, in part, be a psychotic disorder ¹. Some research has found that people with BDD score similarly to people experiencing psychosis when using questionnaires⁶, however there is a lack of research on whether this similarity is also found at the level of the brain. Pharmacological studies suggest that they do not: People with BDD do not respond to anti-psychotics, but they do experience improvements with antidepressant drugs, similar to OCD¹. Thus, while people with BDD may experience delusions on par with psychotic disorders, these two disorders do not appear to have a similar neurobiological nature. It is possible that the delusions experienced by some people with BDD are rooted in their abnormal visual processing, which is more similar to anorexia nervosa than psychotic disorders.

It is clear from the current research that BDD is a multifaceted illness that affects many brain regions leading to obsessive-compulsive, anxious, and delusional thoughts and behaviors. So far, there are no FDA-approved treatments for BDD, and people with BDD only receive symptom-treatment, meaning that therapy focuses on reducing the severity of symptoms but not on addressing the root cause of the disorder. That leads us into a discussion of what the root cause of BDD is. As is the case with other complex mental illnesses, research is still unclear. As mentioned earlier, there may be a genetic link to BDD. A large proportion of people with BDD report a history of childhood emotional abuse and interpersonal conflicts, and BDD may be a maladaptive coping mechanism in response to these traumas. BDD often co-occurs with other mental illnesses such as depression, suicidality, and substance abuse, further complicating research identifying the underlying causes.