Feeling anxious about the way you look is a hallmark of adolescence. Wishing you could change a particular feature, agonizing over pimples, or comparing yourself unfavorably to a movie star or a peer are all fairly typical. But kids with body dysmorphic disorder experience something much more extreme. The words they use to describe themselves are disturbing: I’m monstrous. I’m an eye sore. I’m so ugly it hurts.

Dysmorphic means malformed or misshapen, and kids struggling with body dysmorphic disorder (BDD) are obsessed with what they perceive to be a disfiguring physical flaw. This flaw might be either imagined or a minor flaw that is blown out of proportion. People around them may dismiss their obsession as vanity, but someone with the disorder feels deeply threatened by his perceived flaw. BDD often starts during adolescence, and is related to OCD. And while teenage girls are thought to be more concerned about their appearance than boys, the disorder affects both genders in equal numbers.

Dr. Jerry Bubrick, senior director of the Anxiety Disorders Center at the Child Mind Institute, describes treating someone with BDD who had a small scar on his chin that was the result of a bicycle accident when he was younger. Years later he was a successful graduate student at Harvard, but he nonetheless thought that because of the scar “no one would ever take him seriously.” He believed that professors wouldn’t respect him, girls wouldn’t go out with him and his life was “essentially ruined,” all because of the flaw on his face.

To try to mask the scar he grew a goatee. He also developed a variety of rituals to try to conceal the flaw. “Even with the goatee, he still applied cover-up on it, and he’d spend hours in the mirror making sure the cover-up was there,” said Dr. Bubrick. “Any time he would sweat he’d reapply the cover-up. He would never swim because that would wash the cover-up off. He would only go to the grocery store at night when there’s fewer people there, he would never eat across from someone because they might see the scar, and he would sit towards the back of the class so the professor was less likely to see it.”

More than vanity

The elaborate and time-consuming measures he took to conceal the scar are common for kids with BDD.  Their concern is much more serious than vanity. People with BDD think that things like scars, underdeveloped muscles, pimply skin or irregular features aren’t just flaws, but serious threats to their worth as a human being. When Dr. Bubrick’s patient said his life was ruined because of his scar, he genuinely believed it.

“I’ve heard people talk about it like it’s cancer in the sense that they feel like their bodies are failing them,” says Dr. Bubrick, “like they can’t trust or feel comfortable in their own skin.”

As a result, people with body dysmorphic disorder struggle with feelings of hopelessness and deep distress. According to one study, 80% of people with BDD had a history of suicidal thoughts and 27% had attempted suicide.

Many people with BDD attempt to have plastic surgery to correct their flaws. However these surgeries can actually worsen their distress, and they may continue asking for still more surgeries or procedures when they don’t get the results they are looking for.

Related: What to Do if You’re Worried About Suicide

Symptoms of body dysmorphic disorder

Body dysmorphic disorder can look different in different people, but there are some common signs to look out for. These include:

  • Preoccupation with one or several flaws. Common concerns include (but are not limited to) muscle size (called muscle dysphoria), weight, complexion, scars, hair, or fixations on particular body parts like hips, nose, ears, calves or genitals. Kids with BDD may spend several hours a day being preoccupied with their appearance. They may have difficulty concentrating in school or doing homework because they are worried about their appearance or researching surgeries or procedures they hope might correct their flaws. The disorder can isolate kids from peers, making typical socializing stressful and making “selfies” a nightmare. Some kids may even avoid leaving their rooms at all.
  • Repetitive behaviors. These are things like repeatedly checking the mirror, picking at skin and excessive grooming or makeup application. Kids with BDD may spend hours applying and reapplying makeup, making them late for school and meeting friends. Some kids may compulsively seek reassurance over their perceived flaws from family or friends, while others may keep their concerns secret. Kids may also compulsively compare their appearance with people they are near, or with people they see in magazines or on social media.
  • Believing the flaws are real. While body dysmorphic disorder shares the obsessions and repetitive behaviors we associate with OCD, one big difference is that people with BDD are more likely to believe the things they are fixated on. Psychologists call this “poor insight.” Dr. Bubrick explains, “Most people with OCD will say, ‘I know these thoughts aren’t realistic, but I have so much anxiety that I feel like I have to do my rituals.’” For people with BDD, their obsessions feel a lot more real.“We sometimes talk about how body dysmorphic disorder is like looking at the world through sideview mirrors,” says Dr. Bubrick. “What they see in the mirror they think is a real representation of how they look. What other people see is different, but it’s hard for them to accept that.”

A disorder reinforced by culture

While people with BDD aren’t motivated by vanity, it is undeniable that we live in a world that places a high premium on beauty. Most movie stars don’t have facial scars, after all. Already skinny models will have their thighs airbrushed away. The average teenager is familiar with using tricks like makeup, filters and good angles on selfies.

“Media and society reinforce a lot of this,” notes Dr. Bubrick. There’s anti-wrinkle cream, Botox, fillers, plastic surgery, laser treatments, tummy tucks. When you try to suggest that a perceived flaw might not be a big deal, a person with BDD might counter that people wouldn’t be getting, say, injections to plump out their lips if thin lips weren’t a problem. “It’s hard to argue against that sometimes,” says Dr. Bubrick.

Related: Social Media and Self-Doubt

Getting help for BDD

Providing a countermeasure to that focus on beauty is important. In addition to anti-anxiety medication, which is typically prescribed because of the severity of the symptoms experienced by people with BDD, treatment begins by trying to introduce a broader perspective on what it means to be an attractive, worthy person.

“It’s about getting them to be more flexible with their thinking,” explains Dr. Bubrick. “Maybe there’s more to attraction than flaws. And everyone has a range of attraction. Attraction can be physical, and it can also be emotional, or about connectedness.”

Treatment helps kids test out the theory. People with BDD have a lot of strategies for concealing their perceived flaws, and the therapist will help slowly peel those strategies back. Maybe they’ll practice walking outside at a time that is usually avoided, or the patient will try wearing cover-up for just part of the appointment, and he’ll see if there’s a difference in how people look at him. It’s a gradual, supportive process designed to help people learn to tolerate the anxiety they feel until it lessens and they find they are able to handle still more challenging things. The treatment is called exposure with response prevention, and is successful for treating body dysmorphic disorder.

For the young man with the scar, Dr. Bubrick had him start by slowly reducing the amount of cover-up he wore. Then he shaved off the goatee and got used to that. When the patient was ready for it, Dr. Bubrick took a red pen and rubbed it on the scar to emphasize it. Then they’d walk around and have people look at it. Dr. Bubrick said that the ultimate thing for his patient was when they marked up the scar to accentuate it and then went to Macy’s and asked if he could have a makeover. When they first started working together it would have been unimaginable for him to have a professional makeup person looking right in his face and commenting on how he looked. But after receiving treatment for his BDD, what would have been the hardest thing in the world for him wasn’t that bad, after all.

Like OCD, body dysmorphic disorder is a chronic condition. That means that symptoms can still recur occasionally, but treatment teaches you the skills to handle those symptoms in a healthy way and then move past them.

Read More:
Behavioral Treatment for Kids With Anxiety
What Is Social Anxiety?
What Is an Eating Disorder and When to Worry

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