According to the DSM, body dysmorphic disorder (BDD) is an obsessive, disruptive preoccupation with an imagined defect in the individual’s appearance, or, if a flaw exists, being overly concerned with the effect of that flaw on the individual’s overall appearance.
The concept of bodily dysmorphia first appeared in the writings of Italian physician Enrique Morselli, who described the condition in 1886 as “dysmorphophobia,” or the fear of being in the wrong shape or form.
Body dysmorphic disorder can lead to social anxiety and isolation. Although the condition can cause a person to obsess about any part of the body, common areas of obsession include:
- Eyes or eyelids
- Mouth or lips
- Jaw or chin
Common behaviors that BDD sufferers engage in are:
- Camouflaging the perceived defect with clothing, sitting position, makeup, hairstyles, etc.
- Physical comparison to others
- Seeking cosmetic surgery
- Obsessive and repetitive checking of reflections in the mirror, especially for long periods of time
- Avoiding mirrors
- Picking or pulling at skin or hair
- Excessive grooming or exercise
- Compulsively changing clothes
BDD is prevalent in about 1 percent of the population, equally proportioned between men and women. Onset typically occurs during adolescence, when growth spurts and hormonal changes, combined with social pressure and teasing or bullying, trigger anxiety and the subsequent fixation on appearance.
Causes of body dysmorphic disorder are still unclear, but most medical researchers believe it to be caused by a combination of biological and environmental factors that affect brain chemistry, leading to anxiety, depression, suicidal thoughts, obsessive-compulsive disorder, or other comorbid mental health disorders alongside BDD.
Although this disorder occurs in both men and women, with a focus on marketing and media representations of women, men have received less attention for BDD than women. Men are statistically less willing to come forward to discuss a mental health issue in general as well. However, the popularity of memoirs such as Brian Cuban’s Shattered Image: My Triumph Over Body Dysmorphic Disorder has shown that men and women both are susceptible to this mental health problem for a variety of reasons.
Prevalence of Body Dysmorphic Disorder in Men
While areas of the body like weight, hair quality, and skin health are targets for obsessive thoughts and behaviors in both sexes, the way body dysmorphic disorder manifests is different between the sexes. Although there are few clinical studies examining male body dysmorphic disorder, the small number of them so far have focused on heterosexual men. These clinical investigations show that heterosexual men tend to worry primarily about body weight, muscularity, height, penis size, and body hair, including baldness.
Men who suffer from BDD often seek cosmetic surgery to “fix” perceived flaws in their appearance. This can include rhinoplasty, liposuction, muscle implants, and hair plugs. Although many people each year seek cosmetic surgery, people who suffer from BDD do not find any pleasure in their appearance after surgery, and often do not feel that their perceived imperfection has gone away. They may also suffer anxiety that it will come back. For men, worries about balding, excessive body hair, shortness, lack of muscles, or small, misshapen, or uneven genitals often indicate underlying concerns about masculinity.
Bigorexia, the popular term for muscle dysmorphic disorder, is one of the more common forms of BDD in men. While obsession with muscle size occurs in women, it is much more likely to affect male sufferers of BDD. Some recent studies have suggested that 1 in 10 men at the gym suffers from bigorexia, or “reverse anorexia.” Men suffering muscle dysmorphic disorder believe that they are too skinny or lean, or that their bodies have excessive fat and not enough muscle. This leads to:
- Over-exercising, especially overexertion during weightlifting or working out when injured
- Unfavorable comparison with more muscled men
- Preoccupation or even panic when workouts are missed
- Eating disorders
- Body camouflaging
- Compulsive or excessive examination of the individual’s physical appearance
- Mood swings
- Prioritizing working out and strict eating schedules over social engagements, going to work, or going to class
- Using drugs like steroids or weight loss supplements
Body Dysmorphic Disorder and Substance Abuse
Men suffering from BDD are more likely than the average population to suffer substance abuse disorders as a method of self-soothing anxiety. Both men and women who suffer from BDD are more likely to suffer substance abuse disorders. Of these substances, one study showed that 43 percent abuse alcohol, 30 percent abused cannabis, 9 percent abused cocaine, 8 percent abused sedatives or hypnotics, 6 percent abuse opiates including oxycodone, 6 percent abused stimulants, and 2 percent abused steroids.
Although both genders are likely to develop substance abuse problems related to body dysmorphic disorder, men are twice as likely to develop these problems compared to women. Over half of men with BDD report the onset of body image problems a year or more prior to developing substance abuse problems, indicating that the abuse of drugs or alcohol is a method of self-medicating anxiety, depression, and suicidal tendencies, even though substance abuse exacerbates these problems in the long run.
Concerns about weight have led BDD sufferers of both sexes to develop obsessive calorie-counting behaviors or aversions to specific foods, anorexia and bulimia, and chemical dependency. People with eating disorders have a higher prevalence of chemical dependency. For example, one study showed that 24 percent of people with bulimia also suffered from alcohol abuse. In men, 57 percent of males with binge eating disorder also suffered a substance use disorder. Drugs are often abused as a way to control weight in people with body dysmorphia or eating disorders, and this is especially true of stimulants.
Men who suffer from muscle dysmorphic disorder in particular are more prone to using anabolic steroids to gain muscle mass. Actual statistics on steroid use are difficult to determine because they are illegal substances, but several men in multiple studies of BDD with bigorexia admitted to having used or abused steroids in order to gain muscle. One study indicated that high school boys with muscle dysmorphic disorder took steroids in 6-7 percent of cases.
Steroid abuse has many life-limiting side effects. Short-term effects can include headaches, acne or oily skin, infections at the injection site (if injected), and yellowing of the skin and eyes as jaundice sets in. Long-term effects include liver and kidney damage or failure, enlarged heart, high blood pressure, aggression and mood swings, paranoia and accompanying jealousy, delusions, impaired judgment, and heart attack, even in young people.
Treating Body Dysmorphic Disorder and/or Substance Abuse in Men
Fear of giving up compulsive behaviors around exercise, eating, or grooming prevent many men with BDD from seeking treatment. Men also typically fear admitting weakness or emotional sensitivity, or fear losing muscle mass or gaining body fat by reducing their exercise regime and eating compulsions.
When men with BDD seek help, Cognitive Behavioral Therapy (CBT) seems to work the best. CBT seeks to restructure the person’s thinking, so the person can understand why certain habits are harmful and replace them with better habits. Anti-anxiety medications and antidepressants can help stabilize the person’s mood temporarily, but especially when substance abuse problems are comorbid with BDD, both the individual and the prescribing doctor should monitor habits and side effects closely. Medications like clomipramine, which is used to treat obsessive-compulsive disorder, is also sometimes used to ease BDD symptoms.
In cases of co-occurring substance abuse and BDD, residential treatment may work best. By dealing with the underlying causes of both BDD and substance abuse through talk therapy, CBT, and support groups, men are more likely to understand their disorders, continue to seek help, develop healthy lifestyle habits, and find emotional support in other.