A beautiful young woman comes into my office for her first appointment. “I’m fine,” she says, “except that I don’t like the way I look. I’m only here because my boyfriend wants me to talk to someone.”
I ask her to tell me more about what her boyfriend thinks she should be talking about.
“Well, I just don’t like the way I look,” she says again. “He says I’m crazy and I need help, because he thinks I’m beautiful. But he’s blinded by his love for me.”
Years ago, I might have tried to engage this young woman in a philosophical discussion about beauty and the eye of the beholder. I might even have wondered with her why she needed to be more beautiful than she was. But after many years of working with clients with eating disorders, I knew that perfectionism, self-criticism, shame and mood dysregulation often accompany eating issues, as does an obsessive concern with flaws that seem minor or invisible to others. These symptoms may also be indicators of body dysmorphic disorder (BDD), in which concern about these so-called flaws can interfere with an individual’s social, school and work life. Body dysmorphia is a disorder that the DSM-IV-TR (2000) categorizes as one of a group of somatoform disorders that are generally characterized by complaints about medical or physical conditions that have no ascertainable physical or psychological cause. Not surprisingly BDD has been linked with obsessive compulsive disorder and frequently responds best to a combination of talk therapy, medication and cognitive behavioral tools.
Given the cultural pressure on both men and women to achieve some sort of physical “perfection,” however, obsession with perceived bodily flaws these days is often a “normal” and transient symptom of adolescence. It can also be a symptom of an eating disorder without signaling the presence of BDD. In such cases, the focus on a specific bodily imperfection improves as the other symptoms begin to diminish.
Body dysmorphic disorder is one of the disorders that has been tweaked in the new DSM-5. Categorized as a “somatoform disorder,” BDD is characterized by complaints about medical or physical conditions that have no ascertainable physical or psychological cause. DSM-5 has emphasized the link between BDD and obsessive compulsive disorders. Someone with this disorder may be so focused on a physical flaw (generally one that appears insignificant or even invisible to other people) that she cannot go out of the house because she does not want anyone else to see it.
There are important questions about BDD, some of which are addressed in discussions about the diagnosis as it is being described in the DSM-5 (see the article by Phillips and her colleagues listed below). Some of the major issues have to do with how one distinguishes between symptoms of BDD, certain eating disorders, and gender identity disorders; and whether or not BDD involves delusional thinking.
But here’s the thing – although BDD itself is a serious and distressing disorder that has been around for hundreds of years in some form or another, it seems like some of the symptoms have seeped into the general population. For example, although at one time women typically disliked something about the way they looked and men were far more satisfied, today large percentages of both men and women are not happy with the way they look. One British study, for example, found that 6 out of 10 women “hate the sight” of their bodies. And another report, released as summer brings beach weather, says that 45% of men are dieting to have a body they feel comfortable baring at the seaside, and another 10% say that they are too embarrassed by their bodies to wear swim suits.
Of course, I am not suggesting that these common fears are even close to a BDD diagnosis; but it does seem that we live in a world that makes the disorder more likely to develop. Today real life bodies are seen as somehow defective. I love watching old movies, which have a story to tell, not bodies to sell. Actors and actresses may have misshapen noses, funny eyebrows, large hips and sagging breasts, but they can still be glamorous, exciting, funny, sad, or touching. Even though they were often presenting an unreal world to their viewers, the message was that they, like the people in the audience, were far from perfect. And that wasn’t just okay, it was great. It was being human.
My client, as it turns out, does not have BDD. She worries about how she looks and obsesses about whether she is dressed well. She tries on several outfits before she finds one that she feels that she can wear outside. She spends excessive time in the bathroom getting her makeup perfect. But she is able to get out of her home, and she does not obsessively focus on a single defect in her body or face.
Her worries have meaning, which we have begun to uncover in therapy. She is already less concerned about her body, although she is not always happy with some of the questions she is struggling with now – like her relationship and her job. For her, focusing on her body has been a way of diverting herself from some of her other worries. It’s as if her unconscious has been giving her the message, “Your body we can fix. This other stuff…not so sure.”
We're working on that.
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Some useful readings:
Body dysmorphic disorder: some key issues for DSM-5 by Katharine A. Phillips M.D.and colleagues http://www.dsm5.org/research/documents/phillips_bdd.pdf
DSM-5: Body Dysmorphic Disorder Or Obsessed With Appearances? By Wayne Perry http://www.huffingtonpost.com/2013/05/28/body-dysmorphic-disorder...
Why Do Women Hate Their Bodies? By Carolyn Coker Ross, MD http://psychcentral.com/blog/archives/2012/06/02/why-do-women-hate-their-bodies/