“People say sometimes that beauty is only superficial…it is only shallow people who do not judge appearances.” So wrote Oscar Wilde in his compelling (and some believe his most autobiographic work and only novel), The Picture of Dorian Gray. Dorian, who had “extraordinary personal beauty,” makes a Faustian bargain to remain forever young as his painted portrait ages and becomes for him “the visible emblem of conscience.” As his personality changes from an innocent Adonis, barely out of adolescence himself, to someone capable of extraordinary insensitivity and even murder, Dorian perceives changes in his portrait, and its facial expression bears evidence to him of his cruelty and ultimate depravity. “At first gazing at the portrait with a feeling of almost scientific interest,” Dorian, though, struggles with wondering whether his portrait has actually changed or whether it is just a reflection of his imagination—“an illusion wrought on the troubled senses.”
Continues Wilde, ‘Morning after morning he (Dorian) sat before the portrait wondering at its beauty…He would examine with minute care and sometimes with a monstrous and terrible delight, the hideous lines that seared the wrinkling forehead…wondering sometimes which were the more horrible, the signs of sin or the signs of age…”
Wilde’s novel can be seen metaphorically as a backdrop for a discussion of body dysmorphic disorder, a diagnosis made when bodily preoccupations are severe and incapacitating and involve clinically “distressing preoccupations” with imagined or perceived slight defects that may not even be noticeable to others. For Dorian, his excessive preoccupations with his physical appearance were projected onto his portrait. This disorder, typically beginning in adolescence, is not uncommon, with a prevalence rate of 2.4%. It has been called the “distress of imagined ugliness” by Katharine A. Phillips, M.D., who has written extensively on it. (American Journal of Psychiatry, 1991.)
Those affected often call their appearance “monstrous.” (Of note is that I counted 15 times Wilde uses the word “monstrous” in his 229-page novel.) According to Phillips, about 80% of those suffering have suicidal ideation and almost 30% have actually attempted suicide. (Dorian Gray suicides at the end of the novel.) Those affected often have accompanying obsessive-compulsive symptoms whereby they may spend hours each day thinking about their perceived defects and checking them in the mirror, excessively grooming (e.g. combing, styling, plucking hair) and repeatedly attempting to camouflage the disturbing areas with clothing or makeup, though some may avoid mirrors altogether. (At one point, Dorian, disgusted by his preoccupations, flings a mirror onto the floor and crushes it “into silver splinters beneath his heel.”) Phillips et al (Depression and Anxiety, 2010) emphasize that these behaviors are “time-consuming, typically difficult to resist or control, and not pleasurable.” When severe enough, some refuse to leave their homes, and many are embarrassed and quite secretive about their preoccupations. (Dorian would not let anyone see his portrait and kept it hidden behind a curtain in an unused, upstairs room that he kept locked at all times.)
Typically, those suffering have poor insight and some are even overtly delusional in their fixed beliefs of perceived imperfections. This disorder goes far beyond the common mild preoccupations many people have with their appearance. Most commonly, skin, hair, breasts, abdominal area, (particularly in women, in whom the disorder is more common) and muscle mass (“muscle dysmorphia” particularly in men) are the areas affected, but any area of the body can be a focus of attention. Freud’s famous patient The Wolf-Man, for example, is described as so fixated on his nose that had been “ruined” by electrolysis (used to treat his obstructed nasal sebaceous glands) that he neglected his daily life, engaged in constant mirror checking, and “felt unable to go on living in… his irreparably mutilated state” though “nothing whatsoever was visible” to others. (Brunswick, International Journal of Psychoanalysis, 1928) Many patients actually seek cosmetic procedures, including surgery and dermatological procedures, often to no avail and often leading to overt hostility toward the treating physician. Up to 15% of dermatology patients and up to 8% of those presenting for cosmetic surgery suffer from this disorder. (DSM-5)
Phillips (1991) reviewed the literature and found that this disorder “of a subjective feeling of ugliness” has a “rich tradition in European psychiatry”—first described in the Italian literature in 1891 (ironically, the same year as the publication of Dorian Gray), as “dysmorphophobia.” It did not enter the U.S. psychiatric nomenclature until DSM III-R (1987), where it received its present name “body dysmorphic disorder.” The classification of body dysmorphic disorder is controversial. It has features of an anxiety disorder as well as an obsessive-compulsive disorder. In psychiatry’s DSM-5, (Diagnostic and Statistical Manual), it is found under obsessive-compulsive and related disorders, and in the newly released ICD-10 (International Classification of Diseases), under somatoform, hypochondriacal disorders. There is also considerable psychiatric comorbidity, including anxiety (e.g. social phobia that predates the disorder), depression (the most common comorbid symptom), and obsessive-compulsive symptomatology in those with body dysmorphic disorder. (For a discussion of key considerations involved in its diagnostic classification for DSM-5, see the comprehensive review by Phillips et al, Depression and Anxiety, 2010.)
What is the relationship of weight to body dysmorphic disorder (BDD)? Kittler et al (Eating Behaviors, 2007) assessed weight concerns in 200 individuals with BDD. Of the participants, 29% had weight concerns and were more likely to be younger, female, and have more areas of body concern, greater body image disturbances, depression, and suicide attempts. In general, this subgroup of patients had poorer social functioning and was “a more severely ill and body-concerned group overall.” Significantly, only 3.5% of this group reported that weight issues were their primary concern. Their conclusion was that the “diagnostic boundary” between body dysmorphic disorder and eating disorders is often not particularly well defined. Of note is that in their study, Sarwer et al (Journal of Consulting and Clinical Psychology, 1998) found that of the 79 obese, six had levels of distress, impairment, and preoccupation consistent with a diagnosis of BDD. Mufaddel et al (The Primary Care Companion for CNS Disorders, 2013) emphasize that while obesity and eating disorders may include disturbances in body image and even BDD, body image itself is distinct from it: those with disturbances in body image do not necessarily have the constellation of symptoms seen in BDD.
Hrabosky et al (Body Image, 2009) compared body image among 187 patients with eating disorders, body dysmorphic disorder, and controls in a multi-site study. These researchers found significantly higher levels of body image impairment in patients with anorexia nervosa, bulimia nervosa, and BDD as compared to matched controls. In general, though, those with BDD had fewer concerns with their weight and body shape than those with eating disorders and more concerns with their face and hair and spent more time seeking reassurance from others, mirror checking, and covering up their perceived imperfections. Further, these researchers found that those with BDD had greater overall disturbances with their body image and more impairment in their quality of life (i.e., “greater psychosocial dysfunction”) than either controls or those with eating disorders.
Near the end of Wilde’s novel, Dorian, “prisoned in thought,” becomes more reclusive, avoids most of his friends, and seeks solace in opium dens. Before he ultimately commits suicide by knifing himself in the heart, he viciously stabs his own portrait. When discovered by his servants, Dorian is described as “withered, wrinkled, and loathsome.” The “splendid portrait” of him, though, appears “in all the wonder of his exquisite youth and beauty.” The reader is left to consider that it was, in fact, only his imagination, “grown grotesque by terror” and the “leprosies of sin,” that had distorted Dorian’s reality and contaminated what he saw in his portrait and that ultimately led to his demise.
Though there is still much to learn about BDD, today treatments include cognitive behavior therapy and medications such as the SSRIs (selective serotonin reuptake inhibitors.) There is some suggestion, though there are still few and inconsistent results, that those suffering from this disorder have abnormalities in visual processing and perceptual organization (e.g. over-attention to details), as evidenced by functional neuroimaging studies. (For a discussion, see Madsen et al, Journal of Psychiatric Research, 2013.) Body dysmorphic disorder may be a “brain-based disorder” and is not just a function of vanity, says Phillips (Psychotherapy and Psychosomatics, 2014) who emphasizes the need for appropriate treatment to prevent the considerable morbidity and mortality.
Note: For a general discussion of body image distortions, see my previous blog, The "False Creation” of Body Image Distortions.
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