For adults and parents
Body dysmorphic disorder, skin picking and hair pulling
Body dysmorphic disorder (BDD) is a preoccupation with a perceived flaw that others barely notice, and it has nothing to do with vanity. Skin picking and hair pulling are repeated habits that damage the skin or hair. Each responds to a specific, practical form of CBT.
What BDD is
Body dysmorphic disorder is a preoccupation with a perceived flaw in appearance that other people cannot see or think is minor. The thoughts about it are intrusive and repetitive, take up hours of the day, and lead to checking, hiding or trying to fix the feature. Concerns most often involve the skin, nose, hair, face or teeth and, in men, muscularity. People with BDD are not vain. BDD is a daily conviction of looking disfigured, usually kept secret, and mistaking it for vanity is one reason people do not seek help.
What BDD looks like day to day
- Long sessions examining the feature in the mirror, or covering mirrors entirely.
- Hiding the feature with hair, make-up, hats or a hand over one side of the face.
- Refusing to be in photographs, deleting them or editing them before posting.
- Asking a partner whether it looks bad, then asking again in case they were being kind.
- Avoiding swimming, changing rooms, bright lighting, video calls or going out in daylight.
Why it is so closely related to OCD
The pattern is the same as in OCD. An intrusive preoccupation causes distress, checking or hiding reduces it briefly, and repeating that behaviour teaches your brain that the concern was worth acting on. The differences are that many people with BDD are convinced the flaw is real and visible, and that shame is heavier, which is why BDD often stays hidden for years.
- Trigger: Catching your reflection, or seeing a photo
- Thought: “My nose is huge and everyone notices”
- Feeling: Shame, disgust, dread of being seen
- Checking and comparing: Studying the mirror, comparing, covering up
- Result: Close scrutiny makes the flaw look worse
- Then back to the first step, and the loop runs again.
- Other situations that now set it off too: A photo tagged by a friend, video calls, bright bathroom lighting, someone glancing at you.
Where treatment steps in. You cut down the checking, comparing and covering up, go into situations you have avoided, and practise using the mirror to look at your whole face rather than one feature.
New triggers. Over time, more situations become linked to the trigger and start the loop off too.
What treatment involves
NICE recommends CBT adapted for BDD, including exposure and response prevention, which here means gradually facing the situations you avoid while cutting down the checking and hiding. For adults with moderate BDD, NICE offers a choice between this therapy and an SSRI, and for severe BDD it recommends both together. I do not prescribe. Treatment starts with a precise map of the preoccupation and every behaviour attached to it.
Then, in steps agreed in advance, you reduce the mirror checking, reassurance questions, covering up, photo editing and comparing, because each one brings your attention back to the feature. You also go into situations you have been avoiding, first with the covering up and then without it, and find that you can handle the distress without hiding, and often that what you feared does not happen. The exposure planner helps with planning these steps. We also work on attention, because BDD leads you to look at yourself close up, one feature at a time, in a way most people never do. Practising keeping your attention on the conversation rather than on the image of your face changes how it feels to be with people.
Teenagers
BDD often begins in adolescence and is easy to mistake for self-consciousness or social anxiety. Signs worth taking seriously are missed school, refusing photographs, avoiding swimming or PE, hours lost to getting ready and requests for cosmetic procedures. Parents are often involved in treatment, particularly in how they respond to repeated questions about appearance.
Depression and suicidal thoughts
BDD carries a real risk of depression and of suicidal thinking, which is a reason to have it assessed properly. I ask about this directly, because it changes how treatment is planned. If things are bad right now, tell your GP or use the urgent routes listed at the foot of this page rather than waiting for an appointment. In an emergency call 999.
Skin picking and hair pulling
Skin picking (excoriation disorder) and hair pulling (trichotillomania) are known as body-focused repetitive behaviours. They involve repeated picking or pulling that damages the skin or hair and that the person has tried many times to stop. Picking usually starts from a spot, a scab or a rough patch, and pulling most often involves the scalp, eyelashes and eyebrows. Both usually begin around puberty and are often hidden for years. Unlike OCD, no obsession or feared consequence drives picking or pulling. The urge comes from tension, boredom or the feel of an uneven patch of skin or a coarse hair, and giving in to it is often satisfying in the moment, so the treatment differs from the one used for OCD. Where picking is aimed at correcting a feature you believe is flawed, it can be part of BDD, and the plan then covers both.
- Trigger: Boredom, stress, a mirror, a rough spot
- Urge: Tension, or a pull to make it smooth or even
- Behaviour: Picking or pulling, often before you notice
- Relief or reward: The tension drops, and it can feel satisfying
- Afterwards: Regret, shame, and more to hide
- Then back to the first step, and the loop runs again.
- Other situations that now set it off too: Sitting in the car, scrolling on your phone, watching TV, lying in bed.
Where treatment steps in. Habit reversal steps in at the urge, by noticing it early, doing something with your hands that makes picking or pulling impossible until the urge passes, and changing your surroundings.
New triggers. Over time, more situations become linked to the trigger and start the loop off too.
Some picking and pulling is automatic, happening while you read, drive or scroll in bed, and some is focused, a deliberate episode at the bathroom mirror. Most people do both. The treatment with the best evidence is habit reversal training. First you learn to notice the behaviour early, by recording when and where it happens and by learning to spot the first movement, such as your hand travelling up to your face. When the urge comes, you do something with your hands that makes picking or pulling impossible, such as making a fist or holding an object, and keep doing it for about a minute or until the urge passes. You also change your surroundings so the behaviour is harder to start, for example by removing tweezers and magnifying mirrors or covering the fingertips you use most. Following the ComB model described by Mansueto and colleagues, we also work on the triggers particular to you, such as stress or boredom. A daily record such as the practice log helps from the first week.
With teenagers, parents often notice the evidence first, such as missing lashes or a thinning patch. Inspecting, commenting and pulling their hands away are understandable responses, but they tend to increase shame and hiding, so a calm, matter-of-fact approach usually helps more. Where there is skin damage, infection or hair loss that is not regrowing, it is worth seeing your GP or a dermatologist as well.
Common questions
How is BDD different from just disliking how I look?
Most people have features they would change, and that is not BDD. In BDD the preoccupation takes up hours of each day, is distressing, and leads to checking, hiding, comparing and avoiding that costs you work, relationships or social life. Reassurance also does not settle it. If being told you look fine changes nothing, or helps for an hour, it is worth having it assessed properly.
Would cosmetic surgery fix it?
It rarely does. People who have procedures for BDD are often dissatisfied with the result, satisfied only briefly before the preoccupation moves to another feature, or left with a permanent change and no less distressed. This is because the problem lies in how attention, checking and interpretation lock onto the feature, and that carries on after the procedure. Surgeons and dermatologists increasingly screen for BDD for this reason. If you are considering a procedure, we can talk it through, including what happened after any previous ones.
Why can I not just stop picking or pulling?
Much of the picking and pulling happens outside full awareness, while reading, driving, looking at a screen or standing at the bathroom mirror, and by the time you notice it has often been going on for several minutes. The behaviour also relieves tension and can feel satisfying, which makes it more likely to happen again. Willpower alone does not change either of these. Treatment changes the conditions instead, so that you notice the urge earlier and the behaviour is harder to start.
Free 20-minute call
Not sure whether this is the right fit?
Start with a free 20-minute call. We talk through what is going on, I answer any questions you have, and I tell you whether I think I can help. If I cannot, I will try to point you to someone who can. The call is free and there is no obligation to book.
Weekdays, 9am to 5pm. No GP referral needed.