Body Dysmorphic Disorder: When the Reflection Is Revolting
Fifteen-year-old Joel wakes up two hours before school to begin cleaning his face and covering up his bad skin. Many days this means he’s either late to school or doesn’t show up at all. He spends his entire allowance on skin care products and tanning to cure or camouflage his acne.
When he does make it to school, he sits in the back of the classroom and takes frequent breaks to scrutinize his skin in the bathroom mirror. He convinces his parents to visit several dermatologists, to no avail.
Joel can’t stop thinking that no one likes him and he’ll be alone for the rest of his life because of his appearance. No matter how many times his parents try to reassure him, Joel doesn’t buy it and continues to stress over his obvious flaws.
When Joel and his parents arrive at Jennifer Greenberg’s office, she immediately observes that Joel’s skin has no “noticeable acne or scarring.” Greenberg is a Clinical and Research Fellow in Psychology at Massachusetts General Hospital/Harvard Medical School, who specializes in clients — like Joel — who suffer from body dysmorphic disorder (BDD). BDD is a crippling condition that leaves individuals obsessed with an imagined or minor defect and severely impairs their lives.
Though it’s received some media attention, many have difficulty grasping BDD and misconceptions remain. In fact, even health professionals and physicians largely overlook BDD.
Several myths regarding body dysmorphic disorder continue to circulate:
- It’s not a real disorder. “Many fail to understand that BDD is a real psychiatric condition,” viewing it “as vanity, narcissism or being overly self-involved, and, as a result, don’t take it seriously,” Tom Corboy, M.F.T., director of the Obsessive-Compulsive Disorders Center of Los Angeles said.
- It’s rare. Though many think BDD is an uncommon condition, “community and clinical settings have suggested BDD affects about 0.7 percent to 3 percent of the population,” Greenberg said. Research in medical settings suggests even higher rates, she said.
- It occurs only in the extreme. BDD isn’t always a case of cat woman or Michael Jackson quintessential cases often sensationalized in the media. Instead, a person might obsess over one birthmark or a skin discoloration on one area of the body, said Los Angeles clinical psychologist Sari Shepphird, Ph.D, who regularly works with BDD clients. “It might seem minute to someone who isn’t suffering, but the obsessiveness and torment can be extreme,” she said.
- It occurs only in women. We tend to associate body image issues with women, but BDD occurs equally in both sexes.
Symptoms of Body Dysmorphic Disorder
All of us in some way are dissatisfied with our looks, especially in today’s appearance-crazed society. So what makes BDD all that different? Two things, according to Shepphird: intensity and impairment.
- Intensity. On average, individuals with BDD spend three to eight hours a day thinking about their deformity (Phillips, 2006), which typically involves the face and head, including acne, ear size, nose, teeth, hair and overall appearance, though it can be directed toward any body part. BDD sufferers wholeheartedly believe that others can’t help but stare at their hideous defects and judge them.
- Impairment. Because of their intense thoughts and severe anxiety, BDD patients avoid social activities, school and work. This impairment leads to a poor quality of life poorer than the general population, individuals with depression and those with recent heart disease, Greenberg said. They’re also at greater risk for psychiatric hospitalization and suicide, she said.
Individuals with body dysmorphic disorder use various ways to alleviate their appearance-based anxiety. They may:
- Request reassurance. “Does this seem big to you? Doesn’t it bother you?” By asking such questions, they regularly seek reassurance from others or discuss their area of concern, Shepphird said.
- Use camouflage. They’ll often try to cover up their concerns with cosmetics, clothing, dark glasses, hats and other items.
- Undergo cosmetic surgery. Instead of seeking mental health services, many BDD patients reach out to dermatologists and cosmetic surgeons, because sufferers believe fixing their flaws will fix their lives. According to one study, 77 percent sought cosmetic surgery and about 50 percent sought dermatological treatments, Shepphird said.
In desperation, some patients will play doctor. In his study, Veale (2000) described several DIY cases: one man used sandpaper to lighten his skin and eliminate scars; another used a staple gun on his face to tighten loose skin; a woman, who wanted liposuction, cut her thighs with a knife and tried to squeeze the fat out.
Repairing the deformity rarely relieves anxiety, however. In fact, anywhere from 76 to 83 percent don’t see changes in symptoms, Shepphird said. Others feel worse and regret the procedure. “More often individuals may subsequently blame themselves for having had a procedure they feel made them ‘look worse than before,’” Greenberg said. Some patients might obsess over a new area. In severe cases, BDD patients “have committed suicide and threatened harm against or acted violently toward the treating physician,” Greenberg said.
- Compulsively exercise. Many BDD sufferers exercise excessively common in muscle dysmorphia, a subtype of BDD, that affects mostly males. Because of an intense obsession with muscle shape and size, these individuals spend hours exercising, weightlifting, dieting and using steroids or supplements.
- Engage in other behaviors. BDD sufferers might also compare their concerns with the same area on others; check their reflection in mirrors or windows; tan excessively; pick at skin, which can lead to scarring and, in severe cases, life-threatening wounds.
Body dysmorphic disorder (BDD) sufferers often have “secondary conditions, including major depression, social anxiety and substance abuse,” Corboy said. Seventy-five percent of individuals with BDD will experience major depressive disorder in their lifetime (Phillips & Hollander, 2008).
Suicide also is common. Forty-five to 71 percent experience suicidal ideation due to BDD and 24 to 28 percent have attempted suicide rates higher than in the U.S. population and other mental disorders (Phillips, 2006).
Kids and Teens
Though kids also can have BDD, the disorder usually develops during adolescence. But, because it’s often mistaken for normal teen appearance angst, it’s not diagnosed until much later.
Children’s symptoms are similar to those of adults, “in that they’re extremely upsetting, time consuming and commonly involve the face or head,” Greenberg said. But kids and teens are typically “more convinced that they are ‘ugly’ or ‘monstrous’ and that others are judging them based on their ‘flaws.’”
Compared with individuals who develop the disorder in adulthood, kids and teens are more likely to suffer from other disorders (substance abuse, social phobia, depression) partially because BDD interferes with social opportunities and school during a critical time in development, Greenberg said. One study showed that 94 percent were impaired in social functioning, 85 percent in academic or work functioning and 18 percent had dropped out of school (Albertini & Phillips, 1999).
Young sufferers also are at greater risk for suicide. In the same study, 21 percent had attempted suicide (Albertini et al., 1999). When compared with adults, another study found higher rates of attempted suicide among adolescents (Phillips, Didie, Menard, Pagano & Weisberg, 2006).
Perceived Defects or Distorted Perceptions
It’s uncertain whether people with BDD actually see their defect as truly exaggerated or if they see the flaw accurately but process the information differently, Shepphird said. In one study, 53 percent of the sample “weren’t entirely convinced their deformity was real but couldn’t overcome their thoughts or intensity of distortions,” she said.
Neuropsychological studies suggest that “patients with BDD selectively attend to small details when organizing information in lieu of seeing the big picture and tend to misinterpret ambiguous stimuli as negative,” Greenberg said.
Preliminary neuroimaging research has found other differences, including “small detail (local) vs. whole picture (global) processing, executive dysfunction and potential biases in visual and visual-spatial processing,” she said. Some research also suggests that individuals with BDD have difficulty interpreting emotional expressions (see Saxena & Feusner, 2006).
Albertini, R.S., & Phillips, K.A. (1999). Thirty-three cases of body dysmorphic disorder in children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry 38, 453–459.
O’Sullivan R.L., Phillips K.A., Keuthen N.J., & Wilhelm S. (1999). Near-fatal skin picking from delusional body dysmorphic disorder responsive to fluvoxamine. Psychosomatics, 40 (1), 79-81.
Phillips, K.A. (2006). The presentation of body dysmorphic disorder in medical settings. Primary Psychiatry, 13(7), 51-59.
Phillips, K.A., Didie, E.R., Menard, W., Pagano, M.E., Fay, C., & Weisberg, R.B. (2006). Clinical features of body dysmorphic disorder in adolescents and adults. Psychiatry Research, 141, 305-314.
Phillips, K.A., & Hollander E. (2008). Treating body dysmorphic disorder with medication:
Evidence, misconceptions, and a suggested approach. Body Image, 5, 13–27.
Saxena, S., & Feusner, J.D. (2006). Toward a Neurobiology of Body Dysmorphic Disorder. Primary Psychiatry, 13 (7), 41-48.
Veale, D. (2000). Outcome of cosmetic surgery and “D.I.Y” surgery in patients with body dysmorphic disorder. Psychiatric Bulletin, 24, 218-221.
A selection of BDD programs offering free evaluations and treatment options:
The Body Dysmorphic Disorder Program and the OCD Program at Massachusetts General Hospital
Phone: 617-726-6766, Toll free: 888-HEAL-BDD; Email: [email protected]
The Body Image Program at Butler Hospital in Providence, RI
Phone: 401-455-6466; Email: [email protected]
The BDD Program at Mount Sinai School of Medicine in New York
Phone: 212-369-5123; Email: [email protected]
St. Louis Behavioral Medicine Institute offers help for BDD as well as many other psychological conditions.
EDReferral.com offers links to therapists and treatment in all 50 states as well as internationally.
Marriage and family therapist Tom Corboy founded and remains director of the OCD Center of Los Angeles.
Jennifer Greenberg, Ph.D is a Boston-based psychologist specializing in BDD.
Tartakovsky, M. (2016). Body Dysmorphic Disorder: When the Reflection Is Revolting. Psych Central. Retrieved on November 22, 2017, from https://psychcentral.com/lib/body-dysmorphic-disorder-when-the-reflection-is-revolting/