by Molly Schiffer, LCPC

It will take courage and maybe a leap of faith to seek help, but you can wake up from the nightmare of living with BDD and learn to change the way you relate to your physical appearance.

Recently I stayed at a hotel for a conference and was delighted to see they had a fancy makeup mirror which I had never come across before. The next morning, I decided to make good use of the magnified side of the makeup mirror for more precise makeup application; however, I was immediately assaulted by what could be described as a multitude of unsightly spots, pores, patchy areas, lines and a host of other imperfections that I had formerly not noticed but was now acutely aware of. While this experience ended rather quickly for me it made me think of the clients I have worked with who described with agonizing detail the inescapable torment they experienced when looking in the mirror. These individuals were suffering from Body Dysmorphic Disorder (BDD).

In this blog series, I will be exploring Body Dysmorphic Disorder which is characterized by obsessive thoughts about perceived defects in appearance which lead to compulsive behaviors aimed at fixing, checking, hiding or camouflaging them. This first entry in the series will focus on defining and exploring manifestations of BDD as well as challenges in diagnosing and treating this frequently misunderstood disorder. While BDD was once believed to be rare, it affects approximately 2 percent of the population. However, it often goes undiagnosed for many years due to lack of knowledge about the disorder in the mental health community and the number of cases that go unreported.

Why would someone suffering so much avoid asking for help?

The profound suffering that people with BDD experience is difficult to articulate. People living with BDD may feel demoralized by the overwhelming self-critical thoughts and time-consuming rituals that can dominate every aspect of their lives.  Work, relationships, hobbies and social activities seem to become lower and lower priorities while the drive to cater to the BDD comes first. Despite their best efforts, they are unable to stop the endless rituals, which in turn leads to intense self-criticism and self-loathing that further fuels the sense of inadequacy, the distorted body image, co-morbid depression and sometimes severe suicidal ideation.

People who suffer from BDD often keep their suffering a secret for multiple reasons. Many people who experience BDD feel a deep sense of shame and embarrassment about their preoccupation with their appearance and are afraid of being accused of vanity or narcissism. In addition, they may fear that others are lying to them about their appearance or that they are not being taken seriously. Often times, people with BDD firmly believe that their problem is an appearance problem (as opposed to a mental health issue) so they first seek “help” through cosmetic or even surgical means which reinforces their belief that they are hideously ugly or deformed.

Common Manifestations of BDD

Below is a short-list of the more common areas of the body that those with BDD may become preoccupied with. However, it is important to note that any aspect of appearance can be a target for BDD.

  • Skin such as texture, scars, acne, wrinkles and lines
  • Size or shape of eyes, nose or lips
  • Symmetry of eyebrows, eyes and ears
  • Size or shape of thighs, arms, stomach, buttocks, and breasts
  • Muscle mass (often seen in a variation of BDD called Muscle Dysphoria, which typically affects men)
  • Hair growth, length and texture

Along with the preoccupation, comes the nasty voice of BDD shouting all the ways the sufferer might be rejected, ostracized or outright humiliated due to their imagined ugliness, leading them to make effort to eradicate, reduce or camouflage the area of concern.

Compulsions in BDD

Like OCD, body dysmorphic disorder is characterized by unwanted intrusive thought (obsessions) and behaviors aimed at reducing distress about those thoughts (compulsions).  Compulsions in BDD are behavioral attempts to conceal, examine, fix or get reassurance about the perceived defect. While people with BDD are usually told by many friends and family members that they look fine or that they even look better then fine, the effects of these reassurances are short lived and lead to feeling more isolated and alone. While sometimes the compulsive behaviors are obvious to others, especially in more severe cases, oftentimes they are done in secret.

Here are some common compulsions related to BDD:

  • Checking mirrors or other reflective surfaces to look at perceived defect
  • Avoiding mirrors or reflective surfaces to avoid being triggered by appearance
  • Measuring the size or shape of the concern area to check (e.g. measuring the length of one’s nose or width of thighs)
  • Avoiding foods that are perceived to worsen appearance via weight gain, bloating, or skin blemishes
  • Using lights or magnifying glasses to enhance their ability to see the area
  • Adjusting the lighting in rooms to conceal some aspect of appearance
  • Reassurance seeking questions about disliked body part
  • Making repeated negative commentary about one’s appearance to elicit reassurance
  • Comparing their appearance to others
  • Adjusting body position while sitting or standing to hide the perceived defect
  • Concealing disliked body part(s) via wearing makeup, hats or baggy clothes
  • Repeated visits to dermatologists or plastic surgeons for reassurance and/or having procedures
  • Skin picking or hair pulling in effort to modify or improve appearance
  • Avoiding social situations where there may be attention on them and their appearance

Like all compulsions, these behaviors may alleviate the anxiety briefly but ultimately reinforce self-defeating beliefs, intrusive thoughts, and anxiety, which all contribute to an increased sense of isolation and self-hatred.

BDD in Disguise

Another significant challenge to getting appropriate treatment for BDD is that it can masquerade as other disorders, such as OCD, Eating Disorders, Social Phobia, Generalized Anxiety Disorder, and Major Depressive Disorder. While these disorders can and do co-occur, they can also be disguises for BDD.

Examples:

Robert is 27 years old and works as a researcher at a local university. Robert spends much of his time in the laboratory and does not have much of a social life. Robert had a girlfriend briefly in college but has stated he is not interested in dating because he is busy with his work. Robert was hospitalized for a suicide attempt his senior year in college after his girlfriend broke up with him. Robert still lives at home with his parents. and Robert has been in and out of therapy for depression since high school. Robert’s parents are worried about him because he has stopped coming out of his room except to leave for work and he has stopped socializing with friends and family. Robert has BDD with comorbid depression. Robert hates the size and shape of his nose. He believes that his girlfriend in college broke up with him because she was repulsed by his grotesque nose. Since the break up he has tried to camouflage his nose with hats and sunglasses. He has had multiple consultations with plastic surgeons who have disagreed with his assessment of his nose. Robert has become increasingly depressed and now avoids interacting with others, including his family, so others can’t see his perceived defect.

Ella is 20 years old and a junior in college. Ella has always been active and tries to eat healthy. As of late, Ella has started to restrict her diet even more and insists on running 5 miles daily. Ella says she doesn’t want to be fat. Ella states that she is chubby and is just trying to stay on top of her exercise. As of late, Ella has been isolating from friends and no longer wants to spend time with her family. Her family is worried she is depressed and is developing an eating disorder. Ella has BDD disguised as an eating disorder. Jane believes her thighs are fat and refers to herself as “thunder thighs”. She spends hours exercising and dieting hoping to alter the shape of her thighs and to remove all traces of fat. Ella tries to sit in a way that makes her thighs look thinner to her. She often squeezes the skin on her thighs to check if they are getting larger. She spends hours looking at pictures of supermodels, trying to assess how different her legs are from the pictures. She refuses to wear shorts, skirts, leggings or bathing suits.

Loved Ones Can Be Instrumental in Recovery from BDD

If you are reading this as a concerned family member, you may be absolutely baffled by your loved one’s concerns about their appearance and you might find their behavior difficult to understand. You have probably tried countless attempts to reassure them that they look fine, or even better than fine, and are shocked when your attempts to reassure them are met with resistance, mistrust, and even anger. You look at your loved one and can’t imagine how they could see themselves the way they describe because you don’t see anything wrong at all. In fact, it may cause great grief to find out how your loved one sees them self. Because you love them, you do anything and everything in your power to help, but it always seems to strangely backfire.

If your loved one has BDD, it is important for you to remember that what you’re seeing are symptoms of a disorder, not character flaws. It’s not your fault and it may comfort you to know that your loved one can lead a happy healthy life with the right treatment. This treatment will also require you to make some changes in how you respond to their symptoms. Many of the changes may seem counterintuitive and you may worry about how your loved one will respond to these changes. Seeking therapeutic support for yourself may be an important part of the equation. Recognizing that the whole family, not just the BDD sufferer, has been impacted by the disorder and getting treatment that reflects that can go a long way.

Facing Your Fear

If you are reading this from the perspective of wanting to know more about your own unwanted thoughts and feelings about your appearance, getting to the end of this blog is a brave step. Because it takes a lot of courage to share with someone your deepest thoughts and feelings and to acknowledge that you may not be seeing yourself clearly, you have to start by acknowledging this possibility to yourself. You may be apprehensive about treating your symptoms as a mental health issue, and you may believe with every fiber of your being that the problem is your appearance. It may seem as if people are being cruel when they compliment you, because how could they not see what you see?  You may have shared with others your concerns only to be met with misguided advice or even to be told that you’re being silly. But you are not being silly, nor are your symptoms indicators of vanity or self-preoccupation. They are symptoms of a treatable mental health condition.

You may feel isolated and alone in your own private nightmare, but you are not alone. There are others who have felt the despair you are experiencing and many of them have gotten better with treatment. It will take courage and maybe a leap of faith to seek help, but you can wake up from the nightmare of living with BDD and learn to change the way you relate to your physical appearance.

In the next installment in this series, I will discuss early stages of treatment for BDD which will include the importance of psychoeducation and motivation-building strategies. This will lay the groundwork for how cognitive behavioral therapy (CBT), exposure and response prevention (ERP), Mindfulness, and some BDD-specific interventions can be employed to liberate yourself from this oppressive condition.

Molly Schiffer, LCPC is a psychotherapist specializing in OCD and related disorders at The OCD and Anxiety Center of Greater Baltimore.