Body Dysmorphic Disorder: Symptoms, Risk Factors and Treatment

Body Dysmorphic Disorder is a mental health disorder where an individual is preoccupied with their perceived negative/flawed body traits; which can be characterized with excessive mirror checking and grooming rituals, avoidance, appearance comparison etc. It is comorbid with anxiety, depression, low self-esteem etc.

Contents

1. Introduction

2. Body Dysmorphic Disorder (BDD)- DSM V Guidelines

3. The Indian and Global Scenario: Prevalence

4. Cultural Differences

5. Origins in India

6. Risk Factors for Body Dysmorphic Disorder

7. Social Media and Body Image

8. Body Image and Self-esteem

9. Treatment

10. Embracing Diversity: What Can We Do?

Introduction

Body Dysmorphic Disorder is a mental health disorder where an individual is preoccupied with their perceived negative body traits; which can be characterized with excessive mirror checking and grooming rituals, avoidance, appearance comparison etc. It is comorbid with anxiety, depression etc. Pressure on people to look a certain way, has been observed from centuries; and still persists. Especially for women and also observed in men is the importance given to physical beauty. Traits such as fair skin, thin nose, hour glass figure, pink lips, thinness, thick, soft and shiny hair are all ‘favorable or ideal’ traits for women to possess. Muscular body, tall, fair, abs etc. are all considered ideal for men. Any person who deviates from this rigid image is considered unattractive, some explicitly call them out as ugly or pressure them to fit into the ideal image. From corsets, to weight reduction pills, arsenic powders to become or look fair, creams, dermatological treatments, medical and plastic surgeries to ‘correct their flaws’, harmful diets have all been tried to fit into that image. An image that has been shown as attractive from centuries is so ingrained in our minds that, anything else is an ugly flaw that has to be corrected. History, colonization, capitalism for profits, the advertisement industry, media, family and marital institutions (at least in India) all have their roles to play in perpetuating this ideal image. They become risk factors and predictors for mental health illnesses like Body Dysmorphic Disorder, Eating Disorders like Anorexia Nervosa, Bulimia Nervosa, Binge Eating Disorder, ARFID (Avoidant/Restrictive Intake Disorder) and its associated disorders of depression, anxiety, social anxiety etc.

Body Dysmorphic Disorder (BDD)- DSM V Guidelines

Body image is the total perception or attitudes a person has regarding various aspects of his/her body; for example: its shape, size, color etc. Body image dissatisfaction is where a person is dissatisfied with their body. They have strong subjective and perceived negative thoughts and attitudes about their body (Ahuja & Banerjee, 2021).

A. Preoccupation with one or more perceived defects or flaws in physical appearance, that are not present or are very slight for others

B. The individual has performed repetitive behaviors such as excessive grooming, reassurance seeking, mirror checking etc. Mental acts such as constant comparisons of appearance to others around them are also observed

C. This preoccupation has caused significant distress and functional deficits in social, occupational and other important realms.

D. This is not better explained by concerns with body weight, which is better explained by eating disorders.

Body Dysmorphic Disorder is commonly associated with high anxiety, depression, social avoidance and anxiety, neuroticism, low self-esteem and perfectionism according to DSM V. In severe cases delusions of reference are also present, where the individual perceives that, others around them are mocking their appearance or are taking special notice of their looks. Suicidal ideations and tendencies are high in both adolescents and adults, primarily attributed to their appearance related concerns.

The Indian and Global Scenario: Prevalence

Body image dissatisfaction is stable and might even increase through adolescence to adulthood (Wang, et al., 2019). According to a systematic review to look at the prevalence of Body Dysmorphic Disorder, mostly from the North American, European and with slight representation of the middle eastern, South East Asian, African and South American countries; the prevalence of BDD in the general population ranges between 0.5%-3.2%. This also helps us understand the burden of disease. The prevalence of BDD could be increasing as more people are talking and opening about it and the rise of social media could also be playing a role (Minty & Minty, 2021). Among the student population the prevalence of BDD ranged between 1.3-5.8%. This is higher than the general population; one reason being that adolescence and young adults in their 20s is when these concerns become important. The prevalence in individuals with dermatological concerns was even higher, ranging between 2.1-36%. One study which studied individuals dealing with hair loss; showed the highest prevalence of 25.6% among females and 52.4% in males. Showing that, individuals going through dermatological concerns maybe at higher risk for BDD. Individuals with the concern of acne had prevalence ranging between 14.1-21.1%. Individuals going through cosmetic surgery had prevalence between 2.9%-57%. Those undergoing rhinoplasty had the highest ranging from 31.5%-52%. Skin, nose and hair were the most common areas associated with BDD (Minty & Minty, 2021).

Coming to the Indian scenario, there is a paucity of studies done nationwide. A study conducted in Manipur among 1207 students showed that, 2.6% of them met the criteria for BDD according to DSM V. Almost 92% of them were dissatisfied with some aspect of their appearance. Females were mostly dissatisfied with their skin, hair and nose (71.3%, 34.7% and 59.3% respectively). Males were dissatisfied with their muscle build and eyes (54.8% and 40.3% respectively) (Rushitha, M, Kadirvelu, S, & K, 2022).

Another study conducted in Jharkhand, among hospital outpatient adolescents, showed that clinically significant BDD was high among adolescents as shown by the earlier studies (2.9% met the criteria for BDD) and 34.3% had significant concerns with their appearance. The study also observed gender differences, where body image concerns were higher among females (Hansdah, Purty, & Zafar, 2022).

Cultural Differences

It is interesting to note that, people in affluent countries have shown higher levels of body dissatisfaction. The reason might be their access to media, print media showing idealistic body images. They also might have the economic resources and the tools to modify their body. Those in less affluent countries, might have more important things to worry about than their body image and might also not have the economic resources or access to tools. Highly westernized parts of Asian countries had higher body dissatisfaction. This maybe due to the body conscious western media (mostly US), that is widely circulated and consumed. For a long time, European notions of beauty were held to be ideal. Also, the rigidity of the ideal body image; thin, fair, for men muscular etc.; has no room to include diversity. Hence, beauty is a very narrowly defined in western cultures. It was also noted that, thin was ideal in western cultures; but bigger sizes were considered ideal and popular in many Asian and African cultures.

Even among the different western cultures, Americans seemed to show high body dissatisfaction than the Spanish and Germans. This was attributed to the culture in US which places high importance on appearance. The ideal image also differed among the western affluent countries. While Americans saw thick lips, sharp cheek bones; French girls saw ‘baby face’, long eye lashes and clear face with regards to complexion as ideal. Australians also showed higher similar body dissatisfaction as Americans, when compared to Italians (Holmqvist & Frise´n, 2010).

Origins in India

India is obsessed with fair skin. It is explicitly shown in advertisements, in marriages, in whitewashing actresses etc. Geographically speaking, since we are closer to the equator and the equator tends to receive more direct sunlight, when compared to the poles because of the spherical nature of the Earth. As a result of which our skin is darker when compared to other regions. So, when did our obsession with light skin start in India? Was it always there or did it start with colonization? Mishra (2015) mentioned that ancient India, was initially categorized by occupation rather than birth, as seen in the Rig Veda. But, after the verna system came into existence out of which castes and sub castes and gotras etc. emerged; birth and occupation merged into a rigid structure and became oppressive. Verna system, as mentioned in Rig Veda (PurushSukta) where the Purusha sacrificed himself so that a social order could emerge. The Brahmin emerged from the head, Kshatriya from his hands, Vaishyas from his thigs and Shudras from his feet. Division of labor was done accordingly, noble, scared professions were given to the higher vernas and unclean and polluting professions were given to the lower vernas. The shudras and Dalits were associated with dark skin, because if the nature of their occupations; their occupations involved physical labor in the sun. Taking into consideration the geography and occupations they were constantly exposed to the sun and hence darker than the other castes and vernas (Mishra, 2015).

But, the system wasn’t as rigid as we think and people were not discriminated because of their color. Mishra talks about this citing the example of Maharshi Veda Vyas, the writer of Mahabharata. He was the son of a Rishi and the daughter of a fisherman (lower class), but was respected in the community. Even the frequent fights between the Aryan immigrant community (associated with for skin) and the native tribal population (mentioned in the Rig Veda to be dark skinned) is often associated with discrimination; but they were actually fights over territory more than anything else. Many Indian gods and goddesses are described as dark; including Krishna, Shiva, Droupadi, Parvati. Mishra also mentioned dark heroes of the past who help leadership positions and were respected in the society (Mishra, 2015). Unlike western idealization of thinness; wide hips, tapering legs and large breasts were ideal beauty in India. “The monasteries of Ajanta, for instance, are filled with images of beautiful women—dark-skinned princesses and heavy-breasted dancing girls and courtesans.” (Ahuja & Banerjee, 2021, p. 3).

India and Colonization: We start to see explicit segregation, discrimination based on the color of the skin; linking favorable attributes to light skin and the opposite to dark skin during the British rule. This is the beginning of our internalization of Eurocentric notions of beauty. Colonizers who came with their ideologies of superior Caucasian white skinned race and the inferior dark-skinned race; applied the same in India. Explicit discrimination not allowing Indians into restaurants, their St. George fort settlement was named white town, while the Indian settlement was called black town etc. For their work force, they gave dark skinned Indians menial and low-level jobs; while the fair skinned Indians were preferred for higher level jobs (Mishra, 2015). The same justification they used for their imperialism and colonization was applied in India as well. The justification of their physical features (features of Caucasians) being attributed to beauty, intelligence, superiority and civilized; hence being the superior race, meant to rule over the inferior race and making the ‘savage’ populations more civilized like them. The same dehumanizing strategies used to justify their dehumanized actions. With instilling thoughts such as saying Indians were beastly people with a beastly religion (remarked by Churchill), Rudyard Kipling saying “English men were uniquely fitted to rule ‘lesser breeds without the law” (Mishra, 2015, p. 732). Fair skin, thin nose bridges, blue, brown eyes, straight hair started to be associated with beauty, intelligence, civilized and sophistication. They had colonized our lands and our minds. And the present obsession with fairness in India, it’s safe to say we are still colonized in our minds.

Modern India: Modern India, these colonized ideas are now being perpetuated by the most influential; the media. To observe most of the people we see on advertisements, films, advertisement hoardings are all fair skinned men and women. We even see Caucasian women on the posters and advertisements. We see fairness creams ads, which is a multi-million-dollar industry in India (Mishra, 2015). Earlier, fairness creams advertisements showed that women after using the fairness cream, got married. But recently fairness has started to be associated with empowerment and success; showing a woman becoming more confident after using the fairness cream and landing a successful job. Many actors and actresses have endorsed fairness creams. There is not much representation for dark skinned Indian women in films and the media. Actresses who are wheatish are white washed through photo editing. Any dark-skinned men or women we see are portraying the roles of a villain (bad) fighting against light skinned heroes (good). These media images are considered ideal, beautiful, which pushes men and women to look like them. These images are controlled by powerful corporates who have vested interests and greatly profit from such ideologies (Mishra, 2015).

Risk Factors for Body Dysmorphic Disorder

Child maltreatment, emotional neglect and abuse, physical neglect was seen to be risk factors to later developing body dysmorphic disorder. Various other childhood traumatic events were also associated with BDD. Traumatic events such as a life-threatening illness, homelessness, witnessing violence, torture, self-harm, suicidal actions were reported by individuals experiencing BDD. As severity in abuse and neglect increased, severity in BDD, anxiety and suicidal ideation also increased (Malcolm, Pikoos, Grace, Castle, & Rossell, 2021). Sociocultural factors like teasing or bullying from significant relationships like friends, parents, romantic partners can be risk factors for body image dissatisfaction, drive for thinness, disordered eating etc. Other factors such as media also played a role. Appearance comparison was an important mediating factor between sociocultural influences and body dissatisfaction (Girarda, Rodgers, & Chabrol, 2018; Collison1 & Harrison, 2020).Some other environmental factors that were risk factors were peer dieting, parental care and communication, body shaming (weight teasing) and personal factors of depression and low self-esteem. These factors predicted whether body dissatisfaction will be chronic or not. Depression, low self-esteem, body shaming, low parental care and communication, high peer dieting were all risk factors for chronic body dissatisfaction (Wang, et al., 2019). For men, pressure from media is consistently link with body dissatisfaction; there are many other factors that come in for women along with media (societal pressure on appearance for women, medical comorbidities etc.) (Ahuja & Banerjee, 2021).

Social Media and Body Image

There are two aspects that regulate the influential factors and body image dissatisfaction. Internalization of societal/media/familial and peer ideals of body image and appearance comparison (Ahuja & Banerjee, 2021). Social media has formed into another important influence for both adults and adolescents alike. It has influenced our lifestyles, our habits, way of our interactions, our mental health, our moods etc. Its not new information then, to know that social media has significant influence on an individual’s body image perceptions. The way we use social media, the type of accounts we tend to follow, the purpose we use it for has its implications on body image perceptions. Some problematic aspects of social media that are risk factors for body image dissatisfaction and body dysmorphic disorder are passive usage, highly visual social media platforms which are highly filtered image based, upward comparison behaviors that people engage in etc. Passive use of social media (scrolling through accounts and feeds without any interaction), as opposed to active use is associated with following accounts, having conversations, comments etc. Researches have suggested that passive use of SNS is associated with the facilitation of body image dissatisfaction. Active use is associated with feelings of belongingness, well-being, increased self-esteem etc; as it supports social connections and self-expression. On the other hand, passive use is characterized by scrolling through posts which are filtered, idealized version of others; which increases upward comparison, decreased self-esteem, risk of rumination, self-criticism, addiction, internalization symptoms of depression etc (Ryding & Kuss, 2019). With lockdowns and quarantines, usage of all social media networks increased, which are linked to low self-esteem, body dissatisfaction, drive for thinness etc. With increased focus on health due to the pandemic, appearance focus accounts went viral; which was detrimental ironically. Appearance focused accounts were linked with higher eating disorder risk, body dissatisfaction etc. (Ahuja & Banerjee, 2021).

With all the controversy around Facebook, we have noticed a shift to Instagram and Snapchat. The difference is that the latter are more image based, with the ability to filter before posting images, short videos etc. These are being termed as highly visual social media. (HVSM); and researches have suggested that these highly visual social platforms are risk factors for adolescents developing body image dissatisfaction and internalizing symptoms of anxiety and depression. Adolescents and young adults using social platforms focusing greatly on visual content show greater concerns with body image, disordered eating and emotional related symptoms (Marengo, Longobardi, Fabris, & Settanni, 2018; Ryding & Kuss, 2019); than Facebook and these effects are directly proportional to time spent on these platforms. It is interesting to note that although against HVSM media, Facebook is seen to have less impact. But, when compared against conventional media (magazines, print media etc.), Facebook had significant negative impact on body image (Cohen & Blaszczynski, 2015). HVSM hence, leads to greater body image concerns and these concerns in return lead to greater emotional and internalization symptoms. Also, social networking sites that allow photo manipulation (Instagram, Snapchat etc.) and photo investment (choosing which selfie/photo to post on social media) were linked with higher body image dissatisfaction for both gender (Lonergan, et al., 2019).This happens due to the upward comparison that happens when people scroll through socially idealized posts. The highly filtered posts are seen as a bench mark against which they evaluate themselves; leading to body image dissatisfaction and internalization symptoms of anxiety and depression (Marengo, Longobardi, Fabris, & Settanni, 2018). Upward comparison is also associated with the risk of body dysmorphic disorder and it can maintain BDD because of the following:

1. Upward comparisons can increase one’s focus on appearance

2. Can lead to preoccupation with a selective part or aspect because of its perceived defect.

3. Biased view of appearance of others as a whole (Ryding & Kuss, 2019).

Upward comparison is also seen to be a mediating factor in the relationship between SNS and body image dissatisfaction. Meaning that upward comparisons tend to increase the risk and are highly detrimental to negative appearance focused distortions. Gender differences were seen in the areas of focus. Women and girls tend to focus more on hair, face, stomach, weight, breasts, while men tend to focus more on muscle build, hair and genitals (Ryding & Kuss, 2019). It is important to identify that everything is see on social media is idealized and not real. People post their best selves for followers, validation, likes and many other factors, and we see only their best and not their other side or other aspects. Everything we see is filtered. Nobody looks like their selfies and nobody can look like that all the time. Read more. Here are some TEDx talks on Social Media and Body Image.

There are also some positive factors that act as buffers to all this. Parental support, supportive school environment, media literacy, awareness of dangers of social media, awareness of active and passive use can all act as buffers and offset the negative consequences (Burnettea, Kwitowski, & Mazzeo, 2017). Self-compassion was suggested by some studies to act as a buffer for body dissatisfaction; other studies couldn’t find a significant relationship (Lonergan, et al., 2019). Although we can’t completely take away social media, technology; we can help them understand, be aware of the negative consequences by giving them a safe space to express and to give our support. Children are more likely to reduce their usage if they don’t see their parents using as much and if we make sure they have offline activities to socially participate in and activities that a family can mutually enjoy.

Body image and self-esteem

Many researches suggest a negative correlation between self-esteem and body image dissatisfaction and even BDD. Meaning that, the higher the body image dissatisfaction and the lower the self-esteem is (Kuck, et al., 2021; Berg, Mond, Eisenberg, Ackard, & Neumark-Sztainer, 2010; Pop, 2016). Self-esteem is also linked with many mental health conditions; especially depression. Many studies suggested that, even when controlled for depressive symptoms, the relationship between BDD and self-esteem is significant. BDD is also associated with global self-esteem; which suggests that it’s not just appearance related aspects, but it can spread to other aspects as well. Negative core beliefs such as “I am worthless if my appearance is flawed”; are very commonly observed among individuals (Kuck, et al., 2021). One study also suggests a link between body image dissatisfaction and depressive symptoms; with adolescents experiencing body image dissatisfaction were 3.7 times more likely to report depressive symptoms (Flores-Cornejo, Kamego-Tome, Zapata-Pachas, & Alvarado, 2017). This is another TED talk about the dangers of core beliefs about appearance.

This relationship between body image dissatisfaction and self-esteem is stable across age and gender. So, the link between the above-mentioned variables tend to stay stable even as we age. For boys even across the other variables like weight, race, ethnicity the relationship between the variables stayed the same. But for girls who were under weight, there was no significant relationship, but for girls with average weight and obese there was a significant relationship. With race and socio-economic status; it was significant among all but less significant among people from lower socio-economic status and black and Asian girls (Berg, Mond, Eisenberg, Ackard, & Neumark-Sztainer, 2010).

Treatment

The most common therapeutic approach used to manage BDD is Cognitive Behavior Therapy (CBT). In CBT, firstly they raise awareness of what exactly BDD is. Then, unhelpful thoughts about self and one’s appearance is discussed. Some automatic negative thoughts, core beliefs are identified. Changing these maladaptive thoughts into more adaptive thoughts is done through disputation; through thoughts records, REBT self-help forms, behavioral experiments etc. To deal with self-esteem one can do self-esteem pie and basing self-esteem on other aspects like their personality, skills etc. in the pie chart can be explored. Self-esteem journals, positive self-affirmations can be given as well. Individuals with BDD also engage in some ritualistic behaviors like spending excessive time in front of the mirror and checking themselves in the mirror, avoiding mirrors or public places, meeting people etc. Exposure and response prevention is the approach used to deal with these rituals and avoidances. Individuals are encouraged to engage in situations that are stressful for them; starting from least stressful to most (hierarchy). During these, individuals also get a chance to test their negative thoughts (people will stare at my thinning hair without my hat etc.). They will be asked to reduce their time checking in mirrors or stand at a distance and check instead of close (which will magnify their perceived flaws). It might help them realize that, at a distance themselves and others might not even notice the perceived flaw or even look small and insignificant to them. With regard to medications, although there aren’t specific medications for BDD; Selective Serotonin Reuptake Inhibitors (SSRIs) are usually prescribed that help with negative thinking and behaviors (Hartmann, Greenberg, & Wilhelm, n.d.; Mayo Clinic, n.d.).

Embracing Diversity: What Can We Do?

Let's first start to recognize that, the world would be a boring place if we all looked the same. The diversity is what makes us beautiful; so lets embrace that. Each of us are unique and beautiful in our own ways. Don't let anyone tell you different. For a change stand in front of your mirror and instead of all the flaws you search for, say something positive, something that you like, something that's unique and something that you are thankful for. If you feel like you are basing your self-esteem on your appearance alone, do a self-esteem pie that will help you recognize that you are so much more than just your appearance. Embrace yourself when you are all dressed up, embrace when you just woke up; understand that beauty is who you are and how you are to others and yourself. Superficial beauty might be attractive initially, but its the inner beauty that matters and holds relationships. Accept and embrace your uniqueness and difference. I don't remember That's So Raven on Disney, that I used to watch; but this phrase from it always stuck with me, "People come in different shapes, sizes and colors and every single one of them is beautiful". And the song lyric from Alessia Cara's Scars to your beautiful; "You should know you're beautiful just the way you are and you don't have to change a thing the world could change its heart". Its true because the world changes; when I was young I never saw a plus size model, model walking in their natural hair a dark skinned women on TV. Times change, people do too. So, the world can change its heart; till then we will stay and accept ourselves and there is no greater ideal beauty than that.

What can parents do?

We can’t fully control what image we and our children see on social media sites, on TV, on advertisement banners, magazines, friends, peers, body shaming etc. But, we can help them through maintaining a relationship with them and helping them understand that they are enough and that we love them for all that they are, promoting self-acceptance and love. Parental care and communication as we have seen earlier acts as a buffer against the effects of social media on body image. Reducing social media exposure through family time, family activities, other co-curricular activities, their passions etc., can help with social media addiction and BDD. Giving a trusting, safe and accepting environment can help them communicate and even get early care when needed. Early adolescence is a critical period for social media use and body image dissatisfaction; early action in this period on media literacy, communication about body image, changes in body and self-acceptance can be very helpful. Helping them question concepts of beauty, redefining beauty, showing them diversity in beauty can help them be more positive about themselves and others.

If you feel you or anyone you know needs help, please reach out.

References

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