OCD and BDD: What Do These Disorders Have to Do With Each Other?
Obsessive Compulsive Disorder (OCD) and Body Dysmorphic Disorder (BDD) are conditions that have a lot in common. Due to new understanding, the DSM-5 classifies them under the same umbrella of “Obsessive Compulsive and Related Disorders.” They often appear together as well, showing up co-morbidly anywhere between 3% and 43% of the time.
Even with this, the conditions are unique from one another and may present similarly or worlds apart.
The Basics of OCD
OCD is nicknamed the “Doubting Disease” and for good reason: It causes pathological doubt in its sufferers. It’s not very common with only about 2% of the population diagnosed (despite public perception, a desire for a clean house or an organized shoe rack is NOT OCD). The condition is marked by cycles of obsessions and compulsions that leave those who have it feeling stuck inside their fears.
Obsessions present as intrusive thoughts, unwanted ideas, images, or urges that terrify the sufferer. These thoughts are egodystonic, which means they go against the sufferer’s true desires, values, and morals.
Compulsions are the rituals performed as a way to neutralize the obsessions. People with OCD perform compulsions to assure that their obsessive thoughts won’t come true or haven’t come true already.
For example, an OCD sufferer may have an image in their head of their kitchen going up in flames; this is the obsession. They’ll modulate their anxiety by checking the kitchen, making certain the oven and coffee pot are off, or sniffing the air to make sure they don’t smell smoke; this is the compulsion.
Unfortunately for the sufferer, OCD is a disorder that always wants more and performing a compulsion once, twice, or 2017 times is never enough. Someone who checks their kitchen for fire, for instance, will experience temporary relief from their anxiety. But the obsessive thought will pop into their head again, leaving them compelled to engage in their ritual once more. Sometimes, the thought shows up every few minutes; other times, it might not show up for a day or two. OCD loves to keep its sufferers on their toes.
People with OCD, above all, possess an extreme need for certainty in the context of their obsessions. But this certainly proves elusive, something – it turns out – that doesn’t exist.
The Concept of Intrusive Thoughts
Intrusive thoughts are the main ingredient in OCD but they’re not only seen in those with the disorder. Rather, intrusive thoughts are present in a variety of mental conditions. Interestingly, they’re also prominent in the general population but with one important difference: These people don’t take their intrusive thoughts seriously. They let them come and go and pay them no attention.
People with OCD do the opposite: They react, they analyze, they worry, they fret, they engage in rituals time and time again. But even though they engage in compulsions, they don’t believe their thoughts wholeheartedly.
OCD is distinctive in this regard. In other conditions, such as schizophrenia, the sufferer may entirely buy into their thoughts believing they reflect reality. In OCD, this doesn’t happen. Instead, the sufferer knows they’re acting irrationally and behaving illogically but they do it anyway because OCD tells them they must. It asks, “What if?” over and over again until the sufferer gives into the obsession and performs the compulsion in an attempt to assuage their distress.
For example, someone who touched a community mailbox may have an OCD thought that they’ve been exposed to a deadly disease. Deep down, they know this is highly unlikely and something they should ignore. But OCD pesters and irritates them with questions like, “What if getting the mail gave you COVID? What if you give it to your spouse? What if you give it to your kids?”
The sufferer will then wash their hands over and over again just in case. But, as previously addressed, washing them once or twice is not enough because OCD is never satisfied. So, they’ll wash them over and over again each time the thought of COVID pops into their mind. Some people with OCD wash their hands in bleach or scalding hot water as they attempt to gain certainty.
The Dysfunctional Beliefs of OCD
OCD is founded on dysfunctional beliefs and sufferers tend to harbor the following:
Hyper-responsibility: OCD sufferers often believe that they are responsible for things they can’t control or things well outside what’s considered reasonable. They’re prone to guilt because of this.
Thought-action fusion: this is the idea that thinking about doing something is the same as doing it. For example, someone with OCD who thinks about running over a jogger as they sprint through a crosswalk may feel compelled to go back and check to make sure that that didn’t happen.
A desire to control thoughts: While everyone possesses the inability to control their thoughts, people with OCD desire control. But any attempt to control intrusive thoughts tends to make them more frequent and more powerful.
A tendency to overestimate risks: OCD sufferers tend to make mountains out of molehills when it comes to threats. They also tend to see threats where no threat exists. For instance, someone with Contamination OCD may fear that they contracted HIV from touching a doorknob in a restaurant.
This isn’t an actual threat but it could be a theoretical one and that’s what OCD grabs onto. It tells the sufferer that an HIV positive person could have touched the doorknob with a bloody hand. They could have left a splatter of blood behind. And this blood could have entered the sufferer’s body through an open wound. OCD is extremely talented and clever at turning the theoretical into the probable.
A need for perfection: You don’t have to have OCD to be a perfectionist; with or without a mental disorder, about a third of the population identifies as one. But it’s certainly a common feature in OCD as well.
An extreme need for certainty: Perhaps the most potent part of the OCD experience is the extreme need for certainty that sufferers feel. OCD is a condition that is buoyed by the “better safe than sorry” concept and those who have it need 100% certainty in the context of their obsessions. Even 99.9% certainty might not be enough.
The Symptoms of OCD
The symptoms of OCD vary by the type of OCD the sufferer has. For instance, one of the classical signs of OCD (and arguably the most well-known) is compulsive handwashing. But people will only engage in this ritual if they suffer from Contamination OCD. Someone who suffers from Relationship OCD, Harm OCD, Sexual Orientation OCD, or some other type won’t find themselves consumed with hygiene because their OCD does not center around germs. It centers around something else.
This isn’t to say there aren’t symptoms that transcend subtypes. Typically speaking, some of things most likely to manifest in OCD sufferers include:
- Harboring the dysfunctional beliefs mentioned in the section above
- Experiencing intrusive thoughts that cause distress, panic, terror, and go against the sufferer’s innate and true values
- Engaging in repeated behaviors or rituals (either physical or mental) that modulate the anxiety caused by the intrusive thoughts
- Engaging in repeated behaviors or rituals that are nonsensical (even to the sufferer)
- Engaging in repeated behaviors that take precedence over other things (such as going to school or work), which is why people with OCD may lack punctuality
- Spending a significant time doing everyday tasks or getting from point A to point B
- Asking for reassurance from friends or family members
- Researching on the internet for reassurance (for example, someone with Harm OCD may research news stories for reports of hit-and-runs)
- Having a preoccupation with seemingly minor details
- Avoiding things (someone with Contamination OCD may avoid public restrooms while someone with Harm OCD may avoid knives)
- Experiencing obsessions and compulsions that are exacerbated by stress and/or transitions
- Experiencing obsessions and compulsions that may elicit shame and cause the sufferer to become secretive about their thoughts and actions
The Causes of OCD
There is no smoking gun that causes OCD, or at least not one that has been discovered by science yet. But we do have an idea of why OCD develops in some and not in others.
It appears to be a complex combination of genetics, environment, and abnormalities in the brain, both in structure and in function. In the OCD brain, communication is compromised in the areas of the orbitofrontal cortex, the anterior cingulate cortex, the striatum, and the thalamus. People with OCD also tend to have low levels of serotonin and dopamine, two neurotransmitters that play a role in mood, anxiety, and reward.
Many people with OCD have a family member who has it as well, though this isn’t a guarantee that you’ll get it just as a lack of family history is no guarantee that you won’t.
In fact, both in the presence and absence of a genetic predisposition, OCD is heavily influenced by behavioral conditioning (or compulsions). This doesn’t cause OCD, per say, but it does solidify it as a disorder. If someone with OCD never engages in compulsions, it’s fair to argue that the disorder will never truly come to fruition.
The Risk Factors of OCD
There’s nothing in someone’s lifestyle that causes OCD; it’s not caused by smoking, drinking, or a lack of exercise (though all these elements could make a preexisting disorder worse). Instead, the risk factors of developing this condition include:
- Having a family member with OCD
- Being between the ages of 8 to 12 and 19 to 20 (OCD is most likely to appear during these periods though it can appear at any time)
- Having a history of head injuries (this won’t cause OCD to start but it can trigger a dormant condition)
- Transitions (like head injuries, transitions won’t cause OCD to appear out of thin air but they can act as a trigger even when those transitions are happy)
- Strep throat or scarlet fever (in children whose OCD appears literally overnight, they may be suffering from PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections))
Treatment for OCD
OCD is not a curable disorder, but it is treatable and, with the right treatment, sufferers can live relatively normal lives. In general, there are a variety of methods used to help control symptoms as much as possible.
Medication: While not everyone is responsive to medication, most people are. Yet it comes with a caveat: Medicine is not meant to rid you of OCD (though that would be great if it did). Instead, it intends to make the obsessions manageable enough that the sufferer can successfully perform ERPs (more on that below).
Medications can range from standard (such as Zoloft) to off-label (such as Tramadol). Overall, some of the most common medications used include: SSRIs (such as Luvox, Lexapro, and Paxil), SNRIs (such as Effexor, Cymbalta, or Pristiq), and tricyclic antidepressants (such as Anafranil).
Individual responsiveness, other medications being taken, underlying conditions, and the ability to tolerate side effects are all things that must be considered before starting any type of regimen.
Therapy: The most effective treatment for OCD is cognitive behavioral therapy (CBT) with exposure and response prevention (ERP). During this, sufferers expose themselves to their intrusive thought (either intentionally or organically) and then refrain from performing their compulsions. Because compulsions give the OCD thoughts validity, ceasing them is the key to healing.
ERP is not easy and the vast majority of sufferers fail at least part of the time. But those who are able to persist find that the ERPs get easier the more they do them.
Acceptance and commitment therapy (ACT) is sometimes used along with ERP. Though this is relatively new, it’s becoming more common in OCD treatment. This modality focuses on accepting intrusive thoughts and feelings rather than reacting to them or giving them power. The OCD sufferer is instructed to see their thoughts as nothing more than thoughts, things that have no ability to change reality.
Usually, clever imagery, songs, or other creative tricks are used in ACT. For example, someone whose OCD is telling them that they’re going to suffocate their baby may be instructed to view that thought on a highway billboard, which allows them to disconnect, gain distance, and see their thoughts as nothing more than words on a page.
Mindfulness-based therapies may be used supplementally as well, though most experts agree that ERP must remain at the forefront.
TMS: For those who have severe OCD, Transcranial Magnetic Stimulation (TMS) may help. This is more often used as treatment for depression, but some providers prescribe it for OCD as well. As of now, insurance companies remain on the fence in regard to reimbursing for it.
TMS involves a non-invasive procedure that makes use of a magnetic field to regulate the deeper areas of the brain linked to OCD. It typically requires daily treatment over the course of several weeks followed by maintenance appointments.
Lifestyle changes: Changing your lifestyle, even dramatic changes, doesn’t treat OCD exactly. But adopting healthy habits can decrease the power of the symptoms. Therapy and/or medication is still needed, however.
It’s recommended that those with OCD:
- Eat a diet rich in fruits, vegetables, and whole grains
- Limit caffeine, alcohol, and tobacco
- Exercise regularly
- Practice meditation, mindfulness, or yoga
- Join support groups
- Speak openly about their disorder
The Basics of BDD
The understanding of Body Dysmorphic Disorder has evolved with time. Previously, it was categorized as its own disorder in the DSM-5. But as understanding of it grew, so did its similarities to OCD. As previously noted, it now falls in the category: Obsessive Compulsive and Related Disorders. Other conditions in this category include OCD (of course), trichotillomania, skin picking disorders, and hoarding disorders. It is comparably as common as OCD, with around 2% of the population affected.
By definition, BDD sufferers obsess about their appearance with a propensity to focus on flaws that are minor and insignificant (and possibly not noticeable to others) in addition to focusing on flaws that are entirely nonexistent.
People with BDD may compulsively check their body for imperfections and seek ways to remedy these imperfections. They tend to spend a great deal of time in front of the mirror or engaging in repetitive behaviors (such as brushing their hair or putting on mascara) in an attempt to reach their ideal and perfect appearance.
The above goes well beyond normal grooming and it’s not a symptom of underlying vanity or conceit; like OCD, this is a disorder that completely interferes with the sufferer’s life.
Intrusive Thoughts in BDD
As noted in the sections above, intrusive thoughts are a hallmark symptom of OCD and they’re omnipresent in BDD as well. The power of these intrusive thoughts is the same in both disorders, but the content is different.
For example, someone with OCD may focus on health or safety or whether or not they offended the bagger at the grocery store because they didn’t thank them loudly enough. Someone with BDD, on the other hand, focuses on how they look. As a result, their intrusive thoughts are of this flavor.
They may experience intrusive thoughts about perceived ugliness, perceived obesity (even when they’re thin), and perceived deformity. They may have intrusive thoughts around minor flaws. For instance, someone with BDD who has a tiny pimple on their nose may imagine that pimple much, much larger and more noticeable than reality. They may think their boobs aren’t big enough or their hair not thick enough. They may rue a perceived lack of muscular definition or nostrils that are too wide or hairy.
They suffer from intrusive thoughts surrounding the importance of their appearance as well, meaning they overinflate how vital it is to look spectacular at all times. And they may erroneously believe that others are making fun of them or speaking negatively about their looks. They may also see flaws where there isn’t one. For example, they may visualize a wrinkle across their chin when one doesn’t truly exist.
Like any type of intrusive thought, image-focused thoughts are present in the general public. Yet it’s the degree of their presence as well as the potency that differs. Someone without BDD may dislike the blemish on their chin and may even believe it’s more noticeable than it is. They may complain about it loudly, questioning why zits always show up before yearbook picture day. But they won’t spend hours obsessing over it. They won’t look into surgery to fix it. They won’t miss school because of it. The blemish will only serve as a minor inconvenience until it goes away.
Dysfunctional Beliefs in BDD
Dysfunctional beliefs are present in BDD just as they are in OCD. In the former, sufferers may experience challenges with:
Perfectionism: They may believe their appearance needs to look absolutely flawless at all times.
Thought-action fusion: Based on research, this appears especially important in BDD.
A desire to control thoughts: People with BDD may attempt to stop and/or control the negative thoughts they have about their image. But like with OCD, an attempt to do this is futile and makes the underlying condition worse.
Overestimation of flaws: In OCD, sufferers overestimate risks and threats (sometimes seeing them when they do not exist at all). In BDD, people do this too but with a focus on flaws (or imagined flaws) in their appearance. For example, someone who has a weird looking freckle in the middle of their forehead may assume that this makes them look hideous when, in actuality, hardly anyone else ever notices.
People with BDD may go so far to apply a threat to their imperfections. In keeping with the example above, they may believe that a weird looking freckle is enough to get them demoted at work or cause their spouse to leave them.
A need for certainty: In OCD, the need for certainty lays at the root; in BDD, it sits here as well but the context differs. BDD sufferers seek certainty around their appearance and how they look. They want to be certain that they look perfect, which, naturally, is impossible since perfection is unattainable.
The Symptoms of BDD
Symptoms of BDD vary by person; while one sufferer may focus on their weight, another may focus on their hair. Yet, in general, some of the most common signs include:
- A preoccupation with appearance, paying extreme attention to tiny flaws
- A preoccupation with flaws that don’t really exist
- Compulsively checking for flaws by looking at the body, looking in the mirror, or studying videos or photographs
- A belief that they are ugly, disformed, or overweight
- A belief that others are mocking their looks or making fun of them behind their back
- Attempting to hide flaws with makeup, clothes, hats, or other means
- Seeking corrective surgery or other medical procedures (for instance, someone with BDD may seek liposuction even when they’re a normal weight (or thinner) or a teenager with BDD may seek Botox even though they’re wrinkle-free)
- Feeling insecure around those who they perceive as better looking than them (or avoiding these people entirely)
- Engaging in repetitive grooming behaviors, such as brushing hair, applying makeup, covering blemishes, or picking zits, that interfere with their life and prevent them from engaging in everyday activities (for instance, someone with BDD may call in sick to work because their makeup doesn’t look perfect enough)
- Engaging in compulsions that prevent them from doing things aligned with their values or activities that make them happy
- Avoiding social gatherings or going into public
- Asking others for reassurance surrounding their appearance
- Focusing on the size of body parts (women may focus on breast size while men may focus on penis size) or believing they’re not muscular enough
People with BDD most usually focus on their own appearance but they may, alternatively or in addition, exhibit BDD by proxy, which leaves them focusing on the appearance of others (such as their children). This goes well beyond licking a napkin and wiping a smudge of chocolate from your daughter’s cheek. People with BDD by proxy may spend between 3-8 hours a day focused on the appearance of their person of concern.
The Causes of BDD
On par with OCD, there does not appear to be one thing that causes BDD. However, also like OCD, people with BDD tend to have abnormalities in their brains, including left hemisphere hyperactivity, problems with communication between hemispheres, and an abnormally activated amygdala (the part of the brain that processes threats). They may have defects in the areas of their brain that influence the ability to process visual information (people suffering from anorexia exhibit similar findings).
Genetics come into play too, as 8% of people with BDD have a family member with it as well. This is not as high as with OCD (where around 25% of cases are hereditary) but it’s still significant enough to result in a 4-fold increase when compared to the general population. Environmental factors affect development as well with many sufferers having a history of low self-esteem, a traumatic experience surrounding their appearance, intense peer pressure, criticism of appearance from a parent or other authority figure, or societal pressure to be a specific way (e.g., toned and ripped or rail-thin).
Of course, behavioral conditioning is important too (just as it is important in OCD). People who engage in compulsions about their looks give their intrusive thoughts (e.g., “I’m fat, I’m ugly, I’m deformed”) credence and make sure those thoughts come back. Behavioral conditioning won’t cause BDD (people engage in the behaviors because the BDD already exists) but it worsens it and, effectively, locks it in as a life-interfering condition.
The Risk Factors of BDD
BDD can develop in anyone and at any age, but it’s more likely in certain people, including:
- Those who are in their adolescence (thought it often starts in the teenage years, it doesn’t simply resolve once those teen years are over)
- Those who have family members with BDD, OCD, or any other OCD-related disorder
- Those who live in societies that overemphasize beauty
- Those who identify as perfectionists
- Those who have experienced trauma, neglect, teasing, or abuse
Many people assume that BDD is a disorder that largely affects women, driven by the emphasis on beauty and youth that women tend to more potently feel. However, 40% of those with BDD are men. Still, the disease tends to present differently in males versus females. Women are more concerned with facial flaws, grey hair, wrinkles, and weight and they’re more likely to compulsively groom or check their reflection. Men, conversely, are normally more concerned with the size of their genitalia, whether their hair is thinning, and their muscle mass. They’re more likely to lift weights compulsively.
Treatment for BDD
BDD is treated with similar modalities as OCD and, like OCD, the goal is to control the symptoms and allow sufferers to live as normal a life as possible. Some of the treatments used include:
Medications: The Federal Drug Administration (FDA) hasn’t yet approved any specific medications for BDD but many of the medications used to treat OCD are used for this condition too. Namely, SSRIs (selective serotonin reuptake inhibitors) are used, due in part because of the likelihood that low levels of serotonin influence BDD (just as they do OCD). If these medications are ineffective, some doctors may try other off-label meds until they find something that works.
Therapy: Because, like OCD, BDD involves intrusive thoughts and compulsive behaviors, cognitive behavioral therapy is used to relieve symptoms. Sufferers are encouraged to react differently to their intrusive thoughts and may be asked to explore more flexible ways of thinking.
Exposure Response Prevention (ERP), which falls under CBT, is used as well. The sufferer is asked to expose themselves to their distressing idea or image (e.g., they’ll be told to think about a flaw on their face, whether their hair is receding, or that their butt is too big) and then they’ll be asked to refrain from any type of compulsive behavior (such as looking in the mirror, grooming, or asking for reassurance from others). They’ll also be instructed to cease avoidance behaviors (e.g., avoiding social situations and refusing to leave the house unless they’re dressed to the nines).
ERPs are effective because they strip the intrusive thoughts of their power and, over time, allow the sufferer to view their intrusive thoughts as the nonsense they are. Unfortunately, ERPs are extremely anxiety-provoking for the sufferer and – due to this – require lots of stops, restarts, and do-overs. Like many things, they get easier with practice.
Lifestyle Changes: The same lifestyle changes recommended for OCD (such as adopting an exercise routine or limiting alcohol) are recommended in BDD as well (they’re typically recommended in any anxiety or depressive disorder as well as for general good health). The reason for this is that a healthy lifestyle can help minimize stress, something that surely exacerbates symptoms. In BDD especially, a healthy lifestyle may help decrease triggers. For example, someone with BDD who smokes cigarettes regularly may end up with yellow teeth, a potentially triggering element that could put someone with BDD into an obsessive cycle.
What’s not BDD treatment?
Some people erroneously believe that cosmetic surgery acts as treatment for BDD and this is a route commonly taken by sufferers (as many as 40% of people with BDD end up getting medical or cosmetic intervention). But these procedures aren’t a cure and, instead, act as a compulsion. While cosmetic surgery may appear to “fix” a specific flaw (such as a bumpy nose or a smile line), once the problem is remedied, the BDD simply focuses on another area of perceived imperfection. Some BDD sufferers may appear addicted to cosmetic surgery, undergoing one procedure after another, as they mistakenly believe that this can act as a resolution.
The Similarities Between OCD and BDD
OCD and BDD have a lot of commonalities, something well demonstrated in the sections above. In sum, they both involve:
- Persistent and distressing intrusive thoughts that are beyond the sufferer’s control
- Compulsions or rituals engaged in as an attempt to relieve anxiety or gain reassurance
- A preoccupation with symmetry (This is not always present in OCD but may be depending on subtype. In BDD, sufferers may grow preoccupied with perceived asymmetry of things like eyes, nostrils, or breasts.)
- A tendency to be perfectionistic
- Dysfunctional beliefs around thought-action fusion, certainty, and threats
- Lower than normal level of serotonin
In addition to the above, one of the most significant consistencies between OCD and BDD is the involvement of the amygdala. The amygdala is the “worry wart” of the brain, the region that tells us when we’re in danger and activates flight or fight. While it’s not entirely understood yet in either disorder, individuals with OCD or BDD appear to have a hyperactive amygdala, which could be why they perceive threats from intrusive thoughts that are – in reality – meaningless.
The Differences Between OCD and BDD
On the other end of the spectrum, OCD and BDD are distinct conditions and thus have important differences. These include:
- The focus of OCD varies based on subtype (some people may focus on contamination where others focus on relationships, sexuality, harm, or something else) while BDD always focuses on appearance
- People with OCD tend to be better at recognizing their behaviors as irrational while those with BDD are more likely to believe that their behavior is normal
- People with OCD and BDD both experience intrusive thoughts but the thoughts in BDD are sometimes less intrusive
When OCD and BDD Occur Together
The good thing about having OCD and BDD at the same time (the only good thing) is that much of the treatment is similar, which gives you a chance to kill two birds with one stone. Even so, it’s important to see a therapist who has experience and training in both OCD and BDD. That’s the only way to cover all your bases.