Male Body Dysmorphia: Clinical Insights on BDD in Men

Dr Brodsky: The overriding symptom of BDD involves a very distorted body image. This usually focuses upon a very isolated feature in the person’s appearance. For men, in particular, it could be something about their hair, face, muscles, genitals, or height.

Typically, people with BDD engage in a variety of either concealing or attempts at correcting behaviors. They may cover up with clothing, or if they are worried about their hair or balding, they may wear a hat or a toupee. There is a great deal of social avoidance and being in public[…]for fear of having these imagined flaws exposed.

They may involve correcting behaviors that could include wearing clothing that is extremely shape-forming rather than shape-revealing. It could also involve skin picking to address some kind of defect on the face or skin. It could involve compulsive hair cutting and reshaping. This constant reshaping to compensate for a perceived flaw can lead to hair having a very “strange” look.

Oftentimes, individuals are concerned with the symmetry of their appearance. They engage in constant checking throughout the day, such as looking in mirrors or feeling their muscles, like biceps, to see if they are symmetrical. They may also check for fat around the waist or other features, like hair and skin.

Individuals perform a tremendous amount of comparing to other men, sometimes to celebrities whose retouched photos are not realistic. They often seek reassurance from others, or try to reassure themselves, usually in vain. This is a very time-consuming process that consumes hours of their day and causes acute distress, rather than just a quick spruce up in the mirror.

Other common behaviors include overexercising with extreme and lengthy workout routines; expressing extraordinary distress if a single workout is missed; steroid use or cosmetic procedures, though they usually find no relief from such procedures; or consuming excessive protein supplements and following unusual, ever-changing diets to get an optimum result.

Individuals prioritize these activities[…]over social or work relationships and responsibilities. They are also less likely to seek help.

BDD is a very “democratic” disorder that affects people equally regardless of race, ethnicity, or location. It affects both men and women. Corrective behaviors tend to attract younger men, particularly adolescents. However, it becomes more of an issue as a person ages and they move further from the “ideal Hollywood appearance,” which may lead to more concealing and avoidant behaviors.

Dr Roberto Olivardia: So, with BDD, what a lot of people might be surprised by is that men are just as affected by BDD as women, and that the areas of preoccupation could be their nose, their skin, [or] their hair. As with BDD, this is a psychiatric disorder where people are often preoccupied with a part or many parts of their body in which they think are ugly or abnormal looking. And then, that is coupled with a lot of obsessive thoughts about it, compulsive behaviors, [and] avoidant behaviors.

With men, you might have things that are[…]more unique to them, such as preoccupation with muscle mass or muscle size and, a subtype of BDD[…]called muscle dysmorphia. Things like penis size, height, hair, and hair loss, and things that are[…]assigned to men fitting this kind of role of what it means to sort of be[…]a masculine individual.

It can affect people of all ages. I have worked with boys as young as 9 [years] with BDD. I have worked with men in their late 60s [with]…BDD. We tend to hear it more between adolescence to [age] 30 [years], partly because almost everybody struggles with body image on some level in adolescence, and it becomes[…]more apparent with BDD that this is more than[…a] typical adolescent concern.

But [in] BDD, and particularly with men, there is often a lot of shame attached to it. So, a lot of men are not coming [for] treatment or therapy either due to feelings of shame or not understanding that this is a diagnosis. They just have these beliefs that they are ugly or that something is wrong with their appearance.

Dr Fisher: For men, some of the male-specific concerns—and now I will go into the male-specific concerns—are hair loss[…]It seems women [do not lose hair often], and again this comes back to[…]the cultural aspect of BDD and also the societal aspect of BDD. Because[…]what we are told is important for this ideal—for women, the ideal version of how a beautiful woman should look, or this ideal version for how a handsome man should look, which is promoted on sites like “looksmaxxing.”

Unfortunately, these days, this is what people with BDD latch onto, these ideals. Like the ideal is[…]guys should have a full head of hair[…b]ecause they look more virile that way[…]they are more attractive to the opposite sex. Which again, although women are concerned about that, it really seems to be much more of a male concern. [Y]ou would think that in our society, women being beautiful, attracting men, would be where you would see[…]BDD be more prevalent. But it is actually not the case because sites like “looksmaxxing,” and, for young men especially, being[…]handsome means they are going to be more attractive.

[…T]here’s a lot of cognitive distortions that people with BDD have that are very similar, I might say, to what people with anxiety have. These negative core beliefs and these cognitive thinking errors are similar for a lot of these disorders. And one of the thinking errors that is especially prevalent for men and women with BDD, but especially men when it comes to being sexually attractive[…]is: “If I looked better, my whole life would be better.” And “If I looked better, I’d have a ton of women falling at my feet. I’d have tons of women wanting to date me. I’d have a great job, I’d have a great career. I’d be doing well in almost every aspect of my life,” because there is this equation of looking good and performing well in society and being thought highly of.

Again, I want to stress that that is not totally without basis in reality, because it is important on social media. There [are] filters on social media[…and] “looksmaxxing” sites that are particular for young men on social media. So, there is this emphasis on social media that looking good is important[…]because we are a society that values youthfulness and especially youthful attractiveness. And so, basically, there is this focus in our society on being beautiful or handsome and being youthful-looking[…T]hat is where this hair loss issue comes in for men. Another interesting thing that happens for men a lot is this square jaw phenomenon. Like this emphasis on having a very square, masculine jaw that also is supposed to send out this vibe of masculinity and virility.

Dr Sharon Batista: [C]ommonly, men present with behaviors like excessive mirror checking or mirror avoidance[…to avoid] seeing the “upsetting” parts of their body or their appearance—compulsive exercise, rigid dietary control[…for instance], being[…]very strict about portions and timing and types of foods that are allowed or not allowed. Just like women, men can camouflage their bodies. So, they can wear clothing that[…]hides the areas that are upsetting or try to maintain postures that[…]take attention away from their body; also, grooming, sometimes, so as to camouflage areas that are upsetting or distressing. And then, sometimes, men seek reassurance. They might ask people close to them[…]how do they look or what do they think or try to get some kind of[…]check on[…]how they seem to others.

Again, we did talk a little bit about the overlay with our fitness culture and how that is perceived and reinforced in our culture. So, you will see a lot of these behaviors in fitness environments and, yes, in bodybuilding environments too, in online forums around optimizing or biohacking. [Other things could be…]personal maximizing [or] optimizing perfection oriented stuff. There is a lot of material online around that. And a lot of the norms here I think[…]discourage any disclosure [or…]validation of the distress. So, it is all about[…]masculinity and overcoming and improving. So, you will see that a lot too. [A]lso psychologically high degrees of shame and low self-esteem, [and], at times, rejection sensitivity. [….B]ecause of the areas of discomfort, they will avoid[…]social interaction. So, withdrawing socially[…]as not to be[…]seen or not to have the flaws or the upsetting areas of the body observed, [which…]can lead to some interpersonal difficulty as well.

[…I]f we were to zoom out, it is the same for men and women that we are really going to address how to normalize their function in their everyday life, although it is going to be different based on the manifestations [of] the symptoms themselves. So, the compulsions will be part of our focus in the treatment. [W]hat we would like to do is to focus on increasing activity in their life, increasing, for example, time with friends and family, improving function at work, reducing any compulsions that get in the way of those things or avoidances[…] So the interventions are on[…]the micro level of trying to actually work on improving the quality of that person’s life by engaging fully in their life. [B]y engaging fully in their life, there is less room for so much of those compulsions. And so, we do some education on[…]healthy levels of exercise, what can be harmful, what can[…cause] harm, […and] what can help. But also really trying to build a balance that is not[…]eliminating the behavior completely. It is how[…]we build it into[…]a more healthy level, but by doing so, make more room for other pleasurable activities.

Dr Brodsky: I think it contributes, again, both to men and women, but obviously, there is a tremendous amount of social comparison, constantly checking, rechecking how someone else looks against you or pictures of yourself that are being posted. I [also think] that the internet has provided information that most people in their regular lives would never have been privy to or maybe even interested in before. There is just so much information at your fingertips. With men[…]the whole culture and inner circle of bodybuilding, professional bodybuilding, for example, these are things that are done by relatively healthy people who are just really bringing their body to a certain performance max, mainly for strength. Whereas that information which is always being posted—bodybuilding competitions, pictures of bodybuilders and so forth, information about their special diets, and all kinds of other things—is now equally accessible by just an average person[…]who begins[…]to compare themselves not just to friends and peers, but to these Adonis-like looking professional athletes who compete in the world of weightlifting. So, I think it is enormous. It certainly has fueled it[…and] enabled it. It allows them to engage in these sorts of compulsions. 

The other thing that social media and the internet have provided is porn. There are things that a generation ago most people would literally never see. [I]f they wanted to, they had [to] go to a certain part of town and[…]sneak in with a hat over their head or something to[…]watch this. This is now in every home and certainly every young man’s day-to-day life. Obviously, you are now comparing yourself against the most private aspects of another person’s physique. And I would say with women as well, these are oftentimes extremely unusual, to say the least, body features and shapes. So, now, this is also something that they are comparing themselves to.

Dr Olivardia: Social media is a gasoline on a fire when it comes to BDD and negative body image. Doing this[…for] over 30 years now I have [worked…]with men and boys with eating disorders, BDD, [and] body image issues. And I can almost track to almost the month where social media[…]emerged as to how it elevated this problem[…]Now, it did not[…]start with social media because it [has] been around[…]for a while, but there is no question that it has definitely gotten worse with social media […N]ow, unlike even presocial media, we might have been talking about media imagery of advertising and movie stars and fitness magazines and all of that influence[…]on boys and men and their body image.

But now you have a medium which curates to people on a highly frequent basis. [I]f you imagine the amount of time people spend on their phones, and for my patients with BDD, they are spending way too much time[…]on social media. So, it is curating to them and[…]social media knows what you are spending time looking at and will send you more of that stuff. [S]o, now, these young men and older men, boys are getting this imagery of “Oh, this is what you should look like. These are things you should do to your body, [or] to your face to look more like a man, to be more desired, to be seen as more powerful, [or] to be more respected.”

And that media is really speaking particularly to a lot of young men who feel insecure, who feel inadequate, who feel[…]anxious, [or] who might be depressed. And speaking to them and giving them this sort of messaging that all of that can go away and they can be granted this confidence and granted all this power and assertiveness if they look a certain way. And this is not different from what has been sort of curated to women and girls historically. It is like “if you look thin and if you look this way then all these things will sort of[…]come to you” and boys and men are definitely getting that message and[…]I am seeing[…at] younger ages[…]the sort of development of BDD[…and] also the harm that people are doing to their bodies because some of these influencers are promoting these things that are completely “bonkers.”

I[t is…]harmful that young people will listen to and because someone has[…]5 million followers there is an instant credibility they have. And so, as a provider, as a clinician[…], one of the first questions I ask in an intake, especially when I am working with a [man] with BDD, is “who do you follow on social media?” […M]ost of them I know because I hear the same people often, but if I do not, I will find that content because I want to know what they are basically being fed in all of the hours[…when] they are not in a therapy session, which is obviously more of their life.

And I also have to realize that my credibility as a clinician or for any medical mental health provider is almost either on par if not sometimes lower than the influencers that they are listening to[…] I find myself almost having to debate[…]some of these things that are often taken as fact that[…]influencers[…]might be promoting. And particularly with things like with BDD, [and] with boys and men, let us say, who have BDD around their muscle mass, and they are following people who are avid anabolic steroid users and saying, “Oh, there’s nothing wrong with steroids. In fact, you should be doing them.” [I]t is a big big problem and[…]social media is not going to go away. So, I find a lot of the work sometimes with people is learning[…]how to almost be a more critical consumer of it.

Dr Fisher: After learning about the looksmaxxing site from some parents in my support group — by the way, because I also do a support group of caregivers of people with BDD — and some of the parents expressed concern[…], I looked up the site and[…]was horrified that they actually have what is supposed to be a support forum for young men, and all it is promoting how they can change their appearance to look more masculine. Not only that, but they encourage young men to send[…]images of themselves that then they can compare and[…]see how far off the ideal masculine image their face is, and their body too, but it is very focused on one’s face.

Then there [are] ways that different types of products are promoted, or plastic surgery, or hair implants, or all kinds of ways to fix one’s face, supposedly, to make it this ideal that is going to then[…]make them so marketable. Do I think it could fuel BDD symptoms? Of course[…]Do I think it causes BDD symptoms? No, because there are multiple causes for BDD, and I will not go into them right now.

But [c]ertainly, those sites — like Instagram for women with filters and all that stuff — they do not help because they simply reinforce the message: your looks give you self-worth. Your looks equal your self-worth; that is the message they send. And, I think, as people, especially younger men, especially younger adolescents, [w]hen people’s brains are forming (and they are forming in adolescence) and that is also the primary time that BDD develops. I do not think that is a coincidence.

You do not know any better and, [t]his feels like there is so much out of your control when your hormones are taking over and you are trying to figure out who you are, and what you like, and what you are good at, right? And how you are related to the opposite sex. And that is true for men and women. And unfortunately, [t]here is now social media sites like looksmaxxing that really seem to cater and fuel this obsession.

Dr Brodsky: Unfortunately, a lot of well-trained but maybe uninformed providers[…]especially in the medical field, need to be aware of this. […When] a person comes[…]to a medical provider, let us say a dermatologist, and is…distraught, is looking for some relief […and] reassurance, and providers feel that pressure and […the] need to[…]solve this person’s problem. So, they may engage in unnecessary or repetitive cosmetic procedures.

[It is the] same thing with therapists. If a therapist is not aware that some [one has…] BDD, and there is a whole host of other diagnoses I could speak about that it might mimic, then what happens is that, well-intended but otherwise not informed clinicians, therapists, will[…]end up excessively reassuring the person: “Oh, you look perfectly fine,” “you look very attractive,”[…]and that provides[…]a temporary fix, but it does not really stick. [I]in fact, what it is doing is[…]just reinforcing the very thing that they are trying to do already in order to feel that their appearance is okay. But it does not really work, it just means that you are thinking about your appearance all that more.

As far as motivators, [a]gain to these very extreme measures, usually people who, in general, pursue extreme measures have a certain black-and-white way of thinking. [S]omething is either absolutely perfect or it’s completely [r]epugnant. Very often, people who engage in these very extreme behaviors, these [h]eight-adjusting surgeries that are done [i]n Asia usually, and some [u]nder very disreputable [a]nd not healthy circumstances, a lot of these people have come to view the world, have come to view themselves sometimes, this particular population with the extreme measures, very extreme sort of victim mentality in which, again, they’ve experienced rejection and at a very early age come up with very immature ideas as to what one has to be in order to be in a loving relationship.

The thing that usually [a]dolescents or very young men attach [t]o is their appearance. They begin to develop sometimes even a whole almost [sic] bordering on conspiratorial ideology. Again, we’re just talking about the people who do follow these very extreme procedures. [T]here are some of them who can sometimes have very almost misogynistic conspiracy kinds of theories about how men are controlled by women, that women set, [t]he rules in society as to who’s acceptable [and] who’s not acceptable. It’s a whole big conspiracy that they can often come up with and they view like the entire world in these very black-and-white terms. Some of them have even, again, a small number, but some of them have even been moved to commit violence because of that ideology. So, a lot of times, if you’re going to do something so extreme, you definitely often have a worldview that’s equally extreme.

Dr Olivardia: [I]t is fascinating with a lot of neurological research that is beginning and has been over the last several years looking at how is it that people with BDD, the men who struggle with BDD, are they seeing something different than what you and I might see? Because again, the body image disparity is quite significant. [T]hey may look at something and other people around them are like, “What are you talking about? You look fine”. And you know, in fact, some people might say you look very attractive and they are seeing something completely different. And so [in] a lot of neurologic research[, the question was]…are they… visually seeing it differently? Are they just attending to it differently? Are they interpreting it or feeling differently? And it could be a little bit of all the above. [S]tudies show that for people with BDD, they tend to be very fixated at very small details. So in 1 level they might have a higher visual acuity.

Now the reality is that we look the same from 1 day to the next for the most part. You know somebody will recognize me tomorrow because they know what I look like today. With BDD though it is almost like those small changes like perhaps if I have…darker circles under my eyes tomorrow. I know I still look like me, but maybe my eyes are a little darker because I did not get a good night’s sleep. Someone…with BDD…[with that] area of preoccupation, might see that and their brain…saying, “Oh, there’s a change. I now look completely different and I am now relegated to this different category”. So, they might notice the very small things. Now, this is where it is a chicken and the egg question because is it that their brains are just more wired that way because every brain has different neurologies.

Interestingly, there was a study many years ago that—and I have seen this clinically in my practice—of people with BDD as compared to people with obsessive-compulsive disorder (OCD), depression…[and I believe] post-traumatic stress disorder (PTSD) that found…a significantly higher rate of people with BDD that were engaged in careers that relied on visual stimuli and visual acuity. So things like architect, photographer, interior design, things that rely…on having a good eye for details and for things. Now again, the chicken and the egg question is that we know that people with BDD, one of the compulsive behaviors we will often see is mirror checking, taking selfies…almost…fixated on that body part. So if let us say somebody has BDD around their nose, this might be somebody who is spending up to 4 or 5 hours a day looking at their nose, touching their nose, seeing every sort of crevice and detail of it. So on that end, they may notice differences from 1 day to the next in a way that most of us would not because nobody is critiquing someone else’s nose the way that someone with BDD is critiquing their own nose.

So…is [the brain] primed to see that detail because it is just getting this repeated very fixated exposure or is it that the brain just naturally is almost more geared towards noticing those things visually… [I]t may be a combination of both is what they are showing but it is very exciting research to…see. And similar research is also done for people with anorexia nervosa in terms of how are they processing things, what parts of the brain are being activated. And one of the things that they also find is that with people with BDD when, let us say, they are looking at the body part that they are preoccupied with…there are parts of the brain that get activated…[which are associated with] emotional parts of the brain…[These parts] get activated under periods of stress or threat and parts…that evoke emotions of disgust.

So there is 1 aspect emotionally for people with BDD where they may get anxious because they feel they look a certain way. But the other piece is that there is a real high degree of repulsion that they have. And this is where it is different than somebody that says, “Oh, you know, I don’t like my hair. I don’t like… my skin”….[M]ost of us have negative body image about something. People with BDD, it is like a real disgust. That is why we hear words like ugly, abnormal, mutant… freak, like these sort of real categorically almost off the charts sort of ways that people with BDD would see themselves. So, I am excited about just more of that research being done to help us understand that there is a neurologic component likely to this as well. 

Granet: BDD takes quite a toll on relationships, whether they are romantic relationships or involve friends and family. If someone is having a relationship with a part of their body, it is very difficult to have relationships with other people. Healthcare providers need to stress the importance of getting treatment for this, as there is effective treatment available.

Unfortunately, many people with BDD understandably seek out cosmetic treatment instead. If you are concerned about your nose being misshapen, your first thought is probably going to be to see a plastic surgeon rather than a psychotherapist. However, with BDD, surgery does not help. The vast majority of people with BDD who have surgery to correct a body part do not like the results, feel worse, and then feel an additional element of shame for having done it to themselves.

Other clinicians, especially healthcare providers, must be very careful when addressing whether to perform surgery. One of the most tragic things is when people have plastic surgery, dislike the results, and feel even worse. You cannot turn back the clock and get your original nose back.

In treatment, I never tell someone they cannot have a procedure done because that might be the one piece of hope they hang on to. Instead, I give them the facts: only about 5% of people with BDD who have plastic surgery wind up liking the results or resolving the BDD. I encourage them to do a few months of therapy first and then reassess.

It is important to recognize that most people with BDD also suffer severely from depression, and there is an alarming rate of suicide attempts—about 25% to 30%—with this disorder. Many look at plastic surgery as a life-changing event that will save them. I don’t want to take that away entirely for fear of contributing to more depression, but I want them to commit to therapy and delay the procedure until they recognize they do not need it.

Dr Batista: Now, some of this also means they have to confront situations that are really distressing. So, if they have been avoiding, say, dating or spending time with friends because they are worried about what those people think about them or what they perceive in them, […s]pending more time in those situations means they have to confront those concerns. And so, part of the treatment is helping the person to confront those concerns they have going on in their minds and to develop some tolerance and correction for them. They are thinking about other things when you are hanging out with them. But you have to actually have a lot of times going out and spending time with friends and family to come to that conclusion yourself. And so, [the patient has] got to[…]practice and test the evidence for and evidence against. But [the patient has] got to have more real-life experiences to be able to do those tests. And so, some of the treatment has to do with actually doing experiments in real life that can then help to build out more balanced thinking against the more distorted thoughts that are the self-critical thoughts.

Really commonly, the feelings in BDD, I had [to] say, emotionally, there [are] high levels of anxiety […and] depression. There is a lot of, I’ll call them feelings—maybe they are more just like thoughts—but really strong negative thoughts that are self-critical and self-critical around whatever the areas[…]the person perceives themselves as being imperfect in or flawed in. And so, I have known patients to have really dark, upsetting thoughts about themselves. Things like that they are disgusting, unlovable, that they should be hidden away, [or] should not be viewed. They feel that their appearance is offensive to others sometimes. Things like that[…]are really hard to imagine for those of us who do not have BDD because they are so outsized […and] large. I mean, to think a person could be fundamentally “disgusting” or “unlovable” really just defies logic to me. But that is really how they feel and on an everyday basis.

So, the anxiety state is very high because they are worried about being judged or evaluated or criticized by others, whether outwardly or just in thoughts [in] an unknown way. They are worried about how they are perceived and they are thinking about it the whole time that they are in different social interactions. And so, they are very distracted and stressed when they are out and about sometimes. Or depending on what the flaw is, it may be contextual to that flaw. It is more observable in certain situations than others. There is a lot of time spent and a lot of mental energy spent on planning for certain interactions or certain experiences and getting ready. So getting ready to leave the house could be[…], depending on what the issue may be, [mentally draining]. So, they will be [spending] a lot of [time] invest[ing] in how to get ready. That could be a compulsion, like dress a certain way, apply makeup a certain way, or cover yourself up a certain way, or check the mirror and make sure. But this is all high stress, high anxiety state while approaching leaving the house, something that we do day in and day out and we do not think about. So, it is really globally very distressing for people affected by it.

So, it is not [that…] we just give tips and we say, “Okay, it’s going to be better now, so go on into the world,” right? No. It is a process to really be able to recover from BDD. And so, the way I generally guide patients is that this is really[…]1 small step at a time, and we have to build out 1 small skill at a time. There is not […a] path [or] piece of advice that you give a person and they suddenly feel better about themselves. And actually, let me bring that up—we never recommend reassuring a person or arguing with a patient about their appearance or what they feel their flaws are. That is not productive. It is not helpful to them and they w[ill not] feel better. Actually, they might [feel] even feel worse. And so, our goals are to help with coping with everyday life things and living in a more balanced way on the daily. But it is not to convince a person to think otherwise of themselves. They really have to, over time, come to other conclusions about themselves through education, through getting a more variety of life experiences, and through sometimes therapy. But we are not going to tell a person what to think so as to feel better; that is not effective.