How to Navigate Body Dysmorphic Disorder in a Relationship

I have always obsessed over my appearance. By age 10, I was certain I was hideous. I spent hours per day ridiculing my appearance and comparing myself to others, becoming distraught and dysfunctional around perceived defects. By age 12, I knew the average costs of rhinoplasties, jaw enhancements, lip fillers and liposuction. I would have preferred getting my braces tightened to participating in school picture day. By age 14, I was hospitalized for anorexia, the first of two attempts to starve myself to death upon convincing myself that peace with my body and brain was unattainable.

Body dysmorphic disorder (BDD) is not a cosmetic issue; it is all-consuming. It feels like being imprisoned in an abhorrent cage, overwhelmed by anxiety, self-loathing and shame. It can be incredibly exhausting and isolating because it is often difficult to recognize and explain.

"BDD may be challenging to recognize in oneself as insight into the inaccuracy of one's misperception of the body area is often poor and the individual is often convinced of their perceptions despite any feedback to the contrary," said Marla W. Deibler, Psy.D., a board-certified psychologist in Cherry Hill, New Jersey, and founder and executive director of the Center for Emotional Health of Greater Philadelphia.

Just as a dysmorphic person's relationship with their body is troubled, their relationship with others can be, too.

"Loved ones may have limited insight into a loved one's struggle with BDD as it is often accompanied by feelings of shame and embarrassment," Deibler explained. "Thus, those with BDD may not disclose their beliefs to others and may go to lengths to hide ritualistic behaviors related to their bodily misperception."

Even if a person is aware of another person's body dysmorphic disorder, it can be difficult to understand or respond appropriately, she said. Support and compassion are crucial whether you have BDD or are in a relationship with someone who does.

What is body dysmorphic disorder?

BDD is characterized by a preoccupation with one or more perceived defects in one's appearance, according to Mental Health America. It affects about 1 in 50 people of all genders and typically arises in early adolescence.

"The preoccupation is often dominated by the belief that the body area is ugly, abnormal, deformed or disfigured in some way and is often consuming to the individual, dominating their thoughts," Deibler said. "This creates a very high level of distress."

Body dysmorphic disorder is not to be confused with body dysphoria, a state of feeling unhappy or uneasy, nor is it the same as vanity, body image discontent or insecurity.

"BDD is not just being dissatisfied with a body part," said Rachel Cavallaro, Psy.D., a licensed psychologist with Thriveworks Counseling & Psychiatry in Boston. "Many of us will experience that to some degree. It is having a grossly distorted view of a body part or composition that takes up an excessive amount of time each day and causes significant distress."

The intense distress and intrusive negative thoughts BDD produces, along with compulsive behaviors such as checking, can significantly impact a person's day-to-day functionality.

Depression, anxiety and eating disorders, which frequently co-occur with BDD, can further disrupt a person's life and diminish well-being, Cavallaro explained.

During the crest of my own struggle, a period that lasted from about age 12 to my early 20s, I developed anorexia, bulimia and binge eating disorders, self-harmed and, in later years, abused substances in an attempt to quell my BDD and concurrent depression, anxiety and chronic pain.

I self-isolated, sometimes for weeks or months, because of depression and the distress of merely being perceived. I had few friends, fewer romantic interests and difficulty attending classes or holding down a job. My experience isn't uncommon. But with support and professional treatment, recovery from body dysmorphic disorder is possible.

How relationships can be affected

Feeling unlovable or disgusting, coupled with the desire to avoid social situations, can make it challenging to maintain any kind of relationship, Cavallaro noted. However, the disorder's effects are especially potent in romantic relationships.

People with BDD may have less desire for sex or avoid it altogether due to anxieties and fears about their bodies. They may feel insecure in their relationships, fearing their partner will leave them for someone more attractive. Subsequently, a lack of intimacy can reinforce a person's feelings of unattractiveness and unworthiness. When people with dysmorphia are intimate, they might struggle to achieve an erection or orgasm, and may panic or dissociate.

"During sex, the individual may feel triggered by their partner touching the undesirable body part, or if the individual sees their own body, they may become overfocused on it and become distressed," Cavallaro said. "In some cases, individuals will mentally check out from sex so that they do not have to be in their bodies. When a person with BDD has these difficulties, it can create feelings of rejection for the partner who doesn't have it, as well."

Body dysmorphic disorder can increase the risk of sexually impulsive behavior, as people with the disorder may seek validation through sex or believe providing sex is necessary to receive affection. They might also pursue casual partnerships, despite desiring a committed relationship, out of fear they're not worthy of commitment.

Coping with BDD

I would not wish dysmorphia on anyone, let alone a loved one. I feel incredibly lucky to have a partner who is supportive, compassionate and empathetic. I am also fortunate to have overcome my body dysmorphic disorder, to a certain degree, with years of hard work and professional help.

Despite this progress, even after months of quarantine and more than two years together, I still get a tinge—or a tsunami—of anxiety about my appearance and my partner's perception of it on occasion. In such situations, Cavallaro said communication is essential.

"Letting your partner know that you're struggling can be helpful in getting the other person's support," she said, adding that other in-the-moment coping strategies include attentional training, observing and mindful breathing.

"For attentional training, you work to switch your mind's focus on something else completely unrelated to the body. Ideally, this would be something that would be easy to recall, like a positive memory or reciting a song, poem or passage from a book," Cavallaro explained. "The skill of observing is just that: Instead of focusing on the body, focus on everything else around you. Mindful breathing is wonderful in that you can do it anytime, anywhere. You focus your attention completely on the sensation of the breath, thereby reducing the focus on negative thoughts."

Cavallaro and Deibler advised that partners of people with BDD should be compassionate and supportive, and avoid arguing or being dismissive. They should let a person with BDD know their feelings are valid but remind them that BDD distorts their self-perception.

'[BDD] is having a grossly distorted view of a body part or composition that takes up an excessive amount of time each day and causes significant distress.'

"Even though you cannot see the perceived flaws a partner with BDD has, they are still suffering," Cavallaro said. "Offer them support and validation, acknowledge their pain and provide an opportunity to listen. Try to refrain from telling them it's not that bad or they will grow out of it."

While compliments are generally positive, Cavallaro also noted the importance of not giving in to a dysmorphic person's frequent reassurance-seeking, as this can reinforce an unhealthy cycle of negative thought patterns.

"It's important to work together and decide not to provide the reassurance, as it can maintain the belief that 'there's something wrong unless someone tells me it's OK,'" she said.

Although reassurance helps in the short term, it maintains the potential anxiety. Instead, acknowledge that the person's BDD is prompting them to seek reassurance and divert their attention to something else more soothing, such as a walk or watching a favorite show.

Finally, Cavallaro and Deibler suggested letting your loved one know you're there to help them find resources and professional treatment, as many people with body dysmorphic disorder put off seeking a diagnosis out of fear or shame. In terms of long-term recovery, a blend of pharmacological and psychotherapeutic methods, such as SNRIs or SSRIs and cognitive behavioral therapy (CBT), are usually most effective.

"BDD-specific cognitive behavioral therapy targets the distorted beliefs and perceptions as well as the repetitive behaviors," Deibler explained. "CBT aims to challenge the individual's unhelpful thoughts regarding his or her appearance and develop cognitive flexibility and nonjudgmental self-acceptance. An exposure therapy process is used to challenge the individual to gradually learn to more adaptively respond to distressing symptom triggers and decrease avoidance behaviors."