Appearance-related Distress

What are the aims of this leaflet?

This leaflet has been written to help understand appearance-related distress. It covers what it can feel like, its features and how it can affect your life. You will also find information on what can be done about it.

What is appearance-related distress?

Most of us feel worried about our appearance sometimes. This is completely normal. But for some people, these worries can be overwhelming and hard to manage. They can cause feelings of stress, anxiety and even panic.

You might find yourself doing certain things to try to feel better - like often looking in mirrors, avoiding people, or trying to hide parts of your body. These are called ’safety behaviours’. They might help for a short time, but they often make things harder in the long run.

If you experience appearance-related distress you might:

Spend a lot of time focusing on and thinking about what you believe is a flaw in your appearance - for example, a rash, acne or other skin condition. This might be something that other people do not notice, but it bothers you and makes you extremely self-conscious when in the company of others.
Worry what others might notice your “flaw” and talk behind your back or judge you.
Checking mirrors often and comparing yourself with other people.
Trying to hide the part you are worried about – using your hands, hair, make-up, baggy clothes, or standing in particular ways.
Wanting to change how you look through cosmetic treatments or surgery.
Avoiding things that are important to you because of how you feel about your appearance. This could include activities like going out, swimming, or being close with others.

How the mind and the skin are connected

We know that problems affecting the skin can affect how a person feels about themselves – equally, how we feel inside can affect our skin:

Problems with the skin can be upsetting and cause worry and embarrassment in some people.
On the other hand, stress, anxiety and low mood can sometimes make skin conditions worse or even cause them in some cases.
This is normal and it is not your fault.

Research has shown that different systems in the body - including the skin, gut, nervous, hormone and immune systems – all work together. When one system is affected, it can sometimes cause problems to the others.

This is why, your healthcare professional may suggest support for your mental wellbeing, even when your main worry is about your skin. This can seem a bit surprising but this approach has been shown to be highly effective.

What is body dysmorphic disorder?

Body dysmorphic disorder (BDD) is a severe form of appearance-related distress.

BDD is a type of anxiety. It shares many features with a condition called obsessive compulsive disorder (OCD), where people feel stuck with certain thoughts or routines.

How common is appearance-related distress?

Most people feel unsure about their appearance.

In fact, appearance-related distress is very common people attending dermatology clinics. Some studies suggest that about 10 out of 100 people feel very distressed about how they look. This is especially common when conditions affect the face, including nose, eyes, skin and hair.

Is appearance-related distress hereditary?

Currently, the relationship between appearance-related distress or BDD and our genes is not well understood. More research is needed in this area.

What causes appearance-related distress?

Appearance-related distress can happen for different reasons, and it is not the same for everyone. Experts believe it can be caused by a mix of things:

Genetics (traits passed down from family)
Differences in how the brain works
Social influences, like culture, peer pressure, or social media

Sometimes, this kind of distress may also be linked to conditions such as obsessive-compulsive disorder or certain personality traits

Research also suggests that appearance-related distress may be connected to experiences such as:

Difficult or traumatic events in childhood
Emotional, physical or sexual abuse
Bullying or teasing
Being criticised about your appearance
Pressure from social media

These experiences can have a stronger impact if they happen during sensitive times in life, such as starting secondary school, going through puberty, or starting a new job.

It is important to know that not everyone who feels this way has gone through these experiences. Sometimes there is no clear cause. Scientists are still learning more about what leads to appearance-related distress and conditions like BDD.

Why is it important to recognise appearance-related distress?

Despite appearance-related distress being common in dermatology practice, this condition is under-recognised. This may significantly impact on a person’s quality of life, with many people being housebound, unable to work or study, and experience relationship difficulties. There is also an increased risk of depression and suicidal thoughts. Recognition and discussion of the condition is the first step to treatment and recovery.

People affected by appearance-related distress can worry about their looks and body image. They often feel ashamed and embarrassed about their appearance, but also about the way they feel about themselves.

Some people are also concerned that their appearance-related distress might be viewed as being vain or self-centred. However, research consistently shows that people’s inner experience of appearance-related distress matters more than how “severe” it may appear on the outside.

People affected by appearance-related distress can experience a range of challenging emotions and feelings. These may include:

Depression and feelings of hopelessness (life can feel like not worth living anymore). If you are having these thoughts and feel you want to harm yourself, it is important to seek help right away.
Anxiety and self-awareness. This can involve worrying about whether others notice your skin or appearance concerns or thinking they might believe it’s contagious or that it will worsen over time.
Shame and guilt.
Feeling angry about having a skin condition or frustrated by other people’s reactions.
Feeling disappointed or disheartened, particularly when treatments do not work as well as expected or when there is no cure for the skin condition.

It is important to remember that these emotions are common for people facing appearance-related concerns. Seeking support from professionals and loved ones can make a positive difference.

What help can I get help for appearance-related distress?

With appearance-related distress, the most effective approach is a holistic one, where both the skin condition and the distress it is causing are addressed at the same time.

Some people may find it useful to seek support from psychologists who specialise in dermatology and appearance-related issues. Research has shown that the following approaches can be helpful.

Cognitive Behaviour Therapy (CBT): CBT is a type of talking therapy that helps you learn ways to cope with situations that make you feel anxious or stressed. It can be especially helpful if you feel worried or upset about your skin condition or how you look.

“Having someone understand why I have the problems I do and who could see where I am coming from was so helpful”

CBT helps you understand how your thoughts, feelings, body, and actions are all connected. Once you see these links, you can learn how to change unhelpful thoughts or behaviours.

One type of CBT is called Exposure and Response Prevention (ERP). ERP helps you slowly face the things that make you feel anxious, step by step. Over time, this can help you feel less scared or stressed, and stop habits like checking, avoiding things, or needing to feel “safe” all the time.
Counselling: Sometimes, just talking with a counsellor about worries and anxiety can help you find effective ways to cope with them. The NHS offers talking therapies for free – for more information visit: nhs.uk/mental-health/talking-therapies-medicine-treatments/talking-therapies-and-counselling/nhs-talking-therapies/
Medications: In some cases, medications may be prescribed to assist with appearance-related distress. A group of medicines called serotonin reuptake inhibitors (SRIs) are sometimes used. These include fluoxetine, fluvoxamine, citalopram, escitalopram and clomipramine. In some cases, higher doses than usual might be prescribed . Always discuss the dosing with your healthcare professional.

It is important to discuss any of these treatments with your healthcare professional as they can provide personalised guidance based on your individual needs and circumstances.

Appearance-related distress can affect how see yourself. You might judge yourself unfairly or harshly. CBT can help you learn more helpful ways of thinking and reacting in everyday situations. By changing the way you think and what you do, you can start to feel better.

Unlike some other types of talking therapy, CBT focuses what is happening now, rather than looking into your past experiences. It helps you spot the links between your thoughts, actions and feelings – in this way, it can teach you how to break unhelpful patterns.

Where can I find more information about appearance-related distress and BDD?

Patient support groups providing information:

If you want to learn more about BDD, the Body Dysmorphic Disorder Foundation website has useful information, resources and a list of online support groups.

Body Dysmorphic Disorder Foundation

Web: www.bddfoundation.org

Email: info@bddfoundation.org

Weblinks to other relevant sources:

Mind: www.mind.org.uk/information-support/types-of-mental-health-problems/body-dysmorphic-disorder-bdd/useful-contacts/

Skin Health Info: www.skinhealthinfo.org.uk/support-resources/skin-your-wellbeing/

Jargon Buster: www.skinhealthinfo.org.uk/support-resources/jargon-buster/

Please note that the BAD provides web links to additional resources to help people access a range of information about their treatment or skin condition. The views expressed in these external resources may not be shared by the BAD or its members. The BAD has no control of and does not endorse the content of external links.

This leaflet aims to provide accurate information about the subject and is a consensus of the views held by representatives of the British Association of Dermatologists and Psychodermatology UK: individual patient circumstances may differ, which might alter both the advice and course of therapy given to you by your doctor.

This leaflet has been assessed for readability by the British Association of Dermatologists’ Patient Information Lay Review Panel