SelfhelpMagazine

by Marc D. Feldman, M.D.

First recognized in Europe over 100 years ago, body dysmorphic disorder (BDD) is also known as the "syndrome of imagined ugliness." Patients with BDD are convinced that something is, simply put, quite dreadful about the way they look.

Sometimes individuals with BDD are exaggerating a slight flaw of the face, the buttocks, or the hairline, perceiving themselves as grotesquely disproportioned and offensive. In other cases, the object of their self-perceived freakishness is another part of the body: an asymmetry in the eyes becomes a deformity; bulky arms and thighs become horrible and hideous. Some patients say that the maligned body parts feel abnormal as well.

Few of us are really satisfied with the way we look. Liposuction, facial peels, permanent eyeliner and blush, hair implants, electrolysis, and a panoply of other procedures help the insecure feel a bit less self-conscious about the pockets of cellulite, the crow's feet, the sallow complexion.

But the two million Americans with BDD go beyond the so-called normal concerns about appearance. Instead, the preoccupation with ugliness dominates so much of their thinking that they may put their lives on hold. Lest they offend others with their appearance, they avoid work and social engagements. They worry that people will openly ridicule them or secretly joke about the way they look. Many BDD patients constantly seek reassurance from family members.

The hair, nose, skin, buttocks, eyes, and thighs are the most frequent culprits in the minds of BDD patients. Yet, the average patient implicates three to four different body parts over the course of the disorder, failing to realize that their way of perceiving themselves—not the anatomy itself—is to blame.

The Development of BDD

Adolescence and young adulthood are times when people are especially worried about fitting in. BDD tends to evolve during this vulnerable time. And because, from infancy on, our culture stresses the importance of appearance for females more than males, the diagnosis is more common among women.
Psychoanalytic theorists believe that BDD results from an effort at self-protection.

Susceptible patients, they maintain, shield themselves from difficult emotional or sexual impulses by incriminating a particular body part as reprehensible and guilty instead of dealing directly with their conflicts. Biologically oriented psychiatrists invoke deficiencies of chemicals in the brain, such as serotonin. Sociologists note the influence of mass media depictions of beauty and the acceptance of plastic surgery in our society.

In the most extreme cases of BDD, patients are utterly disabled. They try to conceal the body parts that torment them; failing that, they become shut-ins, perhaps venturing out only at night. Some try to "medicate away" these painful feelings by using alcohol or drugs. Others experience suicidal feelings that can progress to suicide attempts.

Facing Up to BDD

BDD patients often insist that the answer to this complex malady is in fact straightforward: corrective surgery. Yet, cosmetic surgery generally provides only temporary relief. Such patients may have had more than 20 cosmetic operations.

I believe that surgery is rarely even part of the answer. Instead, I note that BDD is commonly entwined with other mental disorders—such as depression, social phobia, and obsessive-compulsive disorder—and that mainstays of treatment for these conditions apply to BDD as well: a judicious combination of medications and psychotherapy.

In some cases, behavior or cognitive therapy improves the chance of success. Overall, treatment can reduce the intensity of the symptoms of BDD in at least 50% of patients—not bad odds with such a potentially disabling condition.

References:

Chosak A, Marques L, Greenberg JL, et al. Body dysmorphic disorder and obsessive-compulsive disorder: similarities, differences and the classification debate. Expert Rev Neurother 2008; 8:1209-1218

Feldman MD, Feldman JM. Stranger Than Fiction: When Our Minds Betray Us. Washington, DC, American Psychiatric Press, Inc., 1998

Sarwer BD, Crerand CE. Body dysmorphic disorder and appearance enhancing medical treatments. Body Image 2008; 5:50-58

About the Author:

Marc D. Feldman, M.D. is the author of "Playing Sick? Untangling the Web of Munchausen Syndrome, Munchausen by Proxy, Malingering, and Factitious Disorder" (2004) and co-author of "Stranger Than Fiction: When Our Minds Betray Us" (1998).