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We’ve all had that feeling some days. That feeling that, no matter what your friends and family will tell you, you look wrong. It might be the way your hair is flipping, or perhaps how your nose is turned up a little too much, or maybe just your physique. It is always unpleasant, but usually goes away within a few minutes or so, maybe an hour at most, and you go about your day. This disorder is not that. The DSM V “Characterizes BDD as a preoccupation with a perceived defect or markedly excessive concern where there is a slight physical anomaly, with associate significant distress and/or functional impairments” (Singh & Veale, 2019, p. S132). Body Dysmorphia is when an individual will hyper-focus on one or more aspects of their physical appearance for long periods of time, consuming sometimes hours trying to hide or fix the defect, convinced that they are horrendously ugly and deformed. These perceived defects can cause a great deal of social anxiety, to the point where, Liane, a patient seeking help for her BDD (Body Dysmorphic Disorder) reported spending 90% of her energy and attention on her appearance in social situations, and was somewhat shocked to find that wasn’t average. The therapist assured this patient that the reverse was very nearly true with people focusing 80% to 90% of their attention on the outside world and only 10% to 20% on their appearance (Waldron & Parker 2018). People with this disorder also have a very hard time getting treatment, either due to shame over their behavior, or misconceptions that what they see is what others see, and they are just abnormally ugly, rather than the possessors of a dangerous mental illness.
Body dysmorphia hasn’t always been known as such, though it has probably existed in one form or another since humans first noticed their reflections. It was first recognized nearly 130 years ago by an Italian psychologist. In 1891, Enrico Morelli used the term “dysmorphophobia”, characterizing it as more of a fear than a disorder. He took the term Dysmorphia from a myth about the ‘ugliest girl in Sparta’. He defined dysmorphophobia as the “fixation in the consciousness of the idea of one’s own deformity…”(History of Body Dysmorphic Disorder, 2013), then went on to describe how it can affect people who seem to be mentally stable, but it will cause this individual to think and worry about their appearance multiple times a day, leading to serious distress and frustration. Morelli may have described it as a phobia because it sometimes manifests as a fear of mirrors or going out in public or a fear of other people’s judgments. In the documentary Ugly Me: My Life with Body Dysmorphia, some sufferers report being terrified of looking in mirrors even while getting their hair done (Waldron & Parker, 2018).
French philosopher, psychologist, and psychotherapist, Pierre Janet referred to “dysmorphophobia” in the description of a patient who refused to leave her hours for 5 years as “I’obession de la honte du corps” (“obsessions of shame of the body”). The woman in question repeatedly attempted to take her own life, and she suffered immensely from the imagined fear that her neighbors were consistently judging and talking about her “hairy face”. Every time that she heard laughter, she imagined that it was directed at her (History of Body Dysmorphic Disorder, 2013).
Freud is still a highly recognized psychologist to this day, and at one point he and Brunswick dealt with the case of an aristocrat known as “the Wolf Man.” Brunswick writes, “he neglected his daily life and work because he was engrossed… in the state of his nose.” This is a classic example of BDD as an obsession over one particular aspect of one's appearance, and ignoring things that give an individual happiness and meaning. The story has a happy ending, as the aristocrat realized that running to the mirror first thing in the morning (and scaring his servants) was maybe not a satisfying way to live one's life, and he was able to modify his behavior and eventually was able to go back to his life (History of Body Dysmorphic Disorder, 2013). However, this is an unusual case; most victims of BDD are not able to self-treat and must go through years of therapy to alter their behavior and attitudes (Waldron & Parker, 2018).
Eventually, BDD was given recognition in the DSM III in 1980 under the name of “Dysmorphophobia”. It was characterized as “ an atypical somatoform disorder” (History of Body Dysmorphic Disorder, 2013). At that time, psychologists did not entirely understand BDD, and were cautious in labeling it as a disorder in the first place, despite not entirely fitting the classifications of a phobia. Phobias are irrational fears, and although BDD is indeed irrational, there is no concrete fear associated with it. Some people wilt before a mirror, others will obsess over them. There is no single body part people will fret over, varying from one's hairline, lips, ears, or anything else to do with the body. It was “used as a diagnosis in DSM III-R in 1987.” Its term was changed to Body Dysmorphic Disorder. Currently, the DSM V has put BDD in a new section of “Obsessive Compulsive and related disorders.” (History of Body Dysmorphic Disorder, 2013). In the end, the classification of a disorder suits the symptoms and characteristics of the disorder much better than filing it with phobias.
As an obsessive-compulsive disorder, BDD affects both men and women fairly equally. Although the numbers for women diagnosed with BDD are slightly higher; over the years the number of men diagnosed with BDD has grown steadily whereas women’s numbers have remained fairly constant. Singh and Veale (2019) comment that overall it is vastly underdiagnosed. They estimated that 1.9% of adults suffer from BDD (p. S132), but due to the nature of the disorder and the deep personal feelings associated with thinking oneself ugly, many people do not believe that they have BDD when they first hear of it. Liane, the subject of Waldron and Parker’s documentary had trouble grasping the idea that she had BDD because, although her obsession with appearance had been causing trouble in her relationship and personal happiness, she did not believe she had the disorder because she believed deeply that she was truly ugly, and she couldn’t fathom that she was the victim of a disorder. The definition of BDD states directly that the subject’s view on their appearance is false, but she knew with 100% certainty that she was ugly, and despite numerous people in her life denying this claim, she insisted that they were lying to spare her feelings. There is also a stigma surrounding BDD (like many mental disorders) that keeps many people from talking about it openly. In fact, the feelings of ugliness are often accompanied by feelings of shame.
My theory on why men’s cases of BDD have spiked hinges on the idea that before now any man who was dealing with it was too ashamed to talk about it or seek the help they needed. This stigma is dangerous, as “Failure to recognize BDD can lead to poor physical and psychiatric outcomes for patients and without treatment BDD appears to have a chronic course” (Singh & Veale, 2019, p. S132). Men also often suffer from a growing trend in a subcategory of BDD called Muscle Dysphoria. This is experienced almost exclusively by men and is the obsession with appearing weak or scrawny, so they will push themselves to build muscle to an unhealthy degree. One man in the article Body Image Obsession in Men stated in regard to his muscle dysphoria, “Why should I be Clark Kent when I can be Superman” (Olivardia, 2002, p. 61).
There are a number of famous people who psychologists now suspect had body dysphoria. I would be surprised if anyone has not heard of the strange parade of people who have gone through tens of thousands of dollars in plastic surgeries to look like Barbie or Ken dolls, but there are many famous, more subtle examples of body dysphoria as well. Michael Jackson is a prime example of someone who had behaviors linked to BDD. He had ten different surgeries on his nose and appeared to be increasingly dissatisfied with his appearance with a continued reticence to discuss it (Meyerson, Mcfadden & Mccarthy, 2009). This is an example of someone with body dysmorphia obsessively trying to fix an aspect of their appearance but never getting the results they are looking for. According to the Body Dysmorphic Disorder Foundation, there are several other idols that showed BDD tendencies, including pop artist Andy Warhol who was reportedly obsessed with the redness of his nose. Also under this blanket of feeling awful about their appearance was the famous writer Frank Kafka who was afraid of mirrors and hated new clothes because he felt he was too ugly for them (Famous People with BDD, 2013).
Since people with BDD often have trouble self-diagnosing, there are several things people can look for to identify if a friend or family member is diagnosable. According to Singh and Veale:
The criteria for BDD also specify that at some point during the purse of illness, the individual will have performed repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, and reassurance seeking) or mental acts (e.g., comparing his or her appearance with that of others) in response to their appearance concerns and painful resulting emotions. Therese repetitive behaviors and mental acts are not pleasurable and are hard to control/resist. (p. S132)
Liane from Waldron and Parker’s documentary, even after being diagnosed and knowing that, despite her beliefs, the was not as ugly as she thought she was, discussed potentially getting a tattoo on her upper lip to make her lips look fuller as well as various other modifications she would like to make. She was dissuaded by her boyfriend who insisted she wait until she had been fully treated to do anything dramatic. Other people suffering from BDD have gone through various plastic surgeries and other body modifications. They have also reported being either repulsed by or obsessively drawn to mirrors. One patient reported fearing sitting alone in a cafe by himself. He suspected that everyone was looking at him and judging his appearance. Some people haven’t left their homes in years for fear of judgment and in the worst cases have considered and even attempted suicide.
Causes of BDD are difficult to nail down as there are multiple theories but still few studies to confirm them. Liane’s therapist took her back in a guided visualization to a family vacation when she was fourteen. She remembered noticing the other girls having fun and hanging out and suddenly feeling very unexceptional and ugly (Waldron & Parker, 2018). Other researchers have begun to point to problems in the visual cortex. They have noticed that subjects with BDD seem to hone in on specific details of images shown, whereas those without BDD focus on the broader image. However, the problem here is determining what comes first. Feusner says, “...we haven’t yet determined whether abnormal visual processing contributes as a cause to developing BDD or is the effect of having BDD. So it’s the chicken-or-the-egg phenomenon” (Pedersen, 2018, para.9). Nauert suggests “that individuals with body dysmorphic disorder (BDD) have, in essence, global ‘bad wiring’ in their brains” (para.1). Either way, it is important for those with BDD to seek treatment.
Treatment seems to focus on either drug therapies or CBT. Treatment in Liane’s case had less to do with pills, and more to do with her mindset. Her therapist suggested she spend less time worrying about her appearance and more time concentrating on what was going on around her. When her boyfriend was brought into a session, they discussed possible ways he could support her when she was feeling bad in social situations without her explicitly asking for comfort. She was also put in contact with another one of her therapist’s patients who had been struggling with BDD for years. This seemed to help Liane as she could talk with someone who really knew what she had been going through (Waldron & Parker, 2018). Singh and Veale discuss studies on the efficacy of antidepressants and cognitive behavioral therapy in treating BDD but concluded that further study is necessary (p. S134).
BDD is an immensely complicated disorder, full of subcategories and potential consequences that are difficult to pin down. The stigma surrounding it makes it hard for people who have BDD to understand, come to terms with their condition, and find treatments that will work for them. Body Dysmorphia has the nasty effect of turning people against themselves to the point of believing the world would be better without them. However, research does progress, and more and more people have been able to come out with their stories of BDD and tell others how, despite the difficulties and hardships, and despite their own judgement, they are beautiful.
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