Compulsive Acts

A psychiatrist's tales of ritual and obsession.

Perfectly Beautiful

Body dysmorphic disorder, with a twist

Body dysmorphic disorder (BDD) is a serious psychiatric condition found in approximately 2.4% of the population, with more women than men affected. The hallmark is severe anxiety linked to an imagined or highly exaggerated defect in one’s appearance. The average age of onset is in the late teenage years, but patients can take several years before seeing a mental health specialist, preferring, instead, to seek care in dermatology, plastic surgery or orthodontic clinics, in order to fix what they think is unsightly ugliness. If and when they decide to see a psychiatrist, patients may benefit from various medication and therapy interventions. Over the years, I have treated patients with a whole range of BDD symptoms, including the thick-haired woman who believed she was bald, the student with the perfectly symmetrical face who worried her left eyebrow was one inch higher than the right one, and the muscular young man who felt his biceps were gradually shrinking and would soon completely disappear. None of these cases, however, prepared me for the challenge of diagnosing “Dana”.

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Dana was referred to me for a psychiatric evaluation, not by her dermatologist, plastic surgeon or dentist as is often the case, but by her daughter’s pediatrician. A forty-seven-year-old interior designer, she had had a successful career creating beautiful spaces for her clients to enjoy. About two years ago, following a lengthy divorce battle that resulted in her winning full custody of her five-year-old daughter “Kaetlin”, Dana was looking forward to a less stressful new chapter. Instead of finding relaxation, however, she started struggling with a new source of worry: For no reason she could identify, Dana started worrying about her daughter’s face. Specifically, she became very concerned that her daughter had very pointy “Vulcan ears”, similar to Mr. Spock’s, the Vulcan science officer in Star Trek. She imagined students making fun of her in class and on the bus, and wondered about her future professional and relationship prospects. She made her grow out her hair so it could cover her ears.

When Dana sought help from her daughter’s pediatrician, he told her that nothing was wrong with Kaetlin and recommended that she discuss the problem with a psychiatrist. His reassurances did not soothe her, and Dana sought advice from a plastic surgeon next. When he refused to operate on a problem he did not see, Dana started making plans to get surgery for her daughter in Asia. She called my office before her scheduled trip, “to make my pediatrician happy”.

In my office on a warm summer day, I met a beautiful, somewhat shy seven-year-old girl whose mother had made her wear a hooded jacket to conceal her ears. “I worry people will make fun of her, so I keep them covered when I can,” Dana said, as she removed Kaetlin’s hood to reveal a pair of perfectly normal looking ears. Absolutely nothing was wrong with Kaetlin’s face. “While Kaetlin looks perfectly healthy and normal to me,” I eventually said, “I believe that your anxiety is real and would like to try to help you.”

I had encountered many patients with unjustified, disabling worry about a body part, but I had never seen a case of body dysmorphic disorder by proxy. Its toll seemed even worse in that it had two victims--the patient and the loved one. But the more I struggled to come to terms with the case, to devise a treatment plan for the mother and try to protect the daughter, the more similar BDD by proxy seemed to other mental illnesses. The neglected kids of depressed or anxious parents, for example, also often pay the price for mom’s or dad’s untreated mental illness. Seen that way, BDD by proxy looks like a dramatic illustration of how patients are rarely ever isolated islands. Their symptoms ripple and reverberate. Their pain is also that of their loved ones.

Dr. Aboujaoude is a psychiatrist and author based at Stanford University. His most recent book is Virtually You: The Dangerous Powers of the E-Personality.

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