Hey guys, Sandra Lee, M.D. (aka Dr. Pimple Popper), here!

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Raising Awareness about BDD and BFRB

You probably feel self conscious about a certain part of your body — some of us don’t like our ears or our nose, we wish our muscles were different or our thighs were smaller. Luckily for most of us, we worry about these imperfections but they don’t affect us on a daily basis. Unfortunately for some people, their worry about their body’s imperfections affects them all day, every day.

This condition is called Body Dysmorphic Disorder, or BDD for short. When people have BDD, they obsess over their perceived flaws for hours each day — they can’t control the self-hating thoughts that are constantly running through their minds, and this causes extreme emotional distress. Even when people tell them they look fine, they won’t believe them. BDD interferes with people’s daily lives — they can’t get themselves to work or school, they won’t go out with friends or see their family, and they isolate themselves because they’re worried other people will notice their imperfections. In extreme cases, they’ll even undergo surgery and cosmetic procedures to “fix” these flaws, but never find happiness in the results.

BDD affects people of all ages, races and genders, but the American Psychiatric Association has identified that BDD most often develops in adolescents and teens, usually around the ages of 12 and 13, and research shows that it affects men and women almost equally. In the U.S., BDD occurs in about 2.5% in males, and in 2.2% of females. What causes BDD is unclear, but both biological and environmental factors can contribute. The biological factors include genetic predisposition, neurobiological factors (like the malfunctioning of serotonin in our brains), or personality traits; the environmental ones are usually life experiences, such as bullying, abuse, or trauma.

BDD episodes and thoughts can last for a few hours or an entire day, and people with the disorder are often obsessed with their body’s muscle mass or definition. They usually avoid leaving their home, may have suicidal thoughts, and/or develop compulsive, repetitive behaviors that help them deal with their BDD. Some examples of those behaviors include camouflaging their body (with clothing, makeup, hair, hats, etc.), seeking surgery, constantly checking or avoiding mirrors, skin picking, excessive grooming, excessive exercise, or changing clothes excessively.

If you know anything about eating disorders (anorexia or bulimia are two of the most common) you may wonder if BDD and eating disorders are the same. A study from the Department of Psychiatry and Human Behavior at Brown Medical School looked at exactly that, and determined that there are some important differences. But the study does note that even though anorexia and BDD should be differentiated clinically, “these disorders overlap in intriguing ways, and in some cases are hard to differentiate. When BDD and anorexia co-occur, it’s important to diagnose both of them because women with both disorders are, it appears, more severely ill than those with anorexia alone.”

In fact, when people have BDD it’s not just eating disorders that they may suffer from simultaneously — they could also have depression, anxiety, social anxiety, and/or obsessive-compulsive disorder (OCD). In some cases, people who are suffering from BDD can be misdiagnosed as having one of these other mental conditions because the symptoms can be so similar. According to the Anxiety and Depression Association of America, an international organization that works to better the lives of people living with certain mental disorders, “The intrusive thoughts and repetitive behaviors exhibited in BDD are similar to the obsessions and compulsions of OCD. And avoiding social situations is similar to the behavior of some people with social anxiety disorder.”

For some people, BDD can also coincide with a body-focused repetitive behavior (BFRB). This is an umbrella term for a behavior that causes people to repeatedly touch, pull, or pick at their skin or hair, sometimes causing themselves physical harm. The most common types of BFRB are hair pulling disorder (Trichotillomania), skin picking disorder (excoriation disorder), and nail biting (Onychophagia).

Some people confuse their habit or “need” to pick their pimples or scabs as BFRB, but those with BFRB have a serious disorder and compulsion.

I have heard from lots of popaholics that BFRBs affect many of you, and that’s part of the reason this issue is so important to me. It’s also especially timely that I’m writing this because it’s currently #BFRBWeek, which is honored the first week of October every year.

Why do people get BDD?

As awareness about BDD continues to increase, researchers are beginning to study why people feel so compelled to hate, and change, their appearance. Both BDD and BFRB are multifaceted, and can occur for a huge range of reasons. For some, these disorders coexist, for others, they’re entirely separate. 

That said, studies over the last few decades have proven that for those with BDD specifically, their disorder is rooted in poor body image. What I found very interesting is that half of adults who seek plastic surgery report a history of bullying. A May 2017 study that was published in Plastic and Reconstructive Surgery (the official medical journal of the American Society of Plastic Surgeons), showed that teenagers who were involved in bullying — both those who were bullied and those who were bullying — were more likely to seek cosmetic surgery to change their appearance. The study explains that bullied teens have “poor psychological functioning” which can lead to an increased desire to seek plastic surgery — a desire that turns out to be long lasting. It’s important to point out that those who are bullying would seek cosmetic surgery in order to look better and therefore become more popular and gain social dominance.

This study also showed that girls are more interested in plastic surgery, as are older teens and those whose parents had a lower level of education. But still, teens involved in bullying had a stronger desire for cosmetic surgery than their peers.

There are a lot of ways to help this population increase their self esteem — more research suggests that cosmetic and plastic surgeons can (and should!) increase psychological testing and screen for a history of bullying in teenagers and adults before they accept potential patients. And of course providing mental health for bullied adolescents — this can certainly help to decrease the desire to seek cosmetic surgery in the first place.

The importance of raising awareness about BDD and BFRB

Jumping back to BDD and BFRBs, I think it’s very important that we raise awareness about these mental issues and their physical manifestation. And that’s why I wanted to take the opportunity to voice something to my fans. According to the statistics on my social media, three quarters of my fans are female and most of you are between 18 and 34 years old.  So this is directed to you. Sometimes I wonder: What would I tell my younger self, the Sandra in her 20s?

When I think about it, I really wish I could tell my younger self not to be catty to others, not to be so competitive. I’m not talking about the competitiveness of getting the highest grade on your organic chemistry test, or taking first place in the long jump or the 100-meter race. I’m talking about supporting and really loving your girlfriends. Build your friends up — remind them of how unique and beautiful they all are. Nobody in this world is perfect, and we all have things about our body we don’t love. It’s okay to be aware of those flaws, but as a friend, remind your friend that the flaws she may think are a big deal really aren’t — you probably don’t even notice them!

Unfortunately, your kind words and positivity toward your friends can’t fix everything, and sadly there are going to be people who find themselves suffering from BDD or BFRB. And for those people, make sure you support them in the best way possible: Help them get help. #BFRBWeek is all about ending the shame and isolation that BFRB causes, and part of that is helping people become aware of what body-focused repetitive behaviors are.

That’s why I’ve written this — to spread awareness about these serious mental and physical disorders, to help teach people that skin picking and BDD aren’t just myths, they’re real issues that people battle every day. I know many of my popaholics are touched by these disorders, and I want you to know you’re not alone — there are resources available for you, and communities where you don’t have to feel embarrassed, isolated, or lonely.


BDD & BFRB Resources

The TLC Foundation offers an entire support page.

Skin Picking Support is another great resource.

The International OCD Foundation has a page dedicated to BDD.

The Anxiety and Depression Association of America (ADAA) has lots of helpful information about BFRB and BDD.

They also have a YouTube video of a presentation that explains BFRB and its treatments.

Get involved with the Picking Me Foundation!


  1. I have trichotillomania and it in no way is related to BDD. I’ve never had shame from it and I didn’t develop it from hatred of my body or my hair. Your intentions are good, but at the same time, you’re perpetuating a lie. A lie I’ve had to fight back against because people wanted to convince me that I hated myself and I needed to tackle my inner demons, the inner demons I’ve never had. Yes, it is sad that people hate their bodies and they should get help, but please do not lump me in with them because it’s simply not what I have. And it’s frustrating to explain that psychologists.

    1. Hi Ashley. We really appreciate you sharing your thoughts with us – we’re sorry that this story made you feel like we were lumping all people with trichotillomania into the BDD category, that wasn’t our intention. We recognize that for some people, they are very separate, but for others they are linked. We’re also sorry to hear about your struggle and having to explain it to the professionals you’ve seen, it sounds very frustrating. Again, thank you for sharing your thoughts. 💗

  2. Hi Doctor Lee, I actually cried after the shock passed. I can’t believe I have BFRB. I never knew I could have something like that. I thought it was a hair thing. I’ve chewed a bit my lips for as long as I can remember. I’ve pulled and peeled them till they bleed. They’re not in a good way and I’ve got missshapen lips with what looks like a lump on one. I don’t know how to stop doing it. I’ve tried lots of times but with no luck. I actually don’t even know I’m doing it most of the time. I’m 43 now and have done it for as long as I can remember. I’d really love any advice you can give me. I’m a massive fan of your YouTube channels and your Snapchat. I’m not on anything else or I’d have followed you. I live in Co Clare in Ireland. Not sure if that’s important I just thought I’d mention it. Any advice or help would be hugely appreciated. Kindest regards.

  3. I love that you are bringing awareness to BFRB. Ever since I was a little girl I incessantly picked my skin- bug bites, pimples, even picked at nothing at all. My mom always told me I turned molehills into mountains and created “unattractive crevices that would cause ugly scarring”, but I still couldn’t stop myself. I found that when I was stressed or anxious about anything the picking got worse. Though, even after large stressors in life passed I still found myself constantly picking at something, to which my mom would say “Why are you still picking? You don’t have anything to stress about right now”. However, what she didn’t know was every time she made a comment like that, commented on my scars, or band-aids it made me feel worse, increasing my stress. When I was 25 years old I got a new primary care physician and she asked me about all my “spots” (as I call them). When I explained them to her so told me that I was not unusual, and that it is actually something that commonly affects people. She called it an “OCD Anxiety Skin Picking Disorder” or dermatillomania. I feel like it definitely helps knowing that you are not alone in this and there is actual diagnosis/name for what you do to yourself. Throughout my childhood I never knew how to answer the other kids, and even some adults, questions, “oh what happened to your arm/leg?” or “why do you have so many band-aids?” I am now 27 years old and though people still ask me those personal questions, I know better how to answer them and don’t feel as though I am fighting this battle alone. I appreciate you bringing awareness to this so people like me know they are not alone, but also so maybe people might realize they shouldn’t go up to other people and ask about scars, wounds, band-aids, etc. Thank you, I am a longtime lover and avid “Dr. Pimple Popper” watcher and appreciate all that you share with us!

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