Body Dysmorphic Disorder

Body dysmorphic disorder occurs when you find yourself spending a lot of time obsessing over, hiding, or trying to correct what you see as flaws however others do not. It is super common, about 1 in 50 people have BDD. This condition affects both men and women of all ages, although most cases begin in early adolescence.

Most BDD patients have no insight into their condition. A good way to understand objective assessment is to ask your family members or close friends whether they see your condition in the same light as you.

When you see our clinicians we place you on a scale of pathology, namely what your objective findings are compared to what we see as clinicians (not as psychologist or psychiatrist).

BDD is super common, we see at least 1-2 cases daily. Most patients have no insight into their skin condition. In order of occurrence-

• Acne scar BDD
• Enlarged pores BDD
• Facial redness BDD
• Stretch marks BDD
• Facial ageing BDD
• Facial asymmetry BDD
• Facial features BDD, nose most commonly
• Fordyce spots BDD

BDD accounts for the majority of unhappy patients. Though they make up less than one percent of our patient cohort, BDD accounts for more than 25% of our counselling sessions. This is because in most cases expectations can not be met, hence it is super important to identify these patients early.

This is by far the most common presentation of BDD as Cutis Dermatology is known for scar treatments. We see a range of severity from extreme severe cases to the other end of the spectrum, mild scarring & even milder BDD patients. 

Body dysmorphophobia scar patients have-

• Objectively mild scars. This means scars that are barely visible in normal lighting. Objective assessment means what others see, not what you see. A good understanding of objectivity is to ask your family & friends their options. If they don’t see or understand what you see, chances are they are telling you the truth.

• Scar seeking behaviour. An overwhelming majority of scar BDD patients use techniques like angled lighting coupled with close examination with a mirror (holding it at 30 cm or less).  We use angled lighting to demonstrate scars, often at distances of 2-3 metres or more, & not at 30 cm. Lighting is used by dermatologists to quickly & efficiently assess contour changes, whilst conversely it is applied in BDD patients to seek out minor imperfections.

• Time spent thinking about scars, treatments & or having had multiple prior treatments that are out of proportion to objective findings. The key word is objective not subjective. For example, objectively severe scars can be demonstrated with normal photography at 2 metres or more. How do we assess objectively severe scars? We put you on a scar scale, measured against other patients & not your own psyche. 

For minor scars (objective, not subjective), a good ethos to follow is low risk treatment. This means our dermatologists will often not subject you to high intensity treatments such as fully ablative CO2 or erbium lasers, surgical subcision, excision or high strength peels. The logic behind this is known as the risk to benefit ratio. Suitable treatments for acne scar BDD patients include-

• Small spot conservative CO2 lasers
• Saline subcision by nurses using small bore cannula
• Fraxel or hybrid lasers
• Microneedling in some
• Vascular & pico lasers for pigmentation

Yes, but we don’t know if you will be happy enough with the outcome. If you have insight into your condition, you will acknowledge that there is an improvement, noting it is an improvement on a perceivably small objective assessment. It is the glass half empty analogy.

At Cutis Dermatology we are honest (most often brutally honest), we are here to help you understand your condition, & not sell you a dozen laser packages.

A dermatologist will place your condition on the scale of pathology. This means they will grade your skin condition according to the spectrum of conditions that we see, not against your subjective scale of imperfections.

It is important to understand the difference between body dysmorphia & true severe pathology. The latter is when subjective assessment reflects objective reality. The former is when subjective assessment is out of proportion to objective findings. We are painfully honest with our assessment.

Lots. We must differentiate BDD from severe pathology or real physical conditions that are objectively (again this word) severe. A classic example would be objectively severe unresponsive scarring, that is recalcitrant to treatments by previous clinicians.

In contrast BDD patients will have objectively mild physical signs, but also have seen lots of clinicians in addition to having had plenty of treatments. We try to identify these patients early in the course of treatments to ensure that expectations are aligned. It is not in our interest or yours to undertake treatments that have a very low satisfaction rate. 

As dermatologists, we are trained to deal with real skin problems. There is an overlap with psycho-dermatology & some of our colleagues are interested in this subspeciality, namely managing patients with psychological concerns that are out of proportion to actual physical findings.

Our procedural dermatologists at Cutis Dermatology do not have this subspecialty interest, nor the skill sets in the context of counselling. For these reasons it is in your best interest to be referred to psychologists or psychiatrists early. We refer suitable cases to psychologists in Bulimba known as the OCD clinic. 

Pore size BDD is super common, ranking with acne scar BDD as the top condition we see as dermatologists. The practice sees at least one patient daily who has pore phobia BDD.

Inevitably patients present as having ‘enlarged pores’, when in reality they have ‘normal size pores’. How do we know what normal size pores are? It is because we have examined faces on a daily basis for the past 2 decades.

Our dermatologists will determine where you fit on a BELL CURVE, based upon objective assessments, not subjective ones. Pore phobia BDD patients are different from true enlarged pores. Pore phobia BDD patients lie in the 40th to 60th centile objectively, whilst true enlarged pores – pick scars – ice pick scars lie beyond the 85th centile.

Redness is part of any normal skin colour. It is abnormal when it exceeds the normal range. True pathology can be seen in patients with rosacea, broken capillaries due to age, sun, trauma & in cases of flushing-blushing. For flushers, we can only diagnose this when you physically flush (which is intermittent).

If you bring a photo to a consultation, & if it objectively shows redness, then your dermatologist will get a better understanding of your condition. If you see redness & other people can not, chances are you have BDD. Procedures including lasers are of little value.

It Is difficult to subjectively improve red faces as lasers work by reducing real redness, not imaginary redness. This is the law of physics & we cannot change that.

If you have intermittent flushing & blushing, the use of medications such as clonidine, & other blood vessel modulators can help. In rare situations your flushing may be secondary to conditions such as carcinoid tumours, pheochromocytoma, medications & other conditions. A medical dermatologist may need to investigate & rule out these conditions.

If you have physiological flushing (what may be absent during the consultation), you are better off seeing a medical doctor. Lasers are not first line as they work best for actual redness.

Stretch mark BDD is common & should be differentiated from real pathology. The latter is easy for us to decipher but can be impossibly difficult for patients to understand. Here are some help differences.

True stretch mark pathology: highly visible (objective not subjective) stretch marks that are contrasted with normal skin colour namely red, pink, or purple visible at 2 metres or more.

Probable stretch mark BDD: barely visible stretch marks at 2 metre or more. Low contrast stretch marks that are usually white or faint pink.

For real pathology, we can make a difference in most patients, especially in the colour of stretch marks. As with any medical condition, results will vary.

We get it, most patients would like to look good for their age. Our dermatologists & nurses are great at facial rejuvenation, however we can not work miracles. Our ethos is honesty, & we will give you realistic expectations. We’re not in it for expectations above & beyond what we can achieve.

By far the most common area for ageing BDD is the jowls. It is because this area can be accentuated with angles of light & flexion of the neck. A surgical option may be required in some patients.

This is another frequent presentation of BDD. An important concept to grasp is that everyone is asymmetrical, it is natural & within reason it is normal. This pertains to eyebrows, eyelids, cheek height, jawline contour & other areas.

In some cases, we can easily correct asymmetry with injectables including treatments & anti-wrinkle, however if we have an inkling that you may have facial asymmetry BDD, our injectors are not for you. There are many other injectors that will take up this job, but our specialist will not treat facial asymmetry BDD.

Fordyce spots are much like pore sizing. Everyone lies on a bell curve. For some patients, the number & size of ectopic sebaceous glands lie within the top 2-10%. Hence these patients may seek treatment.

Unlike facial pores, treating Fordyce spots is difficult. Ablative lasers are required, & on the lips the recovery time pushes past one week. It is an epic procedure to undertake as you cannot eat properly for over a week. Fordyce can recur within a few weeks to months of treatment; hence we discourage patients from undertaking this treatment.

If you are serious about help, visit a psychologist who has an interest in body dysmorphia. In Brisbane, we refer patients to the OCD Clinic in Bulimba. For more information visit the websites below.

• https://www.helpguide.org/articles/anxiety/body-dysmorphic-disorderbdd.htm
•  https://bdd.iocdf.org/professionals/therapists-guide-to-bdd-tx/

Absolutely, providing you have insight. If two specialists concur with a diagnosis, it should hopefully increase your insight regarding your perceived condition. This applies to all facets, including acne scar BDD, flushing-blushing BDD, pore sizing & more.

If you really want help, see a psychologist or a psychiatrist. Most patients are resistant to this idea, as they think their condition lies in the upper range of real pathology. This is the nature of dysmorphic insight. A procedure cannot change a though disorder.