Imagined Ugliness


Key points were clarified and fascinating information was shared at an incredibly insightful presentation I attended with Noah Clyman, LCSW-R and colleagues from NYC Cognitive Therapy earlier this month, Imagined Ugliness: Understanding and Treating body Dysmorphic Disorder, given by Sabine Wilhelm, Ph. D. 

Body dysmorphic disorder (BDD), can be briefly defined as having a preoccupation with one or more perceived defects or flaws in physical appearance that is not observable or appear slight to others (Diagnostic and Statistical Manual of Mental Disorders, DSM-5). BDD usually begins during adolescence, but can occur earlier in childhood and presents almost evenly among genders.

Common physical appearance obsessions:

  • Acne
  • Body or facial hair
  • Thinning hair on head
  • Scars or markings on skin
  • Moles
  • Coloring of skin complexion
  • Wrinkles
  • Facial Asymmetry
  • Shape or size of facial features, various body parts, or muscles

Maladaptive behaviors include: mirror checking, excessive grooming, skin picking or mental acts of comparing appearance to that of others. Many patients also exhibit avoidance behavior. They may avoid places that are very appearance focused (e.g. weddings), brightly lit places and mirrors. This can lead to problems with friends, family or work (calling out, arriving late due to rituals, etc). Preoccupations cause significant distress or impairment in social, occupational or other important areas of functioning. The preoccupations are not attributable to other medical conditions or better accounted for by concerns with body fat or weight in an eating disorder. Muscle dysmorphia–a psychological disorder marked by a negative body image and an obsessive desire to have a muscular physique—is a subtype of BDD.

There are many causes of BDD:

  • environmental factors (teasing, childhood neglect/abuse, socio cultural pressures)
  • psychological factors and personality traits (perfectionist, rejection sensitivity)
  • interpretation biases and information processing abnormalities (detail oriented, self-focused, misperception of neutral facial expressions or situation as threatening)
  • biological theories (involvement of frontal-striata/amygdala brain circuitry, family history).

Associated problems include depression and/or anxiety. Alarmingly, the suicide rate for BDD patients is approximately 45 times higher than the general population.

Effective vs. Ineffective treatments

A few treatments are considered by BDD patients. Non-psychiatric treatments are often sought out, such as dermatologist or plastic surgeons. These are usually ineffective and often the patient consequently feels worse after. They can be disappointed when the desired social result is not achieved (e.g., belief that surgery will lead to having friendships, feeling confident, and so on). A significant amount (27%) of BDD patients obtain cosmetic surgery or dental procedures. Medications that are best studied are antidepressants (SRI’s: fluvoxamine and clomipramine). However, all the SRI’s appear to be effective. Typically patients who suffer from BDD require dosages at the higher end of the therapeutic range for SRI’s. Cognitive behavioral therapy, time-limited psychotherapy that modifies maladaptive thoughts, beliefs and behaviors has been proven effective.

Tips to help a friend or loved one overcome barriers to treatment:                                                                                                         

  • Don’t argue with loved one over the existence of the perceived flaw (or agree).
  • Focus on the excessive preoccupation and how it may be impairing their daily lives. In regards to discussions about surgery or dermatological treatments, start a cost/benefits conversation of strategies (consider CBT and/or medication).
  • If friend or loved one wants to drop out of CBT to get cosmetic treatment, have them consider postponing the surgery. The surgery can always be an option later, see if they are willing to try a certain number of sessions first.
  • Embarrassment about being seen in the waiting room – think of a plan to manage anxiety (arrange appointment time with practitioner so there is no waiting time with other patients).

Tips to enhance motivation for loved one or friend:

  • Look forward by asking loved one a question such as: What do you want life to look like in 5 years (what would it look like with or without CBT)? Also think of extreme scenarios (what is the best/worst case) and encourage change talk.
  • Start at the end by asking questions like: What do you want people to say about you when you aren’t here? When you look back on your life? What memories do you want to have?

Research findings

Results of a recent study (24 treatment completers): BDD Severity of sample decreased and results were sustained post treatment. The mean BDD YBOCS score (questionnaire used to measure BDD severity) was 32.5 pre treatment, 15 post treatment (week 24) and 13.5 at the 6 month follow up.

About the author:

Kaley Montgomery is a second year MSW student at New York University Silver School of Social Work. Making a career change after seven years in the fashion industry, she revisited her long standing passion to help people improve functioning in their lives and relationships. Having worked in corporate offices with a variety of companies in New York City, she understands the stress and pressure that can accompany juggling the many demands of city life. She takes a joint approach while working with clients and is an avid believer of CBT, mindfulness and meditation. To book an appointment with Kaley, visit

Share your reactions, experiences & questions:

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s