Despite the strong association between BDD and impaired psychosocial functioning, greater perceived stress, and reduced quality of life, a question arises as to whether these individuals also have greater underlying stressors or traumatic experiences that may contribute to the development of BDD.

A semi-structured interview was conducted on 18 patients with BDD and 18 normal controls, between the ages 17 and 49 years [11]. It was found that those with BDD tended to have significantly more spontaneously occurring images that were negative, recurrent, and viewed from the observer perspective than the normal participants. That is, they were more likely to report distressing images related to being bullied or teased because of their appearance. This suggests that negative self-images may have developed early on in these individuals, thereby contributing to the development of BDD symptoms.

Beyond childhood events related specifically to appearance, early traumatic or stressful experiences in general, have been also shown to serve as risk factors in the development of BDD. The majority of those with BDD reported a history of childhood mistreatment (79 %), which included emotional neglect (68 %), emotional abuse (56 %), physical abuse (35 %), physical neglect (33 %), and sexual abuse (28 %) [12]. Further, all patients suggested that their traumatic experience preceded their BDD symptoms.

Another study also showed that on comparison with normal controls, individuals with BDD were more likely to experience traumatic events in childhood or adolescence. They reported significantly more physical and sexual abuse and a trend towards a higher rate of emotional abuse compared to controls [13]. A possible explanation for the association between early-life traumatic experiences and the development of BDD may be extrapolated from the experiences of survivors of sexual abuse. Survivors of sexual abuse have been shown to have a distorted view of their body, especially the body part that they associate with the abuse and often develop general dissatisfaction, shame, and hatred towards that body part [13–15]. As such, it can be hypothesized that early-life traumatic experiences may shape a person’s negative core belief, instilling feelings of inferiority and deficiency, and thereby contributing to a negative perception of their appearance. This may in part explain the high rate of suicide attempts among those with BDD. In addition to the distress of the BDD symptoms themselves, it is recognized that individuals with a traumatic history are also more likely to have attempted suicide [12].

Among the various environmental influences, the family arguably has the most profound impact on a child’s development. One review specifically examined the family environment in pediatric populations with obsessive-compulsive and related disorders [16]. Disorders considered to be in the obsessive-compulsive spectrum include BDD, trichotillomania (hair pulling disorder), skin picking disorder, and hoarding. A strong relationship was demonstrated between obsessive-compulsive disorders (OCD) and poor parental mental health, with greater symptoms of anxiety, stress, and depression in parents of those with OCD. In addition, parenting styles tended to induce conflicting control beliefs in children (i.e. perceived low levels of control over one’s life coupled with a desire for increased control). Further, there was a correlation between OCD and family dynamics (low family cohesion, family violence, and distress), familial emotional climate (higher levels of parental guilt, worry, and anger), and low levels of parental warmth. Again, these findings suggest that early-life experiences, especially within the family unit, are extremely important in a child’s cognitive and behavioral development. Further, negative or stress-inducing environments seem to increase the likelihood of developing obsessive-compulsive and related disorders.