Body Dysmorphic Disorder (BDD)

May 16th, 2018

Content Warning(s): Discussion of body image & weight issues, minor body horror.

For Mental Health Awareness Month, we're highlighting certain conditions that may impact the convention community. We're starting off this month talking about Body Dysmorphic Disorder (BDD).

Please note: although I have a psychology degree, I am not a clinician and this is provided for informational purposes.

Diagnostic Criteria

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) lists these criteria for a BDD diagnosis:

  • Preoccupation with perceived defects/flaws that other people don't notice.
  • Repetitive behavior (such as constant mirror checking) or mental acts (like comparing your appearance to others) due to that preoccupation.
  • Preoccupation causes significant mental distress or impaired functioning.
  • The person's signs & symptoms don't fit better in another category.
  • Clinicians can specify whether their client has good/fair insight into their condition ("I know my thoughts probably aren't accurate"), poor insight ("My body probably really does have these flaws"), or absent insight ("I am 100% sure my body looks as bad as I think").

    Closely related to Obsessive-Compulsive Disorder, BDD is when a person has an obsession with some aspect of their appearance. Although it can be mistaken for vanity, it's completely different. Those with BDD are convinced that some part of their body is disgusting and that other people think they're ugly. They may have a fixation that is not based in reality at all (e.g. a person with averaged-sized ears believing they're huge and everyone notices them) or a highly exaggerated perception of something minor (e.g. a person with a small scar on their neck believing that everyone sees it all the time and is grossed out by it). When they think about their appearance, they're filled with shame, not arrogance.

    Someone with BDD will also have compulsions related to their obsession. They may constantly check their appearance in any mirrored surface that's near, repeatedly groom themselves, cover up parts that they feel are "defective," seek reassurance from others (that does nothing to actually help), or exercise excessively. They may seem to have a shopping addiction, as they're frequently buying clothing or beauty products to make themselves look "better." They may engage in more extreme activities, such as getting cosmetic surgery, or even performing surgery on themselves.

    Finally, this fixation significantly impairs someone's life and causes intense distress. They may fail tests because they're too distracted in class to learn the material. They may get fired from work because they're constantly checking their appearance in a mirror and making too many mistakes. Their house may be a mess because they're ignoring chores. They may be afraid to date, or have their partner leave them.

    Those with BDD are more likely to answer 'true' or 'mostly true' to these questions:

    1. Do you feel that you or certain features of yours are moderately to very ugly?
    2. Do you feel like your appearance is the only thing that can give your life value or meaning?
    3. Does this feeling cause you moderate to extreme distress?
    4. Do you find yourself excessively preoccupied with thoughts of your appearance?
    5. Does checking your appearance take up at least two hours a day?
    6. Do you often avoid situations where you fear there might be a focus on your appearance?
    7. Do your feelings & preoccupation have a negative impact on your social life?
    8. Do your feelings & preoccupation have a negative impact on your relationship with your partner, or your dating?
    9. Do your feelings & preoccupation have a negative impact on your schooling and/or work, if applicable?

    Prevalence & Population

    The DSM states that approximately 1 in 50 people in the United States have BDD; outside of the US, the prevalence is slightly lower. In Japan, a culture-specific syndrome, 対人恐怖症 (taijin kyofusho) has a subset named 醜貌恐怖 (shubo-kyofu) is similar to BDD; individuals believe their body is "deformed" and fear it will displease others.

    Regardless of country, BDD is split pretty evenly between those who identify as female (60%) and those who identify as male (40%). However, a specific subtype known as Muscle Dysmorphia is found almost exclusively in those who identify as male. Their preoccupation is with wanting a muscular, lean body.

    The most common age of onset is between age twelve and thirteen, with two-thirds of individuals with the disorder developing it before age eighteen.


    More research needs to be done into the causes of BDD, but some known/suspected risk factors include having a relative with BDD, OCD, or depression; high neuroticism and/or perfectionism; having an overly critical or emotionally abusive parent; and having some level of executive dysfunction - namely difficulty seeing holistically (i.e. the "big picture") and fixating on details instead. Societal pressure to look a certain way may also play a role.


    In terms of medication, selective serotonin reuptake inhibitors (SSRIs) can help reduce the obsessive thoughts and distress. Medication alone is often not enough, however. Most clinicians recommend cognitive behavioral therapy (CBT) - teaching coping skills that allow the client to change thoughts, behaviors, and emotional regulation. As BDD often co-exists with depression, anxiety disorders, eating disorders, and substance abuse disorders, treatment will need to address any comorbid conditions as well.

    Impact on the Cosplay Community

    You may think that nobody with BDD would be interested in cosplay, but it's very possible you know someone in the community who has the condition. That person on Twitter who often posts that she feels ugly, who you assumed was just fishing for compliments. Your friend in a group who always rejects costumes you suggest for them, who you feel is being selfish, because you don't realize that he's terrified at the thought of being in an outfit that left him bare-chested. Someone with BDD may still love dressing up, styling wigs, and play-acting with their friends, or may even hop into the activity hoping it will help them work through their anxiety and fear.

    So, what can you do if you know someone with BDD?

    First, understand that you can't "cure" them. (This will be a running theme in our articles this month.)

    I know that our first impulse when someone insults themselves is to contradict them, but that won't help, either. It may make them feel like you're not listening, or dismissing their thoughts. Instead, try reflecting their emotions and reframing the statement - something like, "It sounds like you're being really critical of yourself." It lets them know you're listening and processing but doesn't reinforce the negative sentiment. Ask them if there's anything you can do for them, but don't get upset if the answer is no. If the person is a friend, you can encourage them to seek treatment, offer to go with them to appointments, etc.

    Even if you don't know someone personally, you can take steps in the community. If you see bullying or someone shaming someone else for their appearance, speak up. If the person who made the comment just seems to be a little insensitive, try to talk with them about how what they said could be insulting and encourage them to be more sensitive in the future. While there are always going to be jerks on the internet, some people genuinely don't understand how what they say could be offensive, and if you engage in a discussion, you may be able to get your point across.

    That said, if they just seem like a habitual bully or a troll, report the comment, block the user, and reassure the target that they didn't deserve to be treated that way.


    While there aren't a plethora of resources for BDD, there are a few sites and books that may be helpful that we have listed below.

    Body Dysmorphic Disorder Foundation
    BDD Section of the International OCD Foundation

    The Body Image Workbook
    The Broken Mirror

    Thank you for reading; our next topic in this series will be PTSD.


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