Mirror mirror on the wall, I see nothing good at all

Body image disorder is a serious mental health condition that can even lead to suicide

woman looking in mirror, bod images issue

Sachin was in his early adulthood when he visited me to talk about his low self-confidence due to his facial appearance. He wanted to lose weight, kept away from talking to or meeting others, and was resistant to come frequently for his therapy sessions. His daily heightened worry about his appearance was taking a toll on him. He started to have suicidal ideation and made certain plans too. As the treatment progressed, Sachin was prescribed medications and psychotherapy ensued. Within weeks, his suicidal ideation reduced and his confidence in social interactions increased. He continues to come for his treatment to increase his self-belief and accept his appearance.

Is it vanity or a serious disease?

What Sachin has is called Body Dysmorphic Disorder [BDD], a mental illness involving obsessive focus on a perceived flaw in appearance. Individuals with BDD worry that their ears are very big, nose is blunt or very sharp or large, head is huge, face has lot of acne and so on. It involves behaviours like staring at one’s appearance in the mirror for long periods of time, excessive grooming such as wearing trendy clothes all the time, having fashionable hairstyles, changing one’s style to keep up with the current trends, applying a lot of make-up, constantly comparing one’s appearance to others, trying very hard to hide a defect by wearing loose clothes, make-up and accessories like cap, glares, long boots, scarf, etc. Such people also try to adjust their body positions so as to keep their ‘defect’ from showing to others. They engage in skin picking, repeated checking of the flawed part, are pre-occupied with it during conversations and seek reassurance from others. Emotionally, the person feels hopeless that ‘nothing can be done to improve the situation’, embarrassment and shame, as they believe that they look ugly. Cognitively, they remain pre-occupied with thoughts of poor body image and continue to think that this is the worst thing that could happen. They are usually delusional or have poor insight, which means that they are completely or almost convinced that their defects are repulsive or deformed. Individuals with BDD tend to have ideas or delusions of reference, that others are looking at, talking about, looking down upon or uncomfortable with their defect.

Other mental disease that co-exist with BDD

BDD often co-exists with other clinical disorders such as anxiety, other OCDs, eating disorders, substance use disorder and depression. The onset of these symptoms is in adolescence and it causes lifetime impairment if left untreated. It is more commonly diagnosed in females than males; however, it occurs equally in both genders. The symptomatology may be different in both genders. For example, men may obsess over their fitness or being too small or insufficiently muscular while women may focus on their skin and facial appearance. Sometimes, individuals have actual flaws in physical appearance which are apparent to others as well. However, their obsession about it is excessive and causes significant impairment in daily functioning.

Individuals with BDD are highly self-critical, apprehensive, withdrawn, feel unacceptable to themselves and others and have low mood. Thus, they are severely distressed which could lead to increased risk of attempting and committing suicide. Sometimes, individuals who are suffering from BDD come to me at a stage when they have already attempted suicide at least once. The suicidal ideations reported by them are higher than that in general population and sometimes, even higher than those diagnosed with depression or other mood disorders. Thus, those diagnosed with BDD are likely to have higher rate of suicidal ideation. BDD is one of the least diagnosed disorders in the clinical setting and it often goes undiagnosed as individuals feel ashamed and like to keep it a secret. They also fear that nobody will understand them. Another reason may be poor insight into their problem. This may again lead to an increased risk of suicide due to untimely intervention. Ideally, treating BDD is easier when diagnosed early, before the thoughts and insecurities become deep-rooted.

The following signs and symptoms need to be recognised when dealing with individuals suffering from BDD:

  1. BDD is diagnosed if the person is markedly worried about slight physical flaws which can be observed with the individual obsessing about them for at least an hour every day and are very difficult to resist or control. This preoccupation may lead to stress and hamper their everyday functioning.
  1. An eating disorder shouldn’t be the precursor for the concerns related to one’s appearance to be diagnosed with BDD. But, BDD and an eating disorder may occur together. Both diagnoses should be avoided and differences analysed.
  1. There are subtle signs such as desire to avoid daylight, finding comfort in dark settings, avoiding social outings altogether and being unusually self-conscious around others.
  1. The person with BDD may have keen interest in cosmetic surgeries.

BDD often goes undiagnosed as individuals feel ashamed and like to keep it a secret

Sometimes, individuals opt for cosmetic surgeries as they believe that their problems will disappear once they correct their flaw(s). However, cases of multiple surgeries are not unheard of and surgeries are not the most effective treatment for BDD. It may benefit some to improve their confidence and make them feel better about their bodies, thereby leading a routine life. However, more often than not, the individuals still remain unhappy with their appearance after the initial phase of satisfaction and may desire more procedures to improve it further, till the time they believe that they have become perfect. Also, their obsession might move onto another body part, once their previously defected part is treated.

How can this condition be treated?

The most effective treatment for BDD primarily includes pharmacotherapy and CBT [cognitive behavioural therapy]. Medications such as Selective Serotonin Reuptake Inhibitors [SSRIS] are very effective to elevate the mood and reduce the anxiety symptoms. If the individual is delusional, antipsychotics may be recommended. The component factor in CBT for individuals with BDD involves mirror training where a client learns to observe their entire body and see it in a holistic way which involves focusing on the areas of the body disliked by the individual. Further, the individual may be refrained from excessive mirror checking, mindfulness and habit reversal for skin picking or hair pulling or plucking. They are also taught relaxation exercises to help them deal with their anxiety. Another goal of CBT is to change the irrational ideas/beliefs to rational ones. Individuals with BDD often have ‘all or none’ thinking, they magnify their perceived flaws, discount the positive attributes and often use ‘labelling’ and ‘emotional reasoning’. During therapy sessions, they learn to identify their irrational thoughts and change them through techniques of cognitive re-structuring and affirmations. Clients with BDD generally have poor insight, so I recommend not asking them direct questions that involve their views on their appearance because for them, their flaws are realistic and not imaginary.

The treatment plan includes a disciplined regime regulating sleep and eating patterns, and physical activity. The family is educated to help them understand the nature and severity of the problem and to help them cope with the same. The other co-morbid disorders are also treated with medication and therapy. Thus, with a holistic approach, BDD is treatable and the person can recover from it completely. An individual, however, may take time to overcome this problem.


Excerpted with permission from Death Is Not The Answer by Anjali Chabbria, published by Ebury Press

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