The Connection Between Body Dysmorphic Disorder and Low Self-Esteem

By Rheyanne Weaver

We live in a society and culture that is constantly telling us that we are not good enough the way we are. We're too fat or too skinny. Our skin isn't smooth enough, our pores are too big and we have too many wrinkles and blemishes. We need to have whiter teeth and shinier hair.

If we're being told every day that we don't look attractive enough naturally and need to fix certain parts of our bodies to be acceptable, it might start to become a challenge for people to have a healthy self-esteem. And if many people are struggling with self-esteem issues, it can be difficult to draw the line between normal body image concerns and mental illnesses like body dysmorphic disorder.

For example, if I can hold down a full-time job and have a decent social life, but I think every day about how disgusting my stomach looks, and stare at my stomach every time I walk by a mirror or window and think about how much better I would look with a thinner stomach, is that normal?

Is it normal to feel so negatively toward certain body parts, yet still be able to get through life (maybe dragging a little)?

Is it only a disorder when you're unable to work and have relationships with other people because of that preoccupation? Experts explain the link between low self-esteem and body dysmorphic disorder, and the differences that separate the two.

Body dysmorphic disorder (BDD) is officially defined as "a preoccupation with a defect in appearance," according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). The manual has three major requirements in order for a person to be considered to have BDD:

1) "The defect is either imagined, or, if a slight physical anomaly is present, the individual's concern is markedly excessive."

2) "The preoccupation must cause significant distress or impairment in social, occupational, or other important areas of functioning."

3) "The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in Anorexia Nervosa)."

Karen Hylen, a primary therapist at Summit Malibu, a treatment facility for addictions and other disorders, said in an email that BDD is considered to be a somatoform disorder.

"This means that the person has the symptoms of a medical illness, but those symptoms cannot be explained by an actual physical illness," Hylen said.

"BDD patients have an obsessive preoccupation with their physical appearance and usually a specific, imaginary defect on their body that they focus their attention entirely on. They often have a relentlessly negative view of themselves and how others view them, and regularly turn to cosmetic surgery in an effort to 'fix themselves.'"

She said BDD and low self-esteem go together.

"You cannot have one without the other unless the person has gone through extensive therapy and treatment to reverse their negative, ruminating thoughts about themselves," Hylen said.

"BDD is a lifelong disorder, but it can be managed with professional intervention."

She said especially in today's world, it can be challenging to decide when a person is suffering from more than low self-esteem unless a person has proper knowledge of the disorder.

"Low self-esteem is prevalent among Americans because of the ridiculous standards of beauty we have set for ourselves," Hylen said.

"However, someone with BDD's symptoms are exponentially worse than someone who simply has low self- esteem."

People with low self-esteem might engage in some compulsive behaviors and have negative feelings toward their bodies or different body parts, but unless these thoughts and feelings take over to the point of causing a major disruption in everyday living, it's not considered a disorder.

"A 'normal' person may spend a lot of time in front of the mirror putting on make-up, fixing their hair, and making a big effort to look their best before they go out in public," Hylen said.

"They may not be happy with the end result, but they still engage in these activities. They will complain about how they look in pictures, or be shy, but they don't disengage from reality."

"Someone with BDD constantly obsesses about their appearance, spends hours in front of the mirror, throws fits because they don't look how they want, [seeks] constant validation about their looks, turns to surgery as a way to change their bodies, focus on one or two specific imaginary defects on their bodies, and are never satisfied - no matter what - with just being themselves," Hylen added.

Natascha Santos, a certified bilingual school psychologist and behavior therapist who specializes in obsessive compulsive disorder and body dysmorphic disorder, said in an email that people with BDD often have depression, which is associated with low self-esteem. Many BDD sufferers also have suicidal thoughts.

"With low self-esteem and overvalued ideation on this perceived/imagined body defect, they really believe that there is something wrong with the body part of concern," Santos said.

Laura Cipullo, a registered dietician, certified diabetes educator and nutritionist, said in an email that some people recovering from eating disorders suffer from BDD, and even more suffer from low self-esteem.

"While there is no clinical definition of low self-esteem, it is generally defined as an absence of a sense of contentment and self-acceptance that stems from a person's appraisal of their own worth, significance, attractiveness, competence and ability to satisfy their aspirations," Cipullo said.

"Those struggling with low self-esteem often take things very personally, have difficulty in social interactions, are unable to accept compliments, and have pessimistic tendencies. Low self-esteem puts one at greater risk for an eating disorder."

She agreed that BDD and low self-esteem almost always are present together.

"Several studies have been conducted finding those suffering from BDD also experience lower self-esteem compared to those not suffering from the disorder," Cipullo said.

"It is unclear at this time whether poor self-esteem predisposes one to BDD and/or is a consequence of the disorder, but a correlation definitely seems present."

She added that today it might be easier to become obsessed over appearances if a person already has low self-esteem, since there is such an overall focus on physical beauty. However, it's important to note that BDD is not something that will go away on its own usually, and it's a disorder unlike low self-esteem, but treatment is available, such as cognitive behavioral therapy.

"BDD is not a disorder of vanity," Cipullo said. "BDD is a serious mental disorder affecting both men and women."

Stacey Rosenfeld, a licensed clinical psychologist, said in an email that low self-esteem is fairly common, especially in women, and that it's even normal for women to be dissatisfied with their bodies in today's society.

"However, when it goes beyond a fleeting thought or feeling and becomes a preoccupation that seems to be more important than anything else, that
is likely BDD," Rosenfeld said.

"Plenty of people dislike aspects of their appearance, but in general feel good about themselves. They're able to look at the big picture. For those w/BDD, the focus becomes incredibly narrowed."


American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorder: Fourth Edition: Text Revision. Arlington, VA: American Psychiatric Association, 2000.

Hylen, Karen. Email interview. April 24, 2012.

Santos, Natascha. Email interview. April 24, 2012.

Cipullo, Laura. Email interview. April 25, 2012.

Rosenfeld, Stacey. Email interview. April 25, 2012.

Reviewed April 26, 2012
by Michele Blacksberg RN
Edited by Jody Smith