Practically every teen (and adult) dislikes something about their appearance, such as an imperfect nose, acne scars, or skinny calves. That’s normal. Some teens, however, obsess about a slight or imagined physical flaw. They’ll spend hours each day fretting about it, scrutinizing it in the mirror, or figuring out ways to hide it with things like makeup or clothing. They may even refuse to leave the house or socialize with friends, fearing judgment or ridicule due to the “hideous’ feature – even though they look completely normal to everyone else. This irrational behavior is known as body dysmorphic disorder, or BDD for short.
Body dysmorphic disorder can negatively impact every area of your teen’s life. If left untreated, symptoms continue into adulthood. Individuals with BDD often resort to countless – not to mention very expensive and potentially risky – cosmetic surgeries in a desperate, but ultimately futile, attempt to “fix” the perceived imperfection.
It can be difficult to determine if your teen’s concern about his or her appearance and seeming obsession with the mirror is normal or not. This brief guide is designed to help you know the signs to watch for and the steps to take if you suspect your teen has body dysmorphic disorder.
Body Dysmorphic Disorder Statistics and Facts
Following are several statistics and facts pertaining to body dysmorphic disorder:
- Body dysmorphic disorder affects approximately 1% of individuals in the U.S.
- The onset of BDD typically occurs during early adolescence, although it can occur at any age
- BDD appears to affect males and females equally
- A study reported in the Journal of Clinical Psychiatry found high rates of suicidal thoughts (78%) in individuals with BDD; over 1/4th of those individuals had attempted suicide
- 97% of individuals suffering from BDD avoided work and/or other social activities, according to a study published in the American Journal of Psychiatry. Nearly 1/3rd couldn’t leave their home due to the disorder.
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Co-Occurring Disorders
Individuals with body dysmorphic disorder often have other co-occurring psychiatric disorders as well. The most common disorders are:
- Major depressive disorder
- Obsessive-compulsive disorder (OCD)
- Delusional disorder
- Social anxiety disorder
- Substance use disorders
- Eating disorders
It’s not uncommon for body dysmorphic disorder to be misdiagnosed as depression or an anxiety disorder. It’s important to let your teen’s treatment provider know about the obsession he or she has regarding a particular physical flaw.
Risk Factors
Following are several risk factors for the development of body dysmorphic disorder in teens:
- Having a first-degree relative with OCD or body dysmorphic disorder
- Having depression, anxiety, or another mental health condition
- A history of childhood abuse, neglect, bullying, or other painful events
- Pressure to be beautiful or handsome
- Being perfectionistic
Looking for and Recognizing the Signs of Body Dysmorphic Disorder
Body dysmorphic disorder can become increasingly worse with time if left untreated. That’s why it’s so important to know what to look for so you can recognize the signs in your teen and intervene sooner than later. Look for and pay close attention to any changes from your teen’s normal behavior, mood, or personality – especially as it pertains to your teen’s feelings about his or her body or appearance.
Signs to watch for include:
- Being obsessed with their body or a specific body part (e.g. nose, skin, muscle size, hair). The most common areas of focus are the face, nose, hair, breasts, genitalia, and muscle size. However, any aspect of the body or one’s appearance can be the focus of obsession and distress for those with BDD.
- Constantly talking about the perceived flaw, always seeking reassurance about it, or trying to convince others how bad or ugly it is
- Significant distress about their body or a specific body part
- Avoiding social or physical activities, especially anything that might expose the perceived flaw they’re trying so hard to hide
- Never being satisfied with efforts to fix or improve the perceived defect
- Frequently or constantly checking how they look in the mirror (or any reflective surface)
- Avoiding mirrors to avoid seeing the perceived flaw
- Belief that others are staring at them or their perceived defect
- Attempts to hide or camouflage a perceived flaw with makeup, their hand or body position, clothes, hair, or accessories
- Excessive grooming, such as spending hours on their hair or makeup
- Frequently asking or even pleading to have surgery or see a dermatologist (or cosmetic dentist, etc.) to correct or remove the perceived flaw
- Feelings of distress about leaving the house (due to feeling self-conscious or believing they’re ugly)
- Frequently missing school, or dropping out altogether
- Spending lots of money on things they believe will fix or hide the perceived defect
- Often comparing their body or a part of their body with others
- Constantly changing clothes
- Avoiding having photos taken of them
- Wearing excessive amounts of makeup
- Excessive exercising or working out (with a focus on improving their appearance rather than their health or fitness)
- Picking at their skin
- Constant or overly restricted dieting
- Low self-esteem
- Deep-seated feelings of shame or embarrassment
- Depression and / or anxiety
- Suicidal thoughts or behaviors*
*Suicidal thoughts or behaviors should never be ignored. Don’t assume your teen is just being “dramatic” or manipulative. The risk of suicide is particularly high for individuals suffering from body dysmorphic disorder, especially if they’re also battling depression or anxiety.
Knowing the First Steps to Take
One of the greatest dilemmas for parents is knowing what to do if they believe their teen has body dysmorphic disorder. Following are the initial steps to take in order to help your teen:
1 – Talk to your teen. Sit down and have an honest conversation with your teen regarding your observations and concerns. Talk to your teen with compassion, and refrain from lecturing, criticizing, or shaming him or her. Let your teen know that you’re genuinely concerned and want to help, and that you’re always willing to listen about whatever is troubling him or her.
Don’t react, get defensive, or be surprised if your teen denies there’s a problem or accuses you of over-reacting (not uncommon behavior for teens).
2 – Set up an appointment for an evaluation. Your teen’s pediatrician or your family doctor can do an initial evaluation, including a physical examination to rule out any underlying medical issues that may be causing or contributing to your teen’s mood or behaviors.
Due to the potentially complex nature of body dysmorphic disorder, it’s imperative to have your teen evaluated as soon as possible by an experienced mental health professional. If possible, work with a psychologist and/or psychiatrist who specializes in treating children and adolescents and who has experience treating body dysmorphic disorder.
3 – Get your teen into treatment. Treatment for body dysmorphic disorder often involves a combination of psychotherapy, or “talk therapy”, and medication.
Psychotherapy – One of the most effective types of psychotherapy for BDD is cognitive behavioral therapy (CBT). This approach helps your teen identify and change negative and irrational thought patterns and behaviors associated with BDD. It also focuses on helping your teen learn healthy coping skills.
Medication – Medication is often prescribed in addition to psychotherapy in more severe cases of BDD. The FDA hasn’t approved any medication specifically for the treatment of BDD. However, there are several antidepressant medications that have been found to be beneficial in reducing obsessive thoughts and repetitive behaviors. Selective serotonin reuptake inhibitors (SSRIs), such as Celexa, Zoloft, Luvox, and Paxil, are often prescribed for BDD. The tricyclic antidepressant clomipramine (Anafranil), often used in the treatment of OCD, is also prescribed for some individuals with BDD.
If medication is prescribed, it’s highly recommended that it be under the supervision of a psychiatrist. Also, it’s important to carefully weigh the potential costs (e.g. side effects and risks) versus the potential benefits of medication, since your teen’s brain is still developing.
Family therapy – Family therapy may be an essential component of successful treatment for your teen’s body dysmorphic disorder. It can address dysfunctional family dynamics that may be contributing to or reinforcing your teen’s fixation on perceived physical flaws. It can also help everyone in the home learn how to be supportive without enabling.
Dual diagnosis treatment – This is usually necessary if your teen also has a substance use disorder – see more below
Residential treatment – See below
Hospitalization – See below
Supporting and Encouraging Your Child
Your teen will benefit greatly from your support and encouragement. Two of the most important things to keep in mind are that 1) BDD isn’t a sign of weakness and 2) it isn’t something your teen can simply “overcome” with sheer willpower and determination. Think of it as you would any other serious health condition.
Tips for parents:
- Educate yourself about body dysmorphic disorder. This will enable you to have greater empathy for and understanding of the challenges your teen faces every day
- Be patient with your teen. Remember, BDD is an illness, not something your teen can easily control.
- Don’t judge, criticize, or minimize what your teen is experiencing, not matter how illogical, absurd, or baffling your teen’s behaviors may seem to you
- Help your teen find healthy ways to manage stress and relax. For example, take regular walks with your teen or enroll him or her in a yoga class
- Seek guidance from your teen’s therapist to learn how to avoid accommodating his or her constant need for reassurance and reinforcing compulsive behaviors
- Maintain normal routines at home and have reasonable expectations (e.g. regular school attendance); enabling your teen may seem kind in the short run but will only reinforce unhealthy behaviors
- Help your teen stay focused on the goals of treatment and encourage him or her to practice the coping skills learned in therapy
- Make sure everyone at home is involved in your teen’s recovery so no one inadvertently sabotages his or her progress. A few family therapy sessions can help achieve this, while also addressing the affect your teen’s disorder may have on the entire family
- Never criticize or shame any aspect of your teen’s appearance or dissatisfaction with some aspect of his or her body
- Respect your teen’s privacy and dignity; your neighbors, relatives, and friends don’t need to know about his or her mental health issues
What to Do When Things Escalate
One of the greatest risk factors for individuals with body dysmorphic disorder is depression, which may be accompanied by suicidal thoughts. In fact, individuals with BDD have a significantly higher suicide rate than those with other psychiatric disorders. Also, those with severe BDD may refuse to leave home. The latter will make it extremely difficult for your teen to go to school, socialize, or attend therapy appointments.
If your teen is becoming increasingly depressed, actively suicidal, or engaging in self-harm, or experiencing severe, acute distress, you must take immediate steps to ensure his or her safety and wellbeing. A visit to the nearest ER or a brief hospital stay may be necessary to keep your teen safe from self-harm and/or get serious depressive symptoms under control.
If things start to escalate you can:
- Contact your child’s treatment provider asap
- Enlist the help of a close family member or friend for support or assistance
- Call an emergency hotline
- Take your child to the nearest hospital emergency room (if you can do so safely)
- Call 911
When Individual Therapy isn’t Enough
Some teens with BDD will require more treatment than individual therapy, even if medication is part of the treatment protocol. A more intensive level of treatment will likely be necessary for your teen if he or she is:
- Refusing to comply with his or her therapist’s treatment recommendations
- Experiencing severe depression, anxiety, or other psychiatric symptoms that require a higher level of care
- Actively suicidal – threatening or planning suicide, and/or engaging in suicide gestures or attempts
- Engaging in cutting, burning, or other non-suicidal forms of self-harm
- Abusing alcohol or drugs
Higher levels of treatment include:
- Intensive outpatient treatment (IOP) / Psychiatric day treatment
- Dual Diagnosis Treatment
- Residential treatment
- Inpatient psychiatric treatment
Intensive outpatient treatment or psychiatric day treatment can vary in terms of the amount of time spent in treatment and how many times a week your teen is required to go. These programs are typically the next step up from regular outpatient treatment.
Dual diagnosis treatment is usually necessary if your teen has a substance use disorder in addition to BDD. Alcohol or drug abuse almost always hinders the effectiveness of individual therapy. A dual diagnosis program addresses the substance use issue as well as your teen’s social BDD (and any other psychiatric issues) simultaneously. Dual diagnosis treatment may be part of a residential treatment program or an outpatient program.
Residential treatment requires having your teen live at a non-hospital treatment facility that specializes in treating adolescents with BDD and other mental health issues. Residential treatment typically lasts between 30 to 180 days, depending on the severity of symptoms and how well your teen is progressing in treatment.
Inpatient psychiatric treatment in a hospital setting is the highest and most intensive level of treatment for adolescents with body dysmorphic disorder. Patients are monitored 24/7. Hospitalization is usually relatively brief.
Taking Care of Yourself
Trying to effectively parent, help, and encourage your teen with body dysmorphic disorder is challenging. It’s perfectly normal to experience a range of emotions, including despair and exasperation. If you don’t take adequate care of yourself, your child’s mental health issues can take a serious toll over time. A few things you can do to bolster your own strength and keep your wits about you include:
- Surrounding yourself with ample support, whether through close friends, family, church, or a local support group for parents of teens with mental health issues
- Make sure you’re getting adequate sleep
- Find healthy ways to keep your stress under control (e.g. regular exercise or meditation)
With proper treatment, your teen can learn to effectively manage his or her BDD, and perhaps even overcome it. Your love, support, optimism, and encouragement will help ensure the best possible outcome.