Body dysmorphic disorder and attention deficit hyperactivity disorder (ADHD)

by Roberto Olivardia, PhD

Although not yet recognized in the scientific literature, the relationship between attention deficit hyperactivity disorder (ADHD) and body dysmorphic disorder (BDD) is worthy of attention. As a specialist in treating patients with BDD, as well as an ADHD expert, I have observed how ADHD can have a negative impact on body image.

What is ADHD? 

There are many misconceptions about ADHD. Unfortunately, some doubt the validity of the diagnosis, which only further stigmatizes people. The symptoms of ADHD generally fall into four categories: inattention, hyperactivity, impulsivity and poor executive functioning. Here are features of each:

Inattention:

• Poor attention span on boring stimuli
• Hyperfocus on interesting stimuli
• Drawn to thrill seeking/stimulating activities
• Distracted very easily
• Hard to follow directions
• Forgetfulness
• Incomplete projects or activities
• Procrastination

Hyperactivity:

• On the go, always in motion
• Hard time sitting through long classes/sessions
• Restlessness, constantly fidgeting
• Mentally racing, multiple thoughts at once

Impulsivity:

• Impulsive behaviors
• Hyperverbal
• Emotionally impulsive
• Impulsive decisions
• Impatient
• Impulse control habits (overeating, substance use, addictive behaviors, etc.)
• Interrupting

Poor executive functioning, including issues with:

• Sustaining focus and attention
• Transitioning from one thing to another
• Control, self-monitoring, and learning from mistakes
• Organization (both of space and ideas)
• Planning
• Prioritization
• Time management
• Working memory
• Emotion regulation
• Motivation issues

Learning disabilities (such as dyslexia) affect 50%–60% of people with ADHD. It should be noted that there is significant comorbidity of ADHD and OCD. Studies find that as many as 30% of those with OCD may also have ADHD. Often times the ADHD goes undiagnosed since symptoms are framed solely under the OCD diagnosis. 

Frank (a pseudonym), 36, reports feeling chronically stressed due to ADHD. “The hyperactivity, the problems with following through on projects, it is just too much.” ADHD often leads to feeling out of control.

There are many unhealthy ways those with ADHD can deal with these feelings, and this includes a hyperfocus on one’s body image. Frank has struggled with ADHD and also has been diagnosed with BDD, where he is preoccupied with the appearance of his skin. “I feel like a failure every day about something. I felt like my appearance was the only thing I can control. So I became hyperfocused on my skin. I check mirrors constantly to make sure my skin looks smooth and clean. I research skin cleansers when I should be doing work. I feel like getting perfect skin is my way of trying to get success. At least if I look good, maybe that will make up for my deficits.” 

Edward, 29, feels similarly when it comes to the way ADHD affects his social skills. “I can be socially awkward and turn women off with my interrupting and random associations. I feel if I look better, people will like me more regardless of the fact that I can hardly carry a conversation. That is what started the road of my exercise addiction.”

This hyperfocus can lead to an overemphasis on the body or a part of the body. One can, at least temporarily, shut out the world when they are focused on a number on a scale or a perception in the mirror. Struggling with both ADHD and weight dissatisfaction (despite being at a normal, healthy weight) Marisol, 24, says, “I don’t always judge accurately whether I have done something well or not. It is so hard to get through an assignment that it never feels well done. I feel like I am in limbo. But focusing on my weight is grounding for me. It is all about a concrete number. It is easy to measure whether I am up or down. Where I stand is much easier to define.”

People with ADHD crave instant feedback, which body image-related behaviors give, although it is a slippery slope between helpful feedback and becoming obsessed. Eddie, 17, while doing homework, found himself touching his arms constantly to see if his biceps were getting bigger. He would get anxious and need to view them in the mirror. If he did not like what he saw, he would start lifting weights in his room. He was diagnosed with muscle dysmorphia. Despite being muscular, he perceived himself as looking “puny.” Meanwhile, his homework was not getting done. He reported that his obsession with his muscle mass also fed into his procrastination issues related to his ADHD. “I know sometimes the BDD came out of me putting off work. It was like I detached from work and then the BDD says, ‘Here’s something to focus on that is more interesting,’ but then it goes from interesting to getting sucked into the dark vortex.”

Body image hyperfocus is highly stimulating, something ADHD brains are attracted to. This hyperfocus, although not pleasurable, can be a preferable mode of stimulation over the “boring” everyday tasks one performs in a day. Charlotte, 19, said that hyperfocusing on her appearance flaws was reinforcing. “It is so stimulating. I get sucked into it so easily because it feels so important. Appearance is important, though. I hate thinking about my body flaws, but it captures my attention.” A hyperfocus on body image leads many to look to popular cultural images as an indication of what they should look like. These images deliver an unhealthy prescription of “perfect” bodies and appearances.  

ADHD-related strategies for BDD:

1) Positive body image is associated with positive self-esteem about other things like your ADHD. It is important to have a positive self-concept around one’s ADHD. ADHD does not make you inferior. There are parts of an ADHD brain that are awesome and parts that can be frustrating. Similarly, there are parts of our bodies that we might love, and other parts we really don’t like. But having ADHD, as well as falling short of any body image ideals, does not diminish your value as a person.  

2) People with ADHD are prone to boredom, so it is important to structure their time and energy on other things so that their attention doesn’t default to their BDD symptoms. Engage in “body mindfulness.” Do not use your attention to body image as an escape from ADHD symptoms or stress. 

3) If social skills are in need of improvement due to ADHD symptoms, take a public speaking or improv acting class. Join a social group as a way to engage with new people. Serena, 33, found that her attention to her appearance dissipated as she became more extroverted. “It was as if I realized that I can offer much more than just the way I look.”

Connection to one’s inherent value, regardless of how they look or whether or not they have ADHD, is the ultimate goal.