Body Dysmorphic Disorder & Acne Scars, At A Glance
- Best ResultsUnlike to occur
- Treatment RecoveryNA
- Procedure TimeAvoid invasive procedures
- Skin SpecialistIdeally psychiatrist/psychologist/nurse
- Duration of ResultsVariable, depending on insight
- Back to WorkNA
Body Dysmorphic Disorder – Acne Scars
BDD or body dysmorphic disorder is a common condition affecting 2% of the population. Perception of acne scarring is one of the most common manifestations of BDD in dermatology. The absolute majority of sufferers have little or no insight regarding this condition. Most don’t even know they have it. Review this page as it may hopefully help you in making decisions about procedures.
FactsFacts on Body Dysmorphic Disorder
- BDD patients often seek the help of dermatologists
- BDD patients have a preoccupation of a perceived flaw, including acne scars
- This flaw is often not objectively quantified, but subjectively distressing
- This may have an impact on patient’s confidence, social behaviour, emotional & mental well being
- Other skin conditions include redness, enlarged pores & aging concerns
- It is important to quantify what is objective pathology versus subjective perception
- For objectively demonstrable & significant acne scars, I employ surgery, powerful lasers, & deep peels
- For subjectively severe perceptions in the absence of objective pathology the algorithm is very different
- BDD patients are best treated with milder treatments & the help of psychologists & psychiatrists
What is body dysmorphic disorder or BDD?
This common disorder manifests as an abnormal preoccupation with perceived defects or flaws in their appearance. BDD is very different from actual pathology whereby objective assessment can demonstrate abnormalities of physical appearance, such as scars, blemishes, pores, redness, age related changes (The problem is that BDD patients do not have this insight).
BDD patients tend to overthink their appearance and perceive their condition to be many multitude of times worse than what others perceive. Severe BDD causes debilitating stress, social isolation, anxiety & depression. A procedural approach (lasers, peels, surgery, injectables) is rarely the sole answer for this condition. Ideally it should be managed by a team of doctors & psychologists.
How does body dysmorphic disorder & acne scars present?
Essentially an individual’s perceived scarring is subjective impactful, though objective assessment shows mild scarring. I find this type of scarring the hardest to treat (by far).
BDD, by definition, is a patient’s perceived flaws that exist in accordance with their own biased judgement and are usually so insignificant to others and are often too minor or undetectable that they go unnoticed. Although, unfortunately for the individual experiencing BDD, no amount of reassurance from others can convince them of this.
If you have BBD, I am not the correct dermatologist to treat your scarring. This has nothing to do with the fact that I won’t offer you solutions. My most likely avenue is to prescribe you a course of low risk, suitable treatments by my nursing team. Treatments include sensible laser resurfacing, suitable peels / TCA Paint.
I will not subject you to the risks of surgery, deep peels & lasers in the context of your scars & what my work entails. For objectively mild scars, the correct solution is a low risk, minimally invasive procedure, supplemented with psychotherapy by trained psychologists & psychiatrists.
What tests are there to determine if acne scarring is objectively severe compared to subjectively severe?
It is difficult to make objective assessments if you have BDD to begin with, as your analysis is subjective. It is much like asking a blind person to see the writing on the board. If one lacks objective insight the only way of assessment is to obtain opinions from family, friends & honest health care professionals.
Your family GP can give you some insight. Seeking the option from family & friends is invaluable. Listen to them. Understanding that you have BDD is the first step in healing (both physical & emotional).
This is how to self-test. The first thing to understand is that healthy scar assessment is based upon the confidence at normal conversational distances under normal lighting. It is not about finding the exact angle of light that highlights your scars. Conversational distances, as defined clinically using the Goodman Baron Grade is at 50 cm. I do think this is way too close. Ideally it should be at 60 to 70 cm. If scarring is not a predominant feature (again measured objectively), then chances are you will not have pathological scarring (different from having no scars).
In normal lighting, take a series of photos from different angles. Distance the camera at 70 cm. Have an objective assessor review your scars & grade them accordingly. If you have mild scars (or no scars) but they have a massive impact on your emotional well-being, you may suffer from BDD. A trained psychologist can provide that diagnosis.
What is the difference between objectively severe scars versus subjectively severe?
Objectively severe scars can be seen by a normal individual at a significant distance. As a guide, the majority of my scar revision patients (as opposed to say a nurse led scar revision list) will have scars visible at 2-3 meters, often up to 6+ meters. The algorithm for managing severe scarring is very different from managing mild scarring. For severe scars I employ surgical, lasers, & very deep peels. For subjectively severe scars, often the entry point for my subcision creates a scar bigger than the scar perceived.
Subjectively severe scars are best corrected with small diameter lasers, non-invasive techniques, & precise focal peels. These procedures are carried out by my nurses. In some cases, I may employ dermal fillers to correct shadow deficits. Medicare does not give any rebate for the management of mild scars (objective assessment).
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How does BDD affect your well-being?
BDD can have a significant impact on your quality of life & emotional wellbeing. A patient’s concern regarding their appearance is frequently not noticeable to others, however the impact of their mental health is very real.
This can result in –
- Social isolation
- Preoccupation and negative thoughts over particular areas.
Engaging in excessive imaging checking or total avoidance of mirrors. This is very different from avoidance of mirrors-reflections in the presence of actual severe scars based by objective measurement. This concept is important to understand. BDD is subjectively measured, true pathology can be objectively demonstrated.
Most patients would have sought extensive medical advice & treatments in an attempt to change perceived flaws. This is very different from failed medical or surgical treatments because of objectively severe pathology. As a guide for every 10 patients I see with severe scarring, one will have BDD.
How common is BDD?
Very. It affects 2% of the population, and often present in young adults. Body dysmorphic disorder is equally representative in men & in women.
As a hidden disorder, most patients with BDD do not realise they suffer from this syndrome. They frequently blame their anxiety, depression & compulsive behaviour on real thoughts & exaggerated physical signs.
Why does acne scarring body BDD develop?
Body Dysmorphic Disorder cannot be pinpointed to a singular causal factor – there are various possible causes that may contribute to the development of BDD These will vary across individuals according to their life experiences and environmental & genetic influences.
In the context of acne scarring, there is undoubtedly a trigger- this is usually real signs (actual acne). Most often there is a long lag between the initial inflammatory insult & when patients are emotionally bothered with the scars.
In some cases, there may be past negative criticism from others or recurrent negative thoughts. Quite commonly BDD follows revision for severe scars (actual pathology). Namely procedures were performed for significant scarring. Most often a demonstrable result has been achieved, but patients then seek more improvement. This is a natural reaction. If 30 scars are present initially & 25 have been treated & improved, the majority of people will focus on the 5 remaining. This may be the initiating factor for BDD.
How do I manage borderline BDD & acne scars?
My role as a dermatologist, in the context of how I practice is to give you realistic outcomes & provide you with a safe, sensible & cost-effective treatment plan. My skill sets are procedural, namely the majority of my work is to treat objectively severe scars with surgical, deep laser & peels.
In most cases these treatments are not ethically nor medically indicated for mild scarring, the caveat is that if there are correctable volume defects, I can address these with fillers. Not all scars are correctable with dermal fillers. (Yes, we all want a life-long permanent solution for you, but if you cannot remodel scars, fillers, dermal grafts or fat is your only sensible option).
For objectively mild scars, there are often sensible, low risk, low-cost treatment options including fractional lasers, microneedling, peels, RF microneedling & structural volumetric filling. These procedures are conducted by my nurses.
If you do suffer from BDD, you should see a psychologist for a diagnosis & a treatment plan. I do not have the skillsets to manage BDD.
What other types of BDD are there?
There are a number of body parts individuals with BDD may experience distress over, which may change over time. Commonly affected areas of concern for individuals experiencing BDD include:
- Nose size or shape
- Lip volume (current trend)
- Acne/ wrinkles/ rosacea / scars / complexion
- Pore sizing (porephobias)
- Body proportions (BBL current trend)
In the context of dermatological disorders, pore phobia ranks as one of the most common BDD presentations. Pore sizing is determined by genetics, made worse with age, collagen breakdown, oil content in the skin, background inflammation (ace/rosacea), & other variables. The majority of patients I see have actual pathology (true enlarged pores). The minority of patients I see have BDD pore phobia (normal pores, or within the range of normal), but perceived to have enlarged pores. With procedures such as lasers, peels & good skin care we can reduce the size of pores (objectively). If you have BDD pore phobia, you may require psychological intervention.
Another common skin manifestation of BDD is facial redness, or flushing. The majority of patients I see are truly red, namely have skin pathology (rosacea, post inflammatory erythema, physiological flushing, secondary pathological flushing), the minority think they are red or flushed. Vascular lasers can markedly improve true pathology, however BDD patients will benefit more from psychotherapy & psychiatric intervention.
What treatments are available for body dysmorphic disorder?
Treatments are available, and they can be effective.
The efficacy really depends on whether you want help in the first place. The vast majority of patients refuse help & refuse to believe in this disorder. As a guide to insight, can I suggest you seek the opinion of professionals. I am quick to refer patients with BDD for second opinions & psychological assessment.
If you really want to improve your quality of life, you should take these three steps outlined below.
Firstly, family and friends to support your emotional wellbeing. Chances are, the people who are close to you cannot see the impact or extent of your problem. Chances are they are indeed correct. Let them guide you as to what objective perceptions are. If you won’t listen to them, you probably will not listen to me!
Secondly, consider seeing a psychologist. This profession can make a great difference to help you understand & manage BDD, including associated anxiety, depression & compulsion. CBT or cognitive behaviour therapy is based on a program of self-help in order to change how a patient thinks & acts. During therapy, you are likely to learn to refocus your attention away from yourself and re-engage with activities that will improve your mood and your life. The main side effects of the treatment are the anxiety that occurs in the short term. However, testing one’s fear gets easier and easier and the anxiety gradually subsides.
Thirdly help via a psychiatrist. This profession will council, & in most cases prescribe medications such as SSRIs, antidepressants & anti-anxiety drugs.
*Note: I do not have the skill sets to treat BDD, my team may work with your psychologist & psychiatrist to provide suitable treatments for your concern. In the vast majority of cases I do not get involved in your treatments, because my line of work is focused on the management of objectively severe pathology including burns, birthmarks, traumatic, surgical scars as well as grade 4B acne scars seen at many meters. If scars or concerns cannot be easily seen at conversational distances under normal lighting by normal people, chances are I will not be involved in your treatment. It does not mean I won’t recommend treatments, it purely means invasive surgical, laser & peels are not indicated for your concerns.
For professional advice and management in Brisbane. https://ocdclinicbrisbane.com.au
What is CBT or cognitive behavioural therapy?
Cognitive Behavioural Therapy (CBT), is a powerful non-pharmacological method of treating BDD. It is one of many therapy methods employed by psychologists.
The core component of CBT teaches the individual how to identify their irrational and automatic negative geared thoughts, and to replace these with more realistic cognitions, through gradual exposure to their feared scenarios – all of course with the ongoing support and guidance from a psychologist. CBT takes multiple visits to start working, so don’t give up.
Where can I get a second opinion?
Be careful who you see. Some dermatologists may treat you with invasive, high cost, high risk – low yield treatments, possibly because you are vulnerable. If you would like a second or even a third opinion, I can arrange a referral for you.
Who to see?
If you think you may suffer from body dysmorphic syndrome, discuss these issues with your general practitioner. They may refer you to a psychiatrist or psychologist. If you are in Brisbane, you should see these guys:
My expertise is procedural dermatology & not psychology. As stated, I can initiate treatments, however very rarely do I get involved in the management of your condition (in the context of mild pathology), as most of my work is invasive-surgical procedures.
Where can I read more about BDD?
You can find more information below. Additionally your GP can guide you. The most important aspect of treatment is for you to acknowledge that you actually want help in the first place. Acceptantance is part of the therapeutic process. My role as a dermatologist is to identify BDD and point you in the right direction. My mode of practice is to treat objectively moderate to severe acne scars.
Davin’s Viewpoint on Body Dysmorphic Disorder
This is a very common condition. The problem is that the absolute majority of patients do not know they have it. I find it a challenging condition to treat, as I do not have the skill sets to manage this condition. Ideally it should be managed with family & friends as the foundation of support, as well as a psychologist & psychiatrist. Unfortunately, the vast majority of patients do not see past their short sightedness & will continue to have a cycle of anxiety, depression, loss of confidence & obsessive compulsive disorders.
In the context of what I do, acne scarring BDD is frequently encountered. My success rate for treating this condition is very low, as I cannot convince patients to seek psychological assistance. My skill sets & mode of practice is not conducive to treating this type of scarring.
Red flags for this disorder include the phrases ‘in certain lights I can see… ‘or ‘my family & friends can not see what I see…’
I base my revision of scars & aesthetics on improving the confidence of people to realise what others may perceive. Ideally, this is the end-point of treatment.
For patients with BDD, it is not that we will not address your concerns (if they are actually there at all), it is important to understand that the ideal solution is not just a medical procedure. Having a healthy outlook is super important, & hence why psychologists can help. In the majority of times, my nurses will provide a reasonable, cost effective solution with minimal risks.
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