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Body Dysmorphic Disorder: A Modern Fear of Our Own Image 

Body image problems are rising, but we know what helps with BDD.

Key points

  • Body Dysmorphic Disorder (BDD) makes people so worried about their image that it interferes with their ability to function normally.
  • Cosmetic surgery often becomes a compulsive obsession to correct the perceived flaws of someone with BDD.
  • Cosmetic procedures can lead to social isolation and an increasing lack of confidence.

Our self-image has to do with how we feel about how we look. It affects everyone at some point, given the nature of human evolution and our social processes. We all have a view on how we can be seen as social objects. Social media, TV, films, and advertisements all play a part in how we compare ourselves to those around us. All of these aspects of social life have an impact on how we feel about our body image. We currently live in a culture that places huge importance on image, dieting and fitness. There is an expectation of regular gym-going, and not always for the health benefits.

The Numbers

Some studies have reported that between 0.7% to 2.4% of the general population experience BDD. BDD tends to be more common with schizophrenia or anorexia, although some studies of people without diagnosed conditions have shown that about 2% to 13% suffer from it. BDD is commonly found in clinical settings, and dermatology services show that between 3% to 53% of patients experience it. In cosmetic surgery settings, between 8% to 37% of patients have the disorder. Individuals with OCD also demonstrate dysmorphic tendencies, although in 11% to 13% of cases, social phobia is a major contributing factor.

Corrective Cosmetic Effect

When patients come to our clinic we have observed that this disorder has a very similar interactive pattern to many other phobic and obsessive disorders (Gibson, 2021). With the growing options for intervention and the seemingly never-ending progress of cosmetic surgery, those who longed to alter their appearance can now do so. Although the belief that it would make them feel more attractive has little evidence to prove it (except in the case of material damage of particular birth defects).

In western societies, males and females sometimes undergo plastic surgery. However, while it has proven itself an indispensable science in reconstructive situations, if used to excess or improperly, the worst effects can be seen in any celebrity magazine. Like any medicine, if taken at the wrong dose, surgery becomes toxic. Patients that obsess about one specific aspect of their body refuse to accept themselves as they are, as they obsessively focus on their perceived "imperfection." When feeling trapped in this perception, they can experience their lives as a living hell, tormented throughout the day by their own image. It is also worth noting that this obsession tends to transform itself into panic, even at the sight of their own image in a mirror or photograph. Tragically, someone suffering in this way may place unbelievable faith in cosmetic surgery—which is rarely realized.

Signs and Symptoms of BDD

  • Being extremely preoccupied with a perceived flaw in appearance that to others can't be seen or appears minor
  • The strong belief that you have a defect in your appearance that makes you ugly or deformed
  • A belief that others take special notice of your appearance negatively or mock you
  • Engaging in behaviours aimed at fixing or hiding the perceived flaw that is difficult to resist or control, such as frequently checking the mirror, grooming or skin picking
  • Attempting to hide perceived flaws with styling, makeup or clothes
  • Constantly comparing your appearance with others
  • Frequently seeking reassurance about your appearance from others
  • Having perfectionist tendencies
  • Seeking cosmetic procedures with little satisfaction
  • Avoiding social situation

An Irresolvable Doubt?

It is important to point out that, in most cases, the perceived 'imperfection' is actually, either non-existent or insignificant. The pathogenic belief of having an unacceptable aesthetic deformation has become a mental fixation for the person. It is also worth noting that these defects are often 'discovered' by patients in response to some problems at a social or relational level. In our clinic, we see patients who have a profound sense of insecurity use this explanation as a way of making sense of their social problems. Their obsessive mind clings to this 'defect' as a way of explaining the foundations of their relationship challenges.

The tragedy is also that they suffer from the illusion, that, once the defect is removed or modified, everything will miraculously fall into place, but we rarely see this happen. This chain reaction that begins usually involves a series of corrective surgeries, leading to an ever increasing dissatisfaction with their image and an increasing sense of social isolation or disgust with themselves. Humans can always find something further to work on, as the mind contemplates the illusion of perfection. The illusion of having control of their problem and the belief that surgery is their only escape plan traps the patient in a game without end and the process spins out of control.

When a Solution Becomes a Problem

As with obsessive-compulsive disorders, the solution patients apply in BDD transforms itself into a new problem, which ends up requiring a 'new solution', which in turn constructs another problem, and so on. This never-ending escalation leads to real and tragic concrete effects, such as real deformations, destroying the natural harmony that existed in the person's unique image. The effects are often devastating and we see patients suffering periods of intense social isolation, often to avoid the panic attacks triggered by their fear of social criticism and potential judgement and rejection by others.

At this point, family and loved ones become more involved and tend to accompany sufferers to situations in which they fear they may panic. Even though the relatives clearly understand that the patient's problem is psychological and indeed not physical, they eventually end up agreeing with the need for further surgery as well. It is also important to note that the conversations with loved ones and attempts to reassure the person of their natural beauty leads the patient to become ever more paranoid and sceptical of how they and other perceive them. They even begin to believe others are lying to them.

All of the above makes this a difficult problem to treat, and patients often only attend therapy long after numerous surgeries or interventions have occurred. This is an unfortunate and tragic reality of BDD. In therapy, the clinician should not make any attempt to rationally persuade the person into stopping their current path through surgery, because this usually ends up increasing resistance to a therapeutic solution. The clinician should slowly help them see that what appears to have given them a means of controlling their problem is now creating an even bigger problem, which unfortunately they can no longer control.

References

Gibson, P. (2019) Advances in Effective Brief Psychotherapy. Lettertec Books.

Gibson, P. (2021) Escaping The Anxiety Trap. Strategic Science Books.

Gibson, P. (2022). Persuasion Principle. Strategic Science Books.

Nardone, G., Portelli, C. (2007) Knowing Through Changing. Crown Publishing.

Janet P. Les Obsessions e t la Psychasthenie. Paris, France: Felix Alcan. 1903.

Zimmerman M, Mattia JI. Body dysmorphic disorder in psychiatric outpatients: recognition, prevalence, comorbidity, demographic, and clinical correlates. Compr Psychiatry. 1998;39:265–270.

Thompson CM, Durrani AJ. An increasing need for early detection of body dysmorphic disorder by all specialities. J R Soc Med. 2007;100:61–62.

Phillips KA, Kaye WH. The relationship of body dysmorphic disorder and eating disorders to obsessive-compulsive disorder. CNS Spectr. 2007;12:347–358.

First MB, Spitzer RL, Gibbon M, Williams JBW. Structured Clinical Interview for DSM-IV-TR Axis I Disorders, Research Version, Patient Edition With Psychotic Screen (SCID-I/P W/ PSY SCREEN) New York, NY: Biometrics Research NYSPI. 2002.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed, Text Revision. Washington, DC: American Psychiatric Association 2000.

Ruffalo JS, Phillips KA, Menard W, Fay C, Weisberg R. Comorbidity of body dysmorphic disorder and eating disorders: severity of psychopathology and body image disturbance. Int J Eat Disord. 2006;39:11–19.

Phillips KA, Wilhelm S, Koran LM, et al. Body dysmorphic disorder: Some key issues for DSM-V. Depress Anxiety. In press

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About the Author

Padraic Gibson, D.Psych, is a Consultant Clinical Psychotherapist and is the Clinical Director of The OCD Clinic®, and director of Training and Organization Consultation at The Coaching Clinic®, Dublin. He is senior research associate at Dublin City University.