Bio: https://www.katharinephillipsmd.com/staff/katharine-phillips-md.html
Most of us have a bad hair day or we’re not happy if we have a little pimple on our face. But that’s quite different from the experience of people with body dysmorphic disorder. (BDD)
More than simple insecurity about one’s appearance, BDD is a disorder in which a person’s perception of their appearance becomes all-consuming and deeply distressing. Perfectly normal looking people can see themselves as horribly ugly. Or one minor detail becomes an enormous fixation, like the patient who said they felt they were just one giant pimple with hands and feet.
In this episode, Dr. Phil Stieg speaks with psychiatrist and BDD expert Dr. Katharine Phillips about how altered visual processing in the brain leads individuals to fixate on minor and often imagined flaws, while behaviors like mirror-checking and reassurance seeking reinforce the cycle of negative perception. Dr. Phillips highlights the serious mental health risks associated with this condition and discusses evidence-based treatments that have led many patients to a meaningful recovery.
Phil Stieg
In a culture dominated by screens, we’re constantly surrounded by images of perfect looking people. Most of us experience moments of insecurity about our looks, but for some people, their reflection in the mirror becomes a source of severe distress. Dr. Katharine Phillips is a leading authority on Body Dysmorphic Disorder, a condition that affects how individuals perceive their appearance. She has authored seminal books that have helped shape how this disorder is recognized and managed worldwide. As a psychiatrist and researcher at Weill Cornell Medicine, she has dedicated her career to understanding and treating this often-misunderstood disorder. And her work has been instrumental in improving outcomes for patients struggling with this distorted body image.
Katharine, thanks so much for being with us today.
Katharine Phillips
Oh, thank you for inviting me. I’m delighted to be here.
Phil Stieg
I mean, I’ve got to admit, I look in the mirror, and I go, ugh, some days, you know, how am I different? I mean, I don’t think I have BDD. There’s a difference between that momentary or weeklong insecurity about the way we look versus somebody who’s got BDD. What is that difference? Is it just the wiring in our brain – or you tell me.
Katharine Phillips
You know most of us have a bad hair day or we’re not happy if we have a little pimple on our face. But that’s quite different from the disorder body dysmorphic disorder. BDD is more severe than that. So there are three key criteria that helps help us differentiate body dysmorphic disorder, which needs mental health treatment, from normal appearance concern. The first is preoccupation, obsession. If you think about your appearance at least an hour a day in total in a negative way, that is, it
Phil Stieg
as to be negative? Okay, yeah.
Katharine Phillips
People with BDD don’t like how they look. They don’t like how these parts of their body look. You know, they may say I look unattractive, but sometimes they use stronger words. They may say I look ugly. That’s a very common one. I look deformed, I look like a monster. Not everyone will say that, but they have a very negative view of how they look when to other people they look normal. And some are very, very attractive, right? So they have a very distorted body image. They see themselves very negatively, whereas that does not reflect the reality of how they look.
I remember one patient saying, saying, you know, I’m just one big pimple without any feet or even any toes. All this person saw when he looked at himself was pimples that the other people hardly, hardly existed, right? And didn’t realize, didn’t even look at the rest of himself
I had one patient who, a beautiful young girl, beautiful, but she thought she looked horribly ugly. Her hair was ugly, her eyes were misshapen and uneven and her lips were too thin. But she was beautiful. And people told her that and said she should work as a model. She still thought she was ugly because she had BDD. Right. She wasn’t seeing herself accurately. She actually gained something like 50 pounds and didn’t even notice. Didn’t even notice because she was so focused on these specific aspects of their appearance.
When people with BDD look at themselves, they zero in on the things they don’t like, and they often ignore the rest of themselves. So that selective attention to the things they don’t like probably further distorts what they’re seeing.
If you get a little spot on your face, a teeny, little spot, and you were to look at it for three hours a day and keep going to the bathroom to check and take magnifying mirrors and look at it, it would probably start looking huge to you also. So that selective attention makes matters worse.
The difference between sort of normal appearance concerns that almost everybody has at least some of the time. And BDD is how much are you thinking about it each day? Is it often on your mind? Does it cause you distress? Does it make you feel down, sad, anxious? Some people feel suicidal over it? And does it interfere with your day to day functioning if it gets in the way of your social life? Going to school, doing your Schoolwork, doing your job, starts getting in the way of your day to day functioning, so that that starts getting somewhat impaired, then that’s also compatible with the diagnosis of BDD.
These three benchmarks, preoccupation, distress and impairment and functioning are the key things that differentiate body dysmorphic disorder from more common, normal body image concerns, wanting something to look a little bit different, thinking your hair doesn’t look so good that day, those kinds of things.
Phil Stieg
I was aware of this, but I’m actually shocked that 5 to 10 million people in America are probably walking around with this. But as I understand it, it’s still kind of misunderstood. How did that happen?
Katharine Phillips
Well, you know, it was just unrecognized for so long. It just got missed until really the 1990s. And even then it’s been very under recognized over the years. I think in part because people with this condition, they think they’re ugly and they worry people are going to think they’re vain. And body dysmorphic disorder is definitely not vanity. Right. It’s a misperception of how people look and they really suffer because of it. And they often just don’t want to talk about it. I think psychiatrists, other doctors weren’t looking for it.
So I just think it was. It was under recognized for a very long time. And I think it still gets under recognized, but it’s become much better known in recent years, thankfully, because it’s often a very, very severe disorder.
Phil Stieg
So what do we really know about what’s happening in the brains of people with BDD?
Katharine Phillips
What we’re learning is that the brains of people with body dysmorphic disorder, are too good at seeing detail. And parts of the brain that are specialized to see detail are working too hard. We can see this on functional MRI studies that show brain activity. Those parts of the brain that see detail are on overdrive. And parts of the brain that specialize in what’s called holistic visual processing, which enables people to see the big picture, and recognize the details are just tiny itty bitty things. Those parts of the brain back in occipital lobe, in the back of the brain are not working hard enough. So details overtake what they see.
And so then, you know, they notice a little asymmetry of their nostrils, for example, and it looks horrifically ugly. You know, we all have a little asymmetry in our faces, everybody. But to people with BDD, though, that detail can really pop out at them and take over what, what they see a little pimple that no one else would notice, or it would just look very small to somebody else, to the person with BDD, it can look huge.
So their brains are seeing too much detail in what they’re looking at, and they assume everyone else sees them that way. But that’s not actually the case. Other people are not noticing the little details that they’re seeing. But to the person with BDD , they look huge and very noticeable.
Phil Stieg
Is there a gender difference? You know, do guys pick up one thing and women pick up another? Or is it just, does it cross all genders?
Katharine Phillips
BDD is mostly the same in men and women. There are some interesting differences, just far more similarities than differences. But one difference is that men are more likely to have a form of body dysmorphic disorder known as “muscle dysmorphia”, where they obsess that their body build isn’t big and muscular enough. Whereas women are more likely to worry that they’re overweight and too fat, when in fact that’s actually not the case.
Men are more likely to worry that they’re going bald even though they’re not. Right? And women are more likely to worry that they have excessive body and facial hair. Men are more likely to have a co-occurring substance use disorder. Women are more likely to have an eating disorder. So some of the differences that we do see between males and females do echo differences that we might see in the broader general population. But overall BDD is quite similar between men and women.
Phil Stieg
In your book, you talk a little bit about a patient that had, quote, a mirror trap. And it kind of reminded me of I was at a party with a bunch of professional dancers which was in a rehearsal studio lined by mirrors and I was stuck, struck by how often the individuals looked at themselves in the mirrors. But I’m presuming they don’t have BDD because they were looking at it and they liked what they saw.
Katharine Phillips
Yes, yes, yes.
Phil Stieg
So what’s the mirror trap?
Katharine Phillips
Well, yeah, for people with BDD, the mirror is the enemy, right? Because they, again, they have this distorted view of how they look. And so they look in the mirror and I think they look awful when they actually don’t. And so people can check mirrors for hours and hours a day, get stuck there trying to fix what they don’t like, maybe picking their skin if they have little skin blemishes, maybe frantically combing their hair because they think their hair looks really strange, trying to get it just right, maybe even cutting their hair, applying makeup.
So most people with BDD spend a lot of time in the mirror and it often makes them feel worse actually, because they’re so distressed by what, what they’re misperceiving in the mirror. Mirror checking can be a clue that someone has BDD. You know, sometimes they don’t tell anyone that they’re suffering with these obsessions that they look bad. But that sometimes can be a clue. Someone’s spending a lot of time in the bathroom or checking mirrors a lot.
Phil Stieg
You gave examples of. I think it was a woman who was so fixated on her facial appearance that she didn’t go to school. She dropped out of school. Can you give us that example?
Katharine Phillips
Sure. Yeah. I’ve seen many, many people like this. They just become so obsessed with, I look awful. People are going to laugh at me. They may not want to go out of the house. They may not even want to leave their bedroom. I have seen patients who won’t even let their family members see them.
I can think of one young woman I treated a long time ago who dropped out of high school. She thought she was too ugly. She couldn’t bear to go and have people see her. She mistakenly thought that other people were staring at her, laughing at her. This wasn’t actually happening.
It was a misperception. And she basically dropped out of school. She couldn’t tolerate going. She was too obsessed to go. She didn’t want people to see her. She thought she was too ugly to be seen. And she just stayed in her bedroom for a decade and wouldn’t come. Wouldn’t even let her parents see her. They put food trays next to her door so at least she could eat.
There was one woman like the one I’m describing who would be willing to let her parents see her about once a month, but she came out of her bedroom with a veil over her face because she didn’t want them to actually see her face.
So BDD at its most severe can be extremely severe. We found, for example, a couple of my studies that about 20% of youth with BDD drop out of school because of it.
Phil Stieg
In a normal close knit family, the parents would be the first people to kind of pick up on, you know, my son or my daughter are spending a lot of time looking at the mirror and they come away from it unhappy. What should the parents do?
Katharine Phillips
Parents, just need to be aware of this disorder. BDD usually starts in adolescence. Two thirds of people with BDD have the onset of BDD before age 18. And I think it’s so easy to assume that, oh, these appearance concerns are just a normal part of being an adolescent. Right. And it’s so easy to just kind of dismiss it. And keep in mind, teens don’t necessarily share with their parents that they think they look ugly or that they’re obsessing about it or that this is the reason they want to stay in their bedroom.
This is a secretive disorder for many parents. They often keep it to themselves. I think parents need to be aware. Talk with their teen. Sometimes it’s in children, actually. Young children can get body dysmorphic disorder. But talk with them. And ask them, you know, just say, “I noticed, you know, you’re spending a lot of time in the mirror. You seem to get upset when you’re looking. You know, you’re willing to tell me what you’re experiencing, you know, what’s going on?”
Listen to them. Don’t make fun of them. “Oh, what do you mean? That’s a silly thing. You know, boys aren’t supposed to worry about those things.” Would be examples. Don’t try to reassure them. “Oh, what do you mean? You’re beautiful!” Because reassurance doesn’t work very well for people with BDD. And then of course, you want to seek the right professional treatment, because treatment usually helps.
Phil Stieg
Sounds to me like a death trap for a parent. You, you can’t tell them they’re beautiful. You can’t tell them they look abnormal. So you’re telling us that as a parent, we should just keep our mouths shut?
Katharine Phillips
Well, you never want to tell a child or a teen that they look bad. Right. That can be really devastating. I think telling a child that they are attractive or look good or whatever is fine. But it doesn’t tend to work when they have body dysmorphic disorder. They tend not to believe it.
Phil Stieg
Okay, but it doesn’t make them feel worse. You know, as a parent, if I tell you “you have BDD” and I say, “oh, you’re still beautiful in my eyes”, does that, is that a bad thing to say? Or Is it going to make them feel worse? I’m trying to get a frame of reference for the parents that have children that have this.
Katharine Phillips
Yeah, I think the main thing is you want to try and avoid the ritual. So there’s not only the obsessive part of BDD thinking over and over again, I look ugly, you know, I look terrible. People are going to laugh at me. But that triggers repetitive behaviors to try to check or fix or hide your appearance, like mirror checking.
One of those is reassurance seeking, where people with BDD may ask other people. Often it is parents a lot, how do I look? Do I look okay? Can you see this on my face? How does my hair look? No, it looks really bad. And I’ve had patients who’ve asked their parents literally a hundred times a day, how do I look? And no matter what the parents say, it’s not helpful.
You could ask, you know, does it help you when I say that you’re a beautiful girl? And the person with BDD will usually say, no. And so then I think it’s better to come up with, together with the person with BDD, what is a more helpful response? You could even say something like, you know, we talked about how it doesn’t really help for me to give you reassurance that you look lovely or that you’re beautiful. Can we talk about something else instead? Can we go out for a walk? Can we watch a movie together? But try not to fall into that trap of providing the reassurance. And then the person with BDD keeps asking for more, and hours can go by in some cases. Ultimately it’s unhelpful.
Phil Stieg
Social media and your cell phone and the continuously looking at yourself doing selfies. What role has all of this played in magnifying BDD or actually creating the disorder for a number of people?
Katharine Phillips
That’s such a good question. You know, we don’t have good answers. I’m sorry to say. it hasn’t been that well studied yet. But I do think that these influences are probably increasing the prevalence of BDD.
Phil Stieg
Or the severity?
Katharine Phillips
Absolutely. That I see in my patients all the time. Yes. You know, they’re comparing themselves online with these unattainable beauty standards. They’re using apps to morph how they look. All these messages about getting cosmetic surgery, and male boys and men are getting these messages as well, not just women.
You know, my colleagues and I wrote a book, the Adonis complex, 25 years ago, talking about all the negative messages that boys and men get about being muscular and trying to be bigger. And I think these messages have intensified so much recently. So I can certainly see with my own patients that all the pressures to change their appearance, improve their appearance certainly can make their BDD worse. And some of them decide to just get rid of some of the apps because it just adds fuel to the fire of their suffering.
Theme music
Narrator
When it comes to adding “fuel to the fire” of people suffering from Body Dysmorphic Disorder, nobody does it quite like twenty-year-old Braden Peters of Hoboken New Jersey – better known on the internet as … “Clavicular”.
Clavicular
Are we up? Oh, finally! Boys, boys, boys, boys. How are we doing today?
Narrator
In his persona as “Clavicular”, Peters spends hours every day live-streaming his activities on the internet as he promotes “looksmaxxing” – a concept which emphasizes physical appearance as the most important measure of a man’s self-worth. He promotes some extreme measures to achieve an ideal appearance. Like taking amphetamines to lose weight – which he calls “leanmaxxing”.
Clavicular
I was gonna talk about a controversial, um, lean maxing hack … For 3 days. I spammed a combination of Adderall and methamphetamine for appetite suppression.
Narrator
In 2024 he was thrown out of college for hoarding illegal prescription drugs in his dorm room, which motivated him to expand into a career as an internet influencer…
Clavicular
And now I am able to fully dedicate my time to looksmaxxing. So I think this is going to wind up being a blessing in the end.
Narrator
As the leading champion of looksmaxxing, Clavicular now earns nearly one hundred thousand dollars a month criticizing the appearance of both men and women.
Clavicular
Your body fat is the first thing that’s holding you back. I can’t even tell if you’re mogging or not. … uh, you know, all the facial convexities are wrong, her radix is recessed. Moving on. Okay, well, how much time do we have on the podcast?
Narrator
While he is vain, cruel and obviously narcissistic, Clavicular does not show symptoms of classic Body Dysmorphic Disorder. Rather, he sees himself as an “evangelist”
Clavicular
My main pursuit is that of esthetics and improving my looks to the maximum degree. So the fact that that’s become a political phenomenon just really doesn’t make sense to me at all.
Narrator
Like an internet version of Typhoid Mary, Braden Peters continues his notorious campaign as Clavicular – spreading unrealistic beauty standards among the tens of thousands of his young followers every day.
Phil Stieg
What about — as I was reading the book, I felt myself getting anxious.
Katharine Phillips
About what?
Phil Stieg
Well, just, I mean, feeling badly for these, the incessant looking in the mirror, picking, combing your hair.
Katharine Phillips
It’s very distressing disorder.
Phil Stieg
Yeah, yeah, it’s got to be hard to live with. So is there a component of an anxiety disorder? And you mentioned something about suicide. So there’s, is there significant depression associated with the disorder as well?
Katharine Phillips
Often now everyone’s different. Right. There’s a spectrum of severity in BDD as in other disorders. So some people have milder BDD and some have very severe BDD, extremely severe. On average. You know, people with BDD really suffer a lot and their daily functioning is impaired.
About 80% of people with BDD do have thoughts at some point in their life that life isn’t worth living, or they wish they were dead. And often it’s because they think they look ugly. About more than a third attempt suicide. And studies, studies have shown that suicidal thinking and suicidal behavior are more common in BDD than in many other psychiatric disorders like depression, major depressive disorder, anxiety disorders, bipolar disorder, PTSD.
I think we have to keep in mind that, you know, suicidal thinking, suicidal behavior, and even actual suicide is a risk for people with BDD. It’s really why we have to recognize it and help people get the right treatment. And many of them are depressed and, and they often say it’s because of the BDD. So it can be very serious, very serious disorder.
Phil Stieg
And the individual with anorexia, is that a severe form, form of BDD or is it a different diagnosis?
Katharine Phillips
A different diagnosis. I love your questions because these, this issue comes up all the time. It is a different diagnosis. So people with anorexia nervosa think they’re fat when they’re actually very thin – almost like a skeleton, very, very thin, but they think they’re fat. So they have distorted body image, as do people with BDD. BDD usually focuses more on the face or the head. It can involve weight. But in both disorders, you see this distorted perception of what they actually look like, but in many other ways they’re quite different disorders. And it’s important not to confuse them because the treatments are somewhat different.
Phil Stieg
So we’ll stay focused on BDD, otherwise we’ll be here all day.
Katharine Phillips
But one thing I should add is all these disorders that you’re asking about can co-occur with bd, right? Any psychiatric disorder, mental health disorder, can co-occur with any other. So sometimes people have both OCD and BDD, BDD and depression, BDD and an eating disorder.
Phil Stieg
Do you find that a lot of people with BDD seek out plastic surgeons?
Katharine Phillips
Oh, yes. Oh, yes, unfortunately, because it almost never helps BDD. So about 3/4 of people with BDD seek cosmetic treatment of some sort, and about 2/3 actually receive it. And I’ve seen 25 year old women who’d already had 25 surgeries on almost every body part.
And the problem with that is that it almost never works. And it can make BDD worse. I’ve seen people who became acutely suicidal after their fifth rhinoplasty nose job because they thought the surgeon said, I can’t do any more after this. And they think, they take the bandages off and they think they still look horrible. And it makes sense, sense that cosmetic procedures wouldn’t work for BDD because BDD isn’t a problem with actual appearance, right? It’s a problem with distorted body image and a tendency to obsess about any minor flaws that the person sees.
And so sometimes, Maybe in about 30 to 50% of cases, after someone gets a procedure, they develop a new body image concern, right? So one patient said to me, well, you know, after my, after my liposuction, my stomach looks a little bit better, but my nose took over from my stomach because it’s this tendency to obsess about little minor things. And of course, we all have a ton of those that we could obsess about, right? And people with BDD do.
Phil Stieg
So is the treatment spectrum, is it talk therapy, psychoanalysis, group therapy? How do you, you, the world’s expert on this topic, approach it with, you know, we’ll start with somebody that’s not suicidal and you know, not living in their bedroom and not ready to drop out of school. But, but they obviously have it.
Katharine Phillips
Okay, we have two evidence based treatments. One is cognitive behavioral therapy, which is a very practical therapy. So, so you don’t lie on a couch and talk about your childhood or your mother. You know, you learn very practical skills. It’s a little bit like being in a class, taking a class, but you know, having good, the therapist has good — therapy skills. That helps a lot. Now cognitive behavioral therapy is used for a variety, a whole variety of mental health and non mental health conditions like for insomnia, for pain, for depression.
So cognitive behavioral therapy always has to be tailored to the specific problem you’re trying to treat. So we have a cognitive behavioral therapy that is specific to treating BDD and it has a few main components. One is to help people learn to develop more accurate and helpful thoughts about how they look. Rather than, I look hideous, everyone’s going to be staring at me tonight if I go to that party, so I can’t go. We teach the patient things like cognitive errors. There were some cognitive errors in what I just said.
Fortune telling – Can you really predict what’s going to happen at the party?
Mind reading, — do you really have Special skills. Can you really read people’s minds? No one really can.
Personalization — Is everyone really going to be focused on you, or might they be there enjoying their friends and the food and the music and things like that?
So we help people to recognize cognitive errors in their thinking, which we all make from time to time. People with BDD tend to make a lot of them, and that makes them feel bad and often makes them avoid going out and doing things. So that’s one component of the treatment. We also help them get control over those repetitive behaviors that we’ve talked about. The mirror checking, the reassurance seeking, comparing their own appearance with that of other people. Those are such toxic behaviors. They just keep you focused on how you look. They keep the BDD going. They waste your time. They usually make people with BDD feel bad. So we help them learn ways to control those behaviors.
We also do some work with self-esteem, self-compassion to help people develop a broader basis of their self-esteem. I think BDD narrows the basis of one’s self esteem and appearance becomes the main basis of their self-esteem. It’s not vanity. People with BDD are not vain, superficial people. I think this is what the disorder does to them.
So we help them learn to appreciate other aspects of themselves. Maybe they’re a great violinist, maybe they are good at math, they’re kind to people, you know, they have a sense of humor. But often people with BDD forget about all those things and appearance becomes the overriding basis of how they feel about themselves.
Phil Stieg
Are there medications you use or are those medications used for the anxiety and the depression and the OCD?
Katharine Phillips
Well, they also help all those problems if they are there, which they often are. But yes, medication, that’s our other first line treatment. Both medication and cognitive behavioral therapy they’re both great. They help most people, people if they’re done, implemented correctly. But medication can be lifesaving. And it’s so important that people with BDD consider a medication, especially if they have more severe BDD.
But the medications that have been shown to work in BDD are called the serotonin reuptake inhibitors. They’re probably familiar to many people. They’re very widely prescribed medicines like Prozac, Zoloft, Lexapro, and they help stop the obsessive thoughts. They give people more control over their own thinking, right.
Rather than being taken over by the obsessions, they help people stop the compulsive repetitive behaviors, which are so time consuming for most people with BDD, they help people feel more comfortable being around. Other social anxiety that’s caused by BDD gets better. And if people are also depressed, if they also have OCD, other anxiety disorders, those usually get better as well.
Phil Stieg
And what’s the success rate?
Katharine Phillips
High. I would say, you know, over. If you really, if you get high enough doses of the medicine, I should say if you get the right medicine, the right dose, if you get cognitive behavioral therapy, I always tell people you have, I’d say at least a 90% chance of substantial improvement. And often people have no symptoms anymore.
Phil Stieg
Well, I have to admit, given the diseases you treat in psychiatry, being able to say that you got a 90% success rate is going to make you feel pretty good.
Katharine Phillips
Yes, But I have to say, sometimes it takes multiple tries of different treatments. But even just one really good medication trial with an SSRI, such a benign class of, you know, benign medications. Right. Just one treatment trial, you have about. About 75% chance of significant improvement. And we see the same with the cognitive behavioral therapy. It’s the same.
Phil Stieg
So the long-term prognosis is also excellent. Meaning once you crack that nut.
Katharine Phillips
Yes, yes.
Phil Stieg
People get on to a normal life.
Katharine Phillips
With the right treatment. Yes, absolutely. So there’s hope. There’s so much hope. Right.
Phil Stieg
Well, that’s what I, I wanted to end with hope.
Katharine Phillips
30 years ago we had no treatments for this disorder. It’s hard to believe, right? Nothing. We knew nothing about it. And now we have really, really good treatments for this disorder.
Phil Stieg
That’s fantastic
Phil Stieg
Dr. Katherine Phillips, thank you so much. For so clearly defining what BDD is.. But most importantly, defining the fact that there is great hope once it is diagnosed. Thank you so much for being with us today.
Katharine Phillips
Thank you so much for having me today. Pleasure.
