Ask the Experts

“My Appearance Is The Only Thing I Can Control.”

If you find yourself setting unrealistic expectations for your body, then you might be dealing with body dysmorphic disorder. Learn how to stop all-or-nothing thinking, and why therapy or medication might be the solution for recovery.

Body Dysmorphic Disorder (BDD) and ADHD: Is There a Connection?
Body Dysmorphic Disorder (BDD) and ADHD: Is There a Connection?

As a specialist who works with patients with eating disorders and body dysmorphic disorder (BDD), I’ve noticed that ADHD has a negative impact on body image. There is no mention of the relationship between body image and ADHD in the scientific literature, but there is anecdotal evidence worth considering.

Body image is more than how you think you look in a pair of skinny jeans. It refers to a person’s attitudes, beliefs, and perceptions of their body: how comfortable we feel about our bodies and how attractive we consider ourselves.

Positive body image is associated with healthy eating and sleep patterns, regular exercise, and avoiding bad habits, like smoking. People with positive body image feel appreciated, valued, and worthy of love. Negative body image can lead to restrictive eating, binge eating, purging, and not exercising at all or exercising excessively. It is associated with feeling unattractive and unworthy of love. Poor self-esteem and feelings of inferiority are both causes and consequences of negative body image.

Body Image and ADHD

Frank, 36, is chronically stressed due to ADHD. “The hyperactivity, the problems with following through on projects — it is too much to handle,” he says. ADHD often leads to feeling out of control. There are many unhealthy ways to deal with stress, including hyperfocusing on one’s body image. Frank has struggled with ADHD and also has been diagnosed with BDD, characterized by a preoccupation with an imagined or slight defect in one’s appearance. In Frank’s case, it is his skin.

“I feel like a failure every day because of my ADHD,” he says. “My appearance is the only thing I can control. So I spend a lot of time on improving my skin. I check myself in mirrors constantly to make sure my skin looks smooth and clean. I research skin cleansers when I should be doing work. Having perfect skin is my goal. If I look good, I feel that will make up for my other deficits.”

Edward, 29, is the same in the way ADHD affects his social skills. “I can be socially awkward and turn women off by interrupting them and saying off-the-wall things. I feel that if I look better, people will like me more, regardless of the fact that I can’t carry on a conversation. That is what led to my exercise addiction.”

A person with ADHD can temporarily shut out the world when he focuses on a number on a scale or his appearance in the mirror. Struggling with both ADHD and weight (despite being at a normal, healthy weight), Marisol, 24, says, “I don’t always accurately judge whether I have done a task well or not at work or at home. It is so hard to get through an assignment that it never feels well done. I feel like I am in limbo. But focusing on my weight grounds me. It is about a concrete number, and it is easy to measure where I stand.”

Stimulation First

People with ADHD crave instant feedback. Weight, appearance, and body-related behaviors give that to them, although they can become obsessions. Eddie, 17, who has been diagnosed with ADHD, found himself touching his arms a lot while doing homework to see if his biceps were getting bigger. He would get anxious and look at his muscles in the mirror. If he did not like what he saw, he would start lifting weights in his room. Despite being muscular, he perceived himself as looking “puny,” a behavior known as muscle dysmorphia. Meanwhile, his homework — and other important tasks — didn’t get done.

Hyperfocusing on body image is stimulating, something ADHD brains are attracted to. Although not pleasurable, it is more interesting than doing boring, everyday tasks.

Some people with ADHD are so stimulated and distracted by everything else that they pay little or no attention to their body image. This may lead them to ignore early signs of health problems or obesity. Mark, 51, has struggled with obesity since adolescence. He attributes his dramatic weight gain to impulsive eating. Unlike those who think they are more overweight than they are, Mark underestimates his weight. “I hardly think about my body. I know that I eat unhealthy foods, but I don’t realize how much weight I have gained until I go to the doctor and get weighed. I gained 40 pounds in one year! I thought I had lost weight.”

1. Acceptance and commitment therapy (ACT). If you have body image challenges, it is essential to work on accepting your ADHD and your body as it is. Understand that neither an ADHD diagnosis nor a less than ideal body diminishes your value as a person. Work on celebrating the aspects of your ADHD and your body that you feel positive about. Healthy self-esteem shouldn’t come from your appearance, since your appearance will change. Self-esteem should come from permanent aspects of your identity, such as intelligence, creativity, humor, athleticism, mechanical abilities, or artistic talent.

2. Cognitive therapy. Be mindful of how you think and talk about your body. Do you look in the mirror and criticize yourself? If you make negative comments, pause and find positive things to say. Are you a fast runner, do you have a heightened visual sense, do you feel strong? These are some reasons to celebrate your body. Those with ADHD are particularly prone to all-or-nothing thinking. “If I have a pimple, my face is ruined.” Many people with ADHD incorrectly assume that others are negatively evaluating their appearance.

3. Body mindfulness. Do not overfocus on body image to escape ADHD symptoms or stress. On the other hand, do not neglect your body either. Eat healthy, exercise, and increase positive self-talk. If you are watching your weight, it is fine to weigh yourself weekly, but no more.

4. Behavioral therapy. Be aware of triggers to unhealthy body image behaviors. Jeanne, 39, checks herself in the mirror before she leaves the house. She used to examine herself several times each day at work and at home. And there are times during the day when she is still tempted to check her appearance. A trigger for Jeanne was a friend, who always talked about her weight gain and the diet she was on. Jeanne gently asked her to stop discussing this.

5. Medication. In addition to taking ADHD medications, people suffering from BDD or severe body image challenges — some of which lead to depressive or obsessive-compulsive behaviors — can benefit from taking selective serotonin reuptake inhibitors (SSRIs). Studies show that SSRI dosages for BDD tend to be higher than those for depression and take longer to work. Bulimia nervosa also responds to SSRIs. Many features of bulimia, such as impulsivity, can also be aided by ADHD stimulant trials.

6. Social skills work. If you need to improve your social skills, take a public speaking or improv acting class. Join a social group as a way to engage with new people. Serena, 33, whose inattentive ADHD often made her feel disconnected from the conversation, found that her attention to her appearance diminished as she became more social. “I realized that I can offer much more than just the way I look,” she says.

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