Body Dysmorphic Disorder

Introduction
This course is aimed at all staff working with children and young people in primary and secondary
education.

The course will give an overview of body dysmorphic disorder (BDD) and the signs that indicate young
people may be suffering from the condition. The course will help you to understand the condition and
recognise signs and symptoms. You will also understand the support required for BDD and how to ensure
that young people are able to access education and appropriate treatment.

On completion of this course, you will be able to:

• understand what body dysmorphic disorder is
• recognise the signs of body dysmorphic disorder
• know how to support young people who have body dysmorphic disorder
• know how to access professional support.

What is body dysmorphic disorder?

Reflective questions

• From your experience, what do you think body dysmorphic disorder is and how might it impact
on the children and young people with whom you work?

• How do you think BDD is different to normal worries about appearance that all children and
young people experience?

“Based on the available research, we know around 2% of the students in your school,
college or university are likely to have this disorder.”

Body dysmorphic disorder (BDD), or body dysmorphia, is a recognised mental health condition where a
person spends a lot of time worrying about their appearance. A person with BDD feels that there are flaws
in their physical appearance that make them different to their peers. These flaws are often unnoticeable to
others but cause considerable distress to the young person.

It is not unusual for children and young people to have worries about the way that they look, particularly
during puberty. However, those with BDD spend significant amounts of time thinking about their
appearance.

The BDD Foundation state that for someone to receive a diagnosis they will be thinking about their
appearance for at least an hour a day and these thoughts will be causing significant distress and affecting
their daily lives. Recognition of the condition is important due to the effect on emotional health. The BDD
Foundation identify that every year, 1 in 330 people diagnosed with BDD are lost to suicide.

The condition can affect people of any age but does appear to be more common in teenagers and young
adults.

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aspects, Tes Global Ltd exclude their liability of the consequences of any errors, omission or incorrect statements to the fullest extent permitted by law and Tes Global Ltd make no warranty or
representation as to the accuracy, completeness or fitness for purpose of any statements or other content in the course.

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without permission in writing by Tes Global Ltd.
Symptoms can include:
• worrying about a specific area of the body (particularly the face)
• spending a lot of time comparing their looks with others
• looking in mirrors a lot or avoiding mirrors altogether
• going to a lot of effort to conceal flaws – for example, by spending a long time combing
or styling hair, applying make-up, or choosing clothes
• picking at skin.

Young people with BDD may try to avoid places or activities because of their concerns about their
appearance. This might be places with bright lights or lots of mirrors or social situations where they will be
seen close up, such as dating. In school they may try to avoid lessons such as PE, where they may feel
more visible to their peers.

Prevalence
Reflective question

• How many children or young people do you think will be suffering from BDD in your educational
setting?

There is limited data on the prevalence of BDD and many researchers feel that numbers may be higher
than reported as not all people seek support.

OCD UK state that approximately half a percent of the population have BDD; this equates to five in every
1000 people.

The condition usually starts in adolescence, but some may have been suffering for several years before
receiving a diagnosis or seeking support. There is also limited information on the cultural influence of the
condition; there could be higher numbers in cultures that place a higher importance on physical
appearance.

NICE Guidance for the treatment of BDD and OCD describe both disorders as frequently recurring and
chronic conditions. This means that even if children and young people have received support for their
condition, they may have further episodes of distress and require interventions. Therefore, it is important
that those working with them can recognise the signs of the condition.

Reasons why people develop BDD

Body dysmorphic disorder is a complex condition, and it is not known exactly what causes it. However,
there are some identified risk factors, including:
• genetics – young people may be more likely to develop BDD if they have a relative with the
condition
• a chemical imbalance in the brain
• mental health conditions such as OCD, anxiety or eating disorders
• a traumatic experience in the past – young people may be more likely to develop BDD if they were
bullied or abused as a child.

The charity Mind identify that experiencing trauma such as abuse can lead to a negative self-image which
may lead to obsessions about appearance.

Whilst Tes Global Ltd have made every effort to ensure that the courses and their content have been devised and written by leading experts who have ensured that they reflect best practice in all
aspects, Tes Global Ltd exclude their liability of the consequences of any errors, omission or incorrect statements to the fullest extent permitted by law and Tes Global Ltd make no warranty or
representation as to the accuracy, completeness or fitness for purpose of any statements or other content in the course.

No part of this material may be reproduced or utilised in any form or by any means, electronic or mechanical, including photocopying, recording or by any information storage and retrieval system
without permission in writing by Tes Global Ltd.
At risk groups
There are potential risk factors for developing BDD that can be found in particular groups of young people.
Researchers identify that low self-esteem can be a risk factor and this may be more prevalent in certain
groups.

Young people identifying as LGBTQIA, those who are experiencing racism, or young people who are
struggling to fit in and feel rejected by their peers may be more at risk of developing BDD.

The effect on how people with these life experiences view themselves may cause them to become fixated
on elements of their appearance. Young people who take part in activities that are very focused on their
body or appearance may also be at more risk.

This could include:

• modelling
• bodybuilding
• sport and fitness.

BDD in schools
The BDD Foundation state that around two percent of the young people in a school are likely to have the
disorder. This means that school staff need to be able to recognise the signs of the condition to provide
support for young people.

Due to the impact on their emotional health, many young people with BDD have low educational
attendance. In one study, almost 60% of 30 young people (aged between 12 and 18) with a diagnosis of
BDD were either not attending school at all or attending only sporadically (Mataix-Cols et al., 2015).

One study found that 18% of students with BDD dropped out of school entirely because their symptoms
were so severe, making it very difficult for these students to maintain certain academic standards.
Sometimes BDD symptoms can be extremely unmanageable, leading teens to think about and even
attempt suicide.

Types of BDD
Reflective question

• Did you know there are different types of BDD? Do you think children or young people
are always focused on the same issues?

Body dysmorphic disorder is the name for a condition where someone worries frequently about a part or
parts of their body or their appearance. However, there are sub-types of the condition which may present
differently or affect different people.

Muscle dysmorphia
Muscle dysmorphia (or muscle dysmorphic disorder) is a sub-type of BDD where young people obsessively
worry about their body being too small, skinny or not muscular enough. The young person experiencing
these worries is likely to be average size or in some cases they may be very muscular.

Whilst Tes Global Ltd have made every effort to ensure that the courses and their content have been devised and written by leading experts who have ensured that they reflect best practice in all
aspects, Tes Global Ltd exclude their liability of the consequences of any errors, omission or incorrect statements to the fullest extent permitted by law and Tes Global Ltd make no warranty or
representation as to the accuracy, completeness or fitness for purpose of any statements or other content in the course.

No part of this material may be reproduced or utilised in any form or by any means, electronic or mechanical, including photocopying, recording or by any information storage and retrieval system
without permission in writing by Tes Global Ltd.
The condition often leads to behaviours that focus on building muscle, such as:
• overexercising, particularly lifting weights to increase muscle mass
• preoccupation with working out and panicking if unable to attend
• overtraining or training when injured
• disordered eating and following special diets or using excessive supplements
• steroid abuse and often other substance misuse
• compulsive comparing of their body with others
• significant mood swings
• prioritising working out over everything else which may affect relationships and schoolwork.

BDD by proxy
BDD by proxy is when a person becomes focused on the appearance of another person, usually someone
close to them. People with BDD by proxy have often had BDD themselves at some time.
The behaviours in BDD by proxy are similar to those of BDD including constant checking of their
appearance and comparing with others. Even though it is not focused on their own appearance it can still
affect considerable amounts of time and cause great distress.
The condition can cause preoccupation with any part of the body but most often involves the face, skin and
hair. Common areas of concern include:
• teeth
• eyebrows
• body shape
• nose
• chin
• lips
• genitals.

When working with young people it is important to be aware that they may suffer from BDD by proxy or be
the focus of the condition.

Signs of BDD
Reflective question

• When working in a school, what do you think are the signs that a young person may have BDD?

There are several signs and behaviours that may indicate that a young person is suffering from BDD. It is
important that those working with young people are aware of these signs in order to be able to offer
support.

Young people may talk about their concerns with their appearance. They may say that parts of their body
are:
• out of proportion, such as being too big or too small
• disfigured or the wrong shape
• lacking symmetry
• the wrong colour or texture.

Young people with BDD may talk a lot about their concerns with these parts of their body or you may notice
that they go to great lengths to alter or camouflage them. Some young people may have negative thoughts
about their appearance in general, stating that they are ugly or not in proportion.
Whilst Tes Global Ltd have made every effort to ensure that the courses and their content have been devised and written by leading experts who have ensured that they reflect best practice in all
aspects, Tes Global Ltd exclude their liability of the consequences of any errors, omission or incorrect statements to the fullest extent permitted by law and Tes Global Ltd make no warranty or
representation as to the accuracy, completeness or fitness for purpose of any statements or other content in the course.

No part of this material may be reproduced or utilised in any form or by any means, electronic or mechanical, including photocopying, recording or by any information storage and retrieval system
without permission in writing by Tes Global Ltd.
Behaviours of young people with BDD
The feelings that young people with BDD experience will lead to them displaying certain behaviours that
may be recognised by those working with them. These include:
• avoiding situations that cause them anxiety or discomfort
• depression or anxiety
• feelings of guilt or shame
• substance misuse
• disordered eating
• discussing the need for medical procedures, such as cosmetic surgery
• obsessive-compulsive disorder
• self-harm and suicidal thoughts.

Some of these behaviours may be difficult to identify immediately in young people when working in busy
environments such as schools. However, there are some behaviours that may be easier to recognise, such
as:
• frequently checking their appearance in mirrors, or avoiding mirrors completely – this may affect
concentration in lessons
• changing their posture or wearing clothes to try and disguise their shape
• seeking reassurance about their appearance and comparing themselves with others
• overexercising
• picking at their skin
• using tanning products or skin-lighteners
• using social media image filters or photo editing apps
• seeking cosmetic surgery or having other types of medical treatment
• wearing excessive make-up or not adhering to uniform rules at school as a way of camouflaging
appearance
• regularly arriving late, inconsistent attendance or not attending at all
• avoiding certain lessons, such as PE, where aspects of their appearance may be more visible
• appearing distracted and finding it difficult to focus in class due to appearance worries invading the
student’s mind
• avoiding being around peers or groups
• student becoming distressed or upset in class
• decline in academic performance.

Further information
Some young people with BDD may also experience concerns about their weight and shape but they are
likely to also experience other concerns around their body image, such as a facial feature. Having BDD is
not an indicator of an eating disorder on its own.

Supporting children and young people who have BDD

Children and young people can be supported by professionals, staff at school, and those they live with at
home.

Within school, a named person within the pastoral or support teams should be allocated for support.
Children and young people may also benefit from a referral to the school nurse or school counsellor to
provide them with a safe, confidential space to discuss their feelings.

Whilst Tes Global Ltd have made every effort to ensure that the courses and their content have been devised and written by leading experts who have ensured that they reflect best practice in all
aspects, Tes Global Ltd exclude their liability of the consequences of any errors, omission or incorrect statements to the fullest extent permitted by law and Tes Global Ltd make no warranty or
representation as to the accuracy, completeness or fitness for purpose of any statements or other content in the course.

No part of this material may be reproduced or utilised in any form or by any means, electronic or mechanical, including photocopying, recording or by any information storage and retrieval system
without permission in writing by Tes Global Ltd.
Families should be advised to seek support from their local GP, in order to assess the need for further
support.

Support from health professionals

Health professionals will offer support and treatment for BDD.

If symptoms are considered mild, young people may be referred for cognitive behavioural therapy (CBT),
which they will have either on their own or in a group.

With moderate symptoms young people will be offered either CBT or a type of antidepressant medicine
called a selective serotonin reuptake inhibitor (SSRI).

If symptoms are more severe or not improving, then CBT and medication will be offered together.

In-school support
When schools identify that young people may have BDD then they can work to support them. To help
schools identify young people, the BDD Foundation have screening questions.

1. Do you spend an hour or more everyday worrying about your appearance?

2. Do you find yourself carrying out lots of behaviours to cope with your appearance worries
(for example, mirror checking, grooming routines, comparing your appearance with others)?
3. Do your appearance worries upset you a lot and/or get in the way of daily activities
(for example, socialising, going to school, leisure activities)?
4. Are your appearance concerns exclusively focused on being too fat or weighing too much?

If they answered ’yes’ to questions 1) to 3) and ’no’ to 4), it is possible the young person may be
experiencing BDD.

The BDD Foundation suggest a number of ways that young people with a diagnosis can be supported in
the school environment to ensure they can continue to attend.

• Allow young people to request time-out from lessons if they are feeling anxious or overwhelmed.
• Make provision for extra time to complete work in lesson or homework tasks and recognise young
people may be tired due to the pervasive nature of their thoughts and rituals they may engage in.
• Avoid commenting on the young person’s appearance – even positive statements.
• Consider reasonable adjustments to ensure the young person is not disadvantaged; for example,
extra time in exams or taking them into a smaller room.
• Be aware that students with BDD may experience difficulties with peer relationships and suffer low
self-esteem. You should look out for signs of bullying.
• Discuss with the young person the triggers within schools and develop a plan together to help them
to manage the impact they have on their learning.

There are general provisions that schools can make to ensure that all young people are adequately
supported, including:
• good pastoral support
• using interventions, not punishments
• being aware of young people with perfectionist tendencies and high anxiety
• discussing BDD in the PSHE curriculum.

Whilst Tes Global Ltd have made every effort to ensure that the courses and their content have been devised and written by leading experts who have ensured that they reflect best practice in all
aspects, Tes Global Ltd exclude their liability of the consequences of any errors, omission or incorrect statements to the fullest extent permitted by law and Tes Global Ltd make no warranty or
representation as to the accuracy, completeness or fitness for purpose of any statements or other content in the course.

No part of this material may be reproduced or utilised in any form or by any means, electronic or mechanical, including photocopying, recording or by any information storage and retrieval system
without permission in writing by Tes Global Ltd.
At-home support
There are simple things that young people can be encouraged to do at home, in order to help them to cope
with BDD. These include:
• developing a sleeping routine
• having a healthy diet
• exercising
• having regular time outside
• avoiding alcohol and drugs.

Young people can use practices such as mindfulness, relaxation, and breathing exercises to help them
take their focus away from thinking about the elements of their appearance that worry them.

The charity Mind suggest ways that young people can improve their self-esteem, by:
• celebrating their successes
• accepting compliments, making a note of them to look over when feeling low or doubting
themselves
• asking people what they like about them
• writing a list of things they like about themselves.

Signposting
There are several charities that provide advice and support for both children and young people and their
families that may be affected by BDD. These include:

• The BDD Foundation - [Link]

The site has advice and support including information on local and online support groups
and access to webchats.

• Mind - [Link]
The site has advice and support including access to local Mind groups and an email
and telephone helpline.

• OCD UK - [Link]
The site contains advice and support on OCD and BDD including access to a telephone
and email helpline and online discussion forums.

Case study - Lucy

Lucy

Lucy is 14 years old and has previously had good attendance at school. She has always achieved well
academically. Lucy is also good at sports and was previously involved in extracurricular sports. Over the
last six months, Lucy has stopped taking part in any extracurricular sports and will often find reasons to
avoid taking part in PE lessons.

Lucy’s grades have begun to drop due to the reduction in her attendance and she is reluctant to share with
school staff why she is not attending. Lucy has supportive parents who work, attend parents’ evenings, and
respond to communication from school.

Pastoral staff worked with Lucy and her parents to try and understand why her attendance was reduced
and her reluctance to take part in activities.
Whilst Tes Global Ltd have made every effort to ensure that the courses and their content have been devised and written by leading experts who have ensured that they reflect best practice in all
aspects, Tes Global Ltd exclude their liability of the consequences of any errors, omission or incorrect statements to the fullest extent permitted by law and Tes Global Ltd make no warranty or
representation as to the accuracy, completeness or fitness for purpose of any statements or other content in the course.

No part of this material may be reproduced or utilised in any form or by any means, electronic or mechanical, including photocopying, recording or by any information storage and retrieval system
without permission in writing by Tes Global Ltd.
After several sessions with the staff, Lucy was able to share that she felt that she did not look the same as
her peers and was spending lots of her time thinking about this and comparing herself to those around her.

Lucy has originally felt uncomfortable when wearing shorts for sports so had withdrawn from sports to
reduce her anxieties. She had then begun to have the same thoughts when wearing her school uniform and
was therefore becoming anxious about attending.

School staff worked with Lucy and her parents to develop ways to help her increase her attendance at
school. Lucy was given reasonable adjustments meaning she could wear school uniform and PE kit that
she was comfortable in.

Lucy was given a named member of the school staff that she could go to if she was feeling overwhelmed. A
named member of staff meant that Lucy was not having to tell her story lots of times to different people.

Her parents took her to see their GP who referred her for some talking therapy in order to support her
recovery.

These reasonable adjustments meant that Lucy was able to increase her attendance at school and take
part in the activities that she enjoyed in a way she felt more comfortable.

Summary
Body dysmorphic disorder is likely to begin in adolescence and is often closely linked with other mental
health conditions such as OCD. As a member of staff you have a crucial role in spotting the signs early on
and can be instrumental in initiating support.

Ensuring children and young people have a healthy relationship with their body image, and talking openly
about body image and its links to self-esteem is one preventive measure of BDD.

Support should be provided to children and young people with BDD to help them to continue to attend
school and achieve their potential. This includes access to talking therapies and medication if required.

You have now completed your course on ‘Body Dysmorphic Disorder’, in which you have learned about
what the condition is, the signs and symptoms of BDD, and the support you can offer to children and young
people who may be suffering with it.

Click ‘Questionnaire’ to complete the accompanying questionnaire.

When you have completed the questionnaire, there is the opportunity for you to leave feedback on the
course and we would be very grateful if you would take a moment to do so.

Whilst Tes Global Ltd have made every effort to ensure that the courses and their content have been devised and written by leading experts who have ensured that they reflect best practice in all
aspects, Tes Global Ltd exclude their liability of the consequences of any errors, omission or incorrect statements to the fullest extent permitted by law and Tes Global Ltd make no warranty or
representation as to the accuracy, completeness or fitness for purpose of any statements or other content in the course.

No part of this material may be reproduced or utilised in any form or by any means, electronic or mechanical, including photocopying, recording or by any information storage and retrieval system
without permission in writing by Tes Global Ltd.