It’s normal to look in the mirror from time to time and notice the features or body parts that trigger insecurities and even a bit of unease. But what if the perceived flaws you’re focused on aren’t your own? Maybe you find yourself obsessing over your spouse’s balding head, teenager’s acne, child’s asymmetrical face, partner’s belly, or a friend’s wrinkles. The fixation on another person’s perceived flaws may even become a full-blown preoccupation, interfering with your daily life and personal relationships, and making you feel anxious and guilty for having these fixations in the first place.
If you relate to this, you may be struggling with body dysmorphic disorder by proxy (BDD by proxy, or BDDBP), a lesser-known form of body dysmorphic disorder (BDD) in which people are preoccupied by other people’s appearances instead of their own.
Fortunately, you don’t have to struggle forever. Read on to learn more about the disorder, and treatment options that can free you from the preoccupation and improve your well-being.
What Is Body Dysmorphic Disorder by Proxy (BDDBP)?
BDD by proxy, or BDDBP, is a type of body dysmorphic disorder. Someone with body dysmorphic disorder (BDD) cannot stop thinking about their own perceived flaw in their appearance. Traits or features that others might see as a slight imperfection—or not notice at all—become all-consuming to people with BDD.
In body dysmorphic disorder by proxy, you are not preoccupied by your own imperfections but by the perceived flaws of another person. You may be fixated on someone’s skin imperfections, thinning or unruly hair, crooked or discolored teeth, wrinkles or other signs of aging, body type or composition—just about any body part or physical feature you believe must be fixed.
According to a 2013 study, the average individual with BDD by proxy is preoccupied by at least five people’s flaws (although it’s certainly possible to be focused on just one). As for who you fixate on, otherwise known as the “Person of Concern” (POC), it can be family members, friends, coworkers, or even complete strangers. However, in many cases, the primary PoC is a significant other.
Understanding BDD by proxy: 5 key characteristics
The characteristics and behaviors of BDD by proxy may differ from person to person. Here are some of the common ways it shows up:
1. Your preoccupation isn’t fixed.
Your preoccupation may move from one person to the next. For example, you may feel concerned about a partner’s crooked teeth. But if you break up, you may move on to worrying about a new partner’s gray hair. You may also become concerned with more than one person. It may start with feeling disturbed by your spouse’s thick eyebrows, but eventually, you might find yourself preoccupied with the characteristics of your children or parents too.
2. Your distress may impact many parts of your life.
Most people suffering from BDDBP experience significant distress. You may feel shame or guilt for focusing on such superficial things, or worry you’re a bad person as a result. It is not uncommon for your obsessive thoughts or ritualistic behaviors to interfere with your day-to-day functioning. You may miss important events or see your productivity at work take a hit. Not surprisingly, BDD by proxy may deeply impact your relationships. If your PoC is a spouse, partner, or close friend, they may feel judged or criticized, which can lead to a strained relationship.
3. You may be relying on avoidance.
Avoidance may become a coping mechanism—one that allows you to cut down on exposure to the perceived flaws of your PoC. If you are preoccupied with your child’s gummy smile, you may avoid signing them up for picture day at school. If you are worried about your spouse’s belly, you may avoid going to the beach together.
4. You may engage in ritualistic behaviors.
Time-consuming ritualistic behavior is a common issue in BDD by proxy. Ritualistic behaviors may help, albeit temporarily, to reduce anxiety or guilt related to BDDBP. In other cases, the behaviors are performed to try to improve the PoC’s appearance. This can look like constantly “checking” to see if the flaw—such as a partner’s bald spot—has gotten worse, or offering your partner a hat to cover up his gray hair anytime he walks out the door.
5. Your thoughts may turn into beliefs.
BDD by proxy doesn’t stop with your internal thoughts about the appearance of the PoC. You may develop inaccurate beliefs about how much attention other people pay to the perceived flaw you’re fixated on, or convince yourself that this “defect” will significantly affect the POC or your relationship with them.
Causes and risk factors
It’s not known specifically what causes BDD by proxy. Like many other mental health conditions, it may result from a combination of issues, including environmental, psychological, and genetic factors. Judy Lair, LPCC, also notes that “over the past few years as social media opens up our lives to each other, there has been a correlating increase in an unhealthy focus on body parts and obsessive drive to fix perceived flaws out of fear of not being accepted.”
Having a family history of BDD, BDD by proxy, or obsessive-compulsive disorder (OCD) may increase your risk of developing BDDBP. Societal expectations and certain personality traits such as perfectionism may play a role. Negative childhood experiences, such as teasing, bullying, or abuse, may increase your risk—as can having another mental health condition, including OCD, anxiety, or depression. Chemical imbalances or abnormal brain function may also be a contributing factor.
Is BDD by proxy an official mental health diagnosis?
Mental health professionals use the Diagnostic and Statistical Manual of Mental Disorders, also known as the DSM-5, to diagnose mental health disorders. Interestingly, while BDD is listed under “Obsessive-Compulsive and Related Disorders,” BDD by proxy is a form of BDD that’s not specified in the DSM-5. This means that BDD by proxy is not an official diagnosis. However, the DSM is regularly updated, and new disorders are added as more and more professionals become aware of a condition and new research sheds light on patients’ experiences.
Until a relatively recent study, most of our information on BDD by proxy came only from case reports. In 2013, researchers finally examined the clinical features of BDDBP. Since then, we’ve seen a small influx of studies on the BDDBP and its treatment.
OCD and BDDBP: What do they have to do with each other?
Though BDD by proxy and OCD are not the same, they are related disorders. Symptoms and experiences of the two conditions may overlap, they may co-occur, and one may trigger the other.
Sometimes the similarities between OCD and BDD by proxy can lead clinicians who are not specifically trained in both disorders to misdiagnose a patient. Here are some examples:
- Both OCD and BDD by proxy involve persistent unwanted thoughts that cause a lot of distress.
- Both OCD and BDD by proxy can lead to ritualistic behaviors to cope with the distress brought on by these thoughts.
- Both OCD and BDD by proxy can involve a preoccupation with things being symmetrical or “perfect.” For instance, facial features that are not symmetrical may trigger someone with BDD by proxy and also someone with the OCD subtype of “Just Right” or Perfectionism OCD.
- Both OCD and BDD by proxy can lead sufferers to isolate themselves or fear the rejection of others.
- Both OCD and BDD by proxy and OCD may impair your daily functioning, affect social interactions, strain relationships, and cause personal distress.
Another factor that can make distinguishing a diagnosis tricky: A subtype of OCD exists called relationship OCD (ROCD). While people with all forms of OCD experience repeated unwanted and intrusive thoughts (that’s the obsessive part) that compel them to perform repetitive behaviors (aka compulsions), in the case of ROCD, these thoughts center around a relationship. People with ROCD can be intensely preoccupied with their partner or relationship for a number of reasons (not all physical), but one manifestation of the disorder is ruminating on certain thoughts about the perceived physical flaws in their partner, says Dr. Patrick McGrath, psychologist and Chief Clinical Officer at NOCD.
“Every day I wake up obsessing over my partner’s looks and whether I find her attractive,” explains one Reddit user who struggled with ROCD. “She has some ‘flaws’ such as some loose skin on her stomach from weight loss but—objectively—she’s an attractive person. That being said, I feel like I can’t stop obsessing over her body and face. When I think she’s pretty it makes me euphoric. When I doubt if I find her attractive, it makes me extremely anxious and causes me to avoid looking at certain parts of her body or touching them.”
This anecdote shows just how similar BDD by proxy and OCD can be—at least on the surface. But don’t worry, it’s definitely possible to figure out what’s truly going on. Despite the similarities, the differences between OCD and BDD by proxy can be determined by mental health professionals who are trained in OCD or both conditions. For example, OCD specialists will be on the lookout to understand if the focus of your preoccupation goes beyond another’s physical appearance.
Why? Well, in BDD by proxy, intrusive and distressing thoughts and repetitive behaviors are always related to a PoC’s appearance. In OCD, on the other hand, obsessions and compulsions cover a broader spectrum and can be based on a wide range of themes. They may be related to orderliness, contamination, counting, harm, relationships, and other areas. Even if you have ROCD, your obsessive thoughts often go beyond appearance—for example, you may be fixated on whether you’re in the right relationship or whether your partner will cheat on you. The underlying root of OCD is based on an inaccurate perception of intrusive thoughts, images, or urges as real threats.
Making an appointment with a trained professional takes a lot of pressure away from having to figure out the underlying cause yourself.
Treatment options for BDDBP
As mentioned earlier, research on treatment options for BDD by proxy is very limited. Just like for BDD, cognitive-behavioral therapy (CBT) seems to be the most promising and is currently the gold standard. A 2016 small clinical trial found that CBT modified for BDDBP delivered in weekly individual sessions over 12 to 20 weeks resulted in an improvement of symptoms. These results were maintained at a 3-month follow-up. A few other studies have found it to be beneficial as well.
CBT is a form of talk therapy that helps you understand the connections between your thoughts, feelings and behaviors—and learn practical skills to manage them. Over time, it may help you change your attitude towards people’s physical appearance and reduce your need to engage in ritualistic behaviors. When therapy alone is not enough, taking serotonin-reuptake inhibitors (SSRIs, or SRIs) combined with CBT may lead to better treatment outcomes.
If you have BDD by proxy, getting an evaluation for OCD can help you know whether both conditions are at play—or whether OCD is the true culprit. That’s important because your treatment plan, if you have OCD, will need to be customized and include a very specific type of therapy designed to treat OCD.
OCD is in fact highly treatable with Exposure and Response Prevention (ERP). This specialized treatment is unlike traditional talk therapy or general CBT, and the effectiveness of ERP in treating OCD is backed by decades of clinical research. The goal of ERP is to retrain your brain to recognize a more accurate threat level. ERP works by gradually exposing you to your triggers, and teaching you response prevention strategies to cope with your distress—things that don’t involve compulsions.
NOCD member Victoria A. says that ERP helped her “learn how important it is to let thoughts be there. I don’t need to respond, I don’t need to do anything with them. Within my first couple of months of treatment, I started to feel some relief. It’s been over 2 years now and I continue to make huge strides.”