Imagined imperfection

Imagined imperfection
Most people feel self-conscious about their body from time to time, however, body dysmorphic disorder  gives someone intense concerns about the way they look and  impact their everyday life. 

When Ennalies Oudendijk was 18 years old, she became fixated with her nose. But this obsession was far more than typical teenage anxiety about her appearance.

“I felt my nose was too big and made me really ugly,” she says. “I wouldn’t go out. I became reclusive and didn’t want to hang out with my friends anymore. I would look in the mirror at my nose for hours a day and even measure it with a ruler. I thought I needed to get it fixed, so I went and had my nose done. A year or so later, I still felt I was ugly.”

Several years on, Oudendijk discovered she had body dysmorphic disorder (BDD), a mental illness characterised by preoccupation with an imagined defect in appearance1. There is, in fact, nothing abnormal about her nose – so the cosmetic surgery was unnecessary.

Mirror, mirror

Men and women affected by BDD constantly worry that they look ugly or disfigured, even though they look completely normal. While their concern often centres on the appearance of their eyes, nose, ears or lips, they may become obsessed with the size or shape of virtually any body part1.

Common symptoms include frequent examination in the mirror or steering clear of the mirror completely to avoid looking at an imagined defect-ridden body; constantly seeking reassurance about personal appearance from others; incessant grooming; and wearing excessive clothing or make-up to camouflage perceived flaws2.

“It’s really debilitating and it can affect people’s social functioning,” says clinical psychologist Dr Ben Buchanan, from Victorian Counselling & Psychological Services. “They often can’t go out on the weekend to parties and social functions, because they’re convinced that they look ugly and they’re also convinced that other people are constantly seeing them as ugly.”

Dr Buchanan says if BDD is left untreated, people typically fall into one of two categories – or both, as in Oudendijk’s case. They will either seek cosmetic procedures like rhinoplasty or breast augmentation to fix their perceived defect (research estimates about 14 percent of people who receive cosmetic treatments have BDD3) or withdraw from the world, only leaving the house when absolutely necessary, because they are intensely fearful of social judgement.

The causes

It’s estimated that 1–2 percent of the population is affected by BDD, though the secretive nature of the condition may mean the real figure is much higher1. Scientists are puzzled by the causes of BDD, but genetics, childhood bullying and brain abnormalities are thought to play a part2.

“Sometimes, BDD runs in families and sometimes it runs in families with obsessive compulsive disorder, but it often occurs without a family history,” says Professor David Castle, Chair of Psychiatry at St Vincent’s Health and the University of Melbourne.

He adds that BDD can also relate to environmental issues, such as childhood teasing or having high value put on appearance in youth. “But these are all very soft in a sense,” says Professor Castle. “Many people would be subjected to those sorts of environments, but very few develop BDD.”

In 2013, Dr Buchanan conducted research that identified differences in the brains of people with BDD4. He says these brain differences have two likely causes: a genetic cause and childhood bullying. In the latter case, bullying a child about their appearance can lead them to “start overthinking things to do with their appearance, which leads to brain changes”, explains Dr Buchanan.

“If someone with a genetic predisposition to BDD thinks about their experience during childhood as a result of bullying, that can exacerbate the brain differences and ultimately lead to the diagnosable disorder.”

Body image issues

As was the case with Oudendijk, BDD usually starts during adolescence when negative experiences about your body or self-image are common2. People with low self-esteem can be vulnerable to the condition, which is especially concerning given research reveals 70 percent of Australian girls want to be thinner and the same number of boys want to be thinner or bigger5.

However, BDD isn’t vanity dressed in psychologists’ clothing. “BDD is not vanity at all,” says Professor Castle. “Vain people tend to be somewhat narcissistic and like being the centre of attention. People with BDD are the complete opposite – they feel completely terrible about themselves and they do not want to be out in the world and scrutinised in any way.”

Treatment options

Oudendijk still struggles with occasional bouts of BDD, but thanks to cognitive behavioural therapy (CBT) – the most common and effective treatment for the condition – the now 35-year-old leads a happier and more content life.

“We know that after about 12 sessions of CBT, people are likely to have significant reduction in symptoms,” says Dr Buchanan. “That’s not to say everyone will be cured – that’s certainly not the case – but we know that CBT has the most amount of evidence for its ability to help.”


What to look out for

Worried that you or someone close to you is affected by body dysmorphic disorder (BDD)? Online youth mental health service ReachOut.com6 recommends keeping an eye on these common symptoms:

  • Frequently checking yourself in the mirror
  • Constantly making sure you’re clean and well groomed
  • Trying to hide the body part you don’t like with make-up or clothing
  • Avoiding friends and family because you feel self-conscious
  • Trying to ‘fix’ the body part with cosmetic surgery
  • Worrying that people are criticising your looks

If you’re concerned that these behaviours sound familiar, see your GP and ask for a referral to a psychologist with expertise in BDD.



  3. The Journal of the American Academy of Dermatology, ‘Body dysmorphic disorder among dermatologic patients: Prevalence and clinical features’ (August 2010)
  4. Psychological Medicine, ‘Brain connectivity in body dysmorphic disorder compared with controls: a diffusion tensor imaging study’ (December 2013)



Information provided in this article is not medical advice and you should consult with your healthcare practitioner. Australian Unity accepts no responsibility for the accuracy of any of the opinions, advice, representations or information contained in this publication. Readers should rely on their own advice and enquiries in making decisions affecting their own health, wellbeing or interest.