Body Dysmorphic Disorder
Northeastern University sophomore Terri* spends at least a few minutes a day critiquing her body in the mirror.
“I have this extra fat on my stomach that I hate,” she said, squeezing her abdomen with both hands.
Terri is an articulate, responsible, political science major and sociology minor who looks and sounds mature beyond her years. She is well-respected by peers and authority figures alike, and she recently landed a co-op job at a prestigious law firm in Boston. This girl has got herself together.
Today, wearing a business-casual purple turtleneck, gray peacoat and glasses, this confident, capable woman points to the area under her chin.
“I’ve just noticed this,” she said, running her fingers under her jaw, across a section of her neck that she believes is dangerously bordering on a double-chin.
Like most people, she sees nothing unusual about her physical concerns.
“Everyone worries about aspects of their appearance,” she said as she turns her attention away from the mirror and finishes getting dressed.
Many people have concerns with the way they look, but some have obsessive, irrational concerns. Like most people, Terri has never heard of Body Dysmorphic Disorder. Although Terri’s body concerns may not constitute the disorder, there are people among us living with the secretive, shameful reality of BDD.
WHAT IS BDD?
Few people have ever heard of BDD, but virtually everyone has exhibited the characteristics of the disorder in its most basic form: a heightened concern with a particular part of their body that they deem “less than perfect,” something that they would like to improve upon and even something that they try to hide.
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Unlike normal appearance concerns, however, BDD is marked by an intense preoccupation with an imagined defect in appearance. A severe and debilitating psychiatric disorder, BDD is characterized by an obsessive fixation on one or more parts of the body that a person perceives as disgusting and unnatural.
If a slight physical abnormality or inconsistency exists in a BDD sufferer’s physicality, their concern is excessive – even to the point of experiencing social withdrawal and suicidal tendencies.
Dr. Roberto Olivardia is a clinical psychologist at the McLean Hospital in Boston and teaches psychology at Harvard Medical School. A specialist in BDD and Obsessive-Compulsive disorders, in general, he acknowledges that BDD symptoms are often mistaken as “normal” fears.
“With BDD there are many, many people walking around in the U.S. who have it that you never know have it. For a lot of people, you don’t know what it is that you have, but you know that life is not normal,” said Dr. Olivardia.
“[People with BDD] are obsessively checking mirrors, trying to hide their defect. A lot never leave their house because they think they’re so ugly and unattractive,” adds Olivardia.
Constant mirror-checking is one of the most common behavioral characteristics of someone with BDD. While most people periodically check their appearance throughout the day, the person with BDD has a highly complex, love-hate relationship with mirrors.
Britney Brimhall, a 25-year-old Arizona State University student finishing up degrees in German and business, is a BDD sufferer who runs BDDCentral, a support website for BDD sufferers. On the site, Brimhall describes the process which many BDD patients (or “BDDers”) endure when encountering mirrors.
“Any mirror will do, along with reflective surfaces such as store windows, although most BDDers will have a handful of favorite mirrors that are in places with, what they consider to be, the most appealing lighting. I’ve heard more than once that the lighting from late morning until early evening create the greatest amounts of distress … Many BDDers prefer to avoid mirrors during this time of day,” she writes.
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In describing a typical BDD patient, Arie Winograd, director of Accurate Reflections, a BDD support group in Los Angeles, is quick to bring up this ritual.
“A lot get stuck in mirrors, wherever they go. Some are mirror-avoiders, but most get stuck in them,” Winograd said. “[BDDers] base their self-worth on how they look, so they are obsessed with their defects.” The obsession is ever-present, and so they experience a heightened concern with how they look at all times.
A typical person with a mild case of BDD goes to school, has relationships, goes to work, “but they can’t stop thinking about their appearance,” Winograd said. “Their brain actually locks on their defects; it can’t stop thinking about them.”
One of the most common manifestations of BDD occurs in sufferers’ reactions to public situations. BDD, especially in those with severe cases, often seriously impacts social, occupational, and relationship functioning. According to Olivardia, BDDers “sometimes won’t go to work if they think their nose looks ugly that day.”
Brimhall relates the social anxiety experienced by those with BDD to a feeling of alienation and a sense of not belonging.
“Most BDDers find that they are very uncomfortable in social situations for several reasons. They first feel strangely inhuman,” she says on her site.
“It almost seems narcissistic, feeling so singled out from the rest of the public, yet at the same time, we do not feel that we are separated from society because we are better than anyone else. We feel almost as if we do not exist, and that we are separated from the rest of the human race,” she writes.
Ironically, this sense of inferiority, perhaps the most characteristic complement of the disorder and the reason that BDDers pay constant attention to their appearance, is often wrongly regarded as vanity.
“It’s not a problem of culture; it is a psychiatric disorder. This is the antithesis of vanity, the opposite of vanity,” Winograd emphasizes. “In fact, BDD sufferers do not bring up their concerns [to friends and family members] because they are afraid of being accused of being vain.”
Whereas most people choose their outfits based on what they feel best flatters their figures, BDDers partake in a much more aggressive form of covering up, which doctors refer to as camouflaging. This refers to the tendency of BDD sufferers to meticulously pick clothes or arrange their hair, sunglasses or hats to hide their perceived defects.
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“An interesting aspect of this camouflaging behavior,” according to Brimhall, “is many BDDers alternate their ideas on what looks acceptable and what doesn’t. I’ve known several BDDers that will wear their hair down for two years, never letting a single hair blow out of place, because they feel they will look ugly if their face is revealed. Then, they suddenly believe that their face is much too long, and long hair only emphasizes this, and will vow never to wear their hair down again.
“Some will apply heavy face makeup for years, to suddenly decide that they look like a drag-queen, and opt to never wear makeup ever again. Decisions are black and white, and usually very extreme,” she said.
SUFFERING
Jennifer Kaplan, a member of the online Yahoo! BDD group has been in and out of therapy and on some type of medication for her BDD and depression for 13 years. She has had 18 bilateral shock treatments in her life and has “been on chemical cocktails of every psychotropic that is on the market.”
A 30-year-old Colorado resident who lives with her boyfriend of five years, Kaplan is unemployed and just now building up the courage to search for work. She has not finished her undergraduate degree, which she attributes to the life-consuming fear and lack of focus caused by BDD and bipolar depression
She can remember the roots of her BDD reaching as far back as her early childhood, when she began binge-eating at the age of five, and was sent to camp for overweight children six years later.
“[As a child], I was socially and physically very awkward. I was an overweight child as well. My parents were both movie start gorgeous, which only made things worse … My brothers were very good-looking and I was the ‘bad seed.’ I was sent to ‘fat camp’ at age 11, though I was not terribly overweight – I was chunky … My parents were very concerned about that fact that I wasn’t slim.”
It was around this time that Kaplan began to obsess over her appearance. Although she would later discover that her mother suffered from eating disorders and both of her parents endured personal bouts with low self-esteem, her negative image of herself continued to worsen. She began exhibiting typical BDD behavior as an adolescent, worrying often about her appearance and going to great lengths to mask it.
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“At the age of 11 or 12 my friend pointed out that my nose looked a hawk’s nose and that sent me reeling. From that day forth I obsessed with my nose and never stopped obsessing about it from every angle imaginable. Mirrors became an all consuming preoccupation. I centered my world around mirror-checking and learned how to apply makeup at a very early age.
“[Makeup] became war paint for me and I used it to mask myself. It lent itself to all sorts of fantastical facades. It was the thickest veneer I could hide behind …” Kaplan said.
During periods when her BDD is especially bad, she will go to extremes to avoid looking at herself or allowing others to look at her.
“On avoidant days or weeks I will bathe in the dark, dress in the dark, or avoid leaving the house altogether for fear of catching my reflection in a window,” she said. “I have hibernated in bed for what feels like months to avoid presenting my deformed face and fat body to the rest of the world.”
Kaplan published a journal entry on the group’s message board which she had written during a self-described “bad BDD episode in which I found some solace in journaling.” What Kaplan referred to as a “bad episode” many BDDers describe as “BDD attacks,” periods of time, whether a day, week, or month, during which they experience an unnaturally severe and debilitating sense of obsession and depression about their defects.
Her entry typifies the thought processes that many BDDers share; thoughts which may shock the average observer, but which are common for those suffering from the disorder:
“I dream that I am beautiful sometimes. And waking up is the real nightmare. I want to pick at my face and body. I want to take a pair of sharp silver hair stylist’s scissors and cut. I want to cut away the ugliness and surrender what remains to rebirth. I want to regrow a new nose, a new mouth, new soft, silky, lean thighs. I want to cut the cottage cheese cellulite and discard it. Allow new soft flesh to breath and replace the old … My big giant deformed face. My ugly eyes and forehead and mouth and chin and NOSE. I look weird. Odd. Scary. Offensive. Disgusting. I can’t stay in this skin. This skin is killing me. I cannot live inside of it … I was not meant to be ugly. And it isn’t a sin for anyone else. Anyone else can be ugly or average or less than gorgeous. They have worth. They have beauty inside. I am ugly all over.”
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This obsession with perfection often leads BDDers to seek cosmetic surgery as an answer to their insecurities.
According to Winograd, the average BDD has patient has between one and four body parts that they obsess over, usually from the neck up, and like Kaplan, they believe that these parts are ugly or defective. As a result, they often have surgeries to correct these perceived defects.
“The problem with surgery is it’s a compulsion; it just doesn’t work with BDD,” he said. “Surgery doesn’t work because BDD is about the brain; the problem usually intensifies after surgery.”
Olivardia described a patient who was still dissatisfied with his appearance after undergoing three surgeries.
“One patient had three nose jobs; he wasn’t satisfied after his first one. He went on to get two more, and now he likes the way his nose looks, but he doesn’t like the way his cheeks look with his nose. Now he’s worried about his cheeks,” he said.
“Ninety-three percent of people with BDD who get surgery are still unhappy with their appearance afterward,” Olivardia said. “They may believe the surgery made them look worse, or become obsessed with something new.”
Attempts at self-surgery are a disturbing tendency among some BDD sufferers. Kaplan admits that she has “attempted self-surgery several times on my nose with dental tools and I have fantasies about self-surgery more than one should.”
Brimhall, who has experienced the degenerative effects of BDD firsthand, created her website as an opportunity for BDDers to unite and support each other.
“I decided one day, back when I was around 18 or so, that I was sick and tired of having BDD control my life. I started researching … and I realized that there was not much information out there about the disorder or overcoming it. For this reason, I started my own egroup, so that people could chat about BDD,” Brimhall said. “I was hoping that we could help one another by discussing the disorder, coming up with techniques to overcome it, experiment with these techniques, and record what worked and what didn’t.”
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Over time, Brimhall gathered enough information to launch BDDCentral, a website which continues to unite BDD sufferers in support.
“It’s been great, because sometimes we get experts and researchers visiting the forum,” Brimhall said about the site. “… It’s visited by many people and has helped many as well, so I feel my efforts, time and money spent have been worth it.”
DIAGNOSIS AND TREATMENT
Winograd estimates that approximately one percent of the general population, or 2.81 million people, has BDD, with popular estimates ranging between one and two percent. However, the number of people who actually have BDD is considered by many experts to be much higher than the number diagnosed.
This is due in part to the shamefulness and secretiveness that accompanies BDD; when people have the disorder, they are embarrassed of the defects they perceive in themselves, and so they try to hide their obsession from everyone, even those closest to them, said Winograd.
BDD is also commonly misdiagnosed. In fact, Winograd was working with patients diagnosed with Obsessive Compulsive Disorder when he came upon BDD.
“I was finding that quite a few individuals who had been referred to me with OCD had, in fact, BDD. A lot of time BDD seems a lot more deeply rooted than OCD,” said Winograd. “It was a frequent misdiagnosis.”
OCD is estimated to affect about 2.3 percent of the U.S. population between the ages of 18 and 54, approximately 6.5 million Americans, in a given year
BDD is actually what Winograd refers to as a “cousin disorder” of OCD. It is considered an OC spectrum disorder, one which has many similarities to OCD but involves a specific psychiatric tendency; other OC spectrum disorders include Trichotollomania (hair pulling), Compulsive Hoarding, Hypochondriasis, and Social Anxiety Disorder.
Because BDD is commonly coupled with depression (17% of BDD-diagnosed patients attempt suicide), it is often treated with a combination of Selective Serotonin Reuptake Inhibitors (SSRIs), or antidepressants, and a form of cognitive behavior therapy designed to treat BDD called Exposure and Response Prevention Therapy.
In addition to prescribing an SSRI, Lexapro and Prozac being two of the preferred medications, clinicians work with patients in therapy to overcome their fears by introducing them into situations which they typically avoid.
Olivardia will often take his patients out to Harvard Square when it’s packed with people, in an effort to force them to face their fears of appearing in public.
“We work with them and help them understand how irrational their thoughts are,” said Olivardia. “Whatever situation they fear, we expose them to it. [At the beginning of therapy] their anxiety is raised, but they eventually become desensitized to it.”
Experts are hesitant to classify BDD as curable at this point, however.
“Some people see themselves as less ugly [following therapy]; some people de-obsess. Some people can live life, thinking they are still ugly, but they can at least handle it and function normally,” said Olivardia. “Wouldn’t used the word ‘cured’ but it can be managed effectively. They can often at least get to a normal state.”
Winograd agrees that BDD researchers are far from an easy answer.
“A lot of other work needs to be done,” he said. “It would be irresponsible to say that [SSRIs and Exposure and Response Prevention Therapy] is enough. There needs to be much, much, much more research.”
Kaplan, who has been with the same therapist for almost two years now, does not believe that there can be one solution for all BDD sufferers.
“Everyone is different and has his or her own way of dealing with [the disorder]. What works for one could be detrimental to another. That is why it is so vital to find a therapist who can cater to your personal needs. BDD origins are unique to all of us, and so should our treatment,” Kaplan said.
“I strongly believe that cognitive behavioral therapy does not work for everyone. In fact, for most of us, sadly, it does not,” she said.
“So what can help us? Helping others can help us. Distracting ourselves from us can help us.”
Facts
Although their is no cure, BDD is most commonly treated through a combination of SSRIs and cognitive behavorial therapy.
BDD sufferers are not vain; they are abnormally worried about others noticing defects which they perceive as very real.
BDD is not an eating disorder. Although eating disorders and depression are common in BDD sufferes, BDD is a form of Obsessive Compulsive Disorder – people with BDD obsess about perceived defects in their appearance.
BDD warning signs include:
* Constantly looking at, or avoiding, mirrors.
* Spending a lot of time (over an hour) grooming every day.
* Attempting to cover/disguise parts of the body that one thinks are ugly/defective
* Constantly seeking reassurance about your looks, but discounting positive feedback you receive.
* Depression in regards to appearance.
For a closer look at BDD: Check out “The Broken Mirror,” the first in-depth writing on BDD, by renowned BDD specialist Dr. Katherine Phillips
