Body Dysmorphic Disorder: A pediatric dermatologist’s perspective

Dr Margaret Lee, Boston University School of Medicine

Imagine talking to a teenager who wants the strongest therapy available for acne, but you don’t see any red bumps. Imagine being told by a young woman that when she wears a bikini she constantly holds her arm a certain way to make sure no one can see the benign mole smaller than the size of a chocolate chip. How would you advise the mother who says that her 10-year-old spends more than an hour every morning in the bathroom tending to blemishes most people don’t see, or visits the bathroom to check the mirror five times a night? What skin care recommendations could possibly help them?

These are the kinds of scenarios I find myself in as a pediatric dermatologist. And these are some of the patients I worry about the most. Why? People think none of them have a serious, life-threatening disease, that they are worried about nothing and just need to “GET OVER IT.” But all of them have or are at risk for body dysmorphic disorder (BDD), which has the highest suicide rate among all mental health conditions relevant to dermatology. Actually, psychosocial health, which includes mental health versus illness, is relevant to ALL skin conditions.    

The current social media selfie culture and ability to instantly edit photos has not helped matters. There is now a recognized problem called “Snapchat dysmorphia,” where people are becoming obsessed with their appearance both online and offline, asking dermatologists and plastic surgeons to help them look like their edited photos. The reality is celebrities have been doing this for years. How many of them have BDD? And how many kids, young adults and even those celebrities need to be cyberbullied before everyone out there agrees that any verbal attacks over physical appearance, race, religion, or creed, is as unacceptable as physical violence?

I don’t have any answers for you. But I am here writing because if dermatologists ally closely with mental health professionals, I believe we can learn to identify subthreshold BDD, early risk factors, and functional BDD patients who are hiding intense pain, so that we all can help put out a fire before it destroys the whole house. Programs like Early Intervention, which aids toddlers with signs of developmental delay, has proven that some kids will thrive when given a bit more professional attention.

Dermatologists have an opportunity (and in my opinion, the responsibility) to be looking for and referring these kids to psychologists and psychiatrists ASAP, not after years of suffering. I for one have made a pledge to be at the forefront of making this happen.

If you have BDD or know someone with BDD symptoms, many of which were described above, you don’t have to be an expert to show your concern or do something to help. I suspect that just showing sympathy and empathy rather than downplaying someone’s skin/body concerns will be a relief. Feelings of isolation and alienation, that no one understands us, is a common experience especially in adolescence and early adulthood, but it becomes intolerable when the whole world seems to be saying it.    

I believe that dermatologists and mental health professionals have a lot to learn from patients and the public in general. If you have BDD and can remember how it felt in the very beginning, please leave a comment and tell us whether you think anything could have helped prevent it, or what you wish your friends, family and healthcare professionals would do now!

Margaret S Lee, MD, PhD is the Director of Pediatric Dermatology and Assistant Professor of Dermatology and Pediatrics at the Boston University School of Medicine.