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June 05, 2015

The science of ... body dysmorphic disorder

People who have the severe psychiatric condition see themselves as ugly or deformed despite looking normal to the outside world

What do you see when you look at yourself in the mirror?

Most of us wish we had clearer skin or less wrinkles, and we probably wouldn't mind trading in a facial feature or two. We all have our physical flaws that bug us some days and not others.

But people who have a severe psychiatric condition called body dysmorphic disorder always see themselves as ugly or deformed — say, with a repulsive nose or blemished skin — despite looking normal to the outside world. Patients may spend hours in front of the mirror, checking and rechecking their apparent defect, or groom themselves to the point of obsession.

The condition can be severe enough to disrupt work, school, or other aspects of daily life. Those with body dysmorphic disorder may stop socializing altogether out of shame and low self-esteem, describing themselves as unattractive or even hideous. But where do these extreme self-images stem from? Are patients looking into the mirror and actually seeing their faces or bodies this way?

“Individuals with features of body dysmorphic disorder have been described in the medical literature for well over 100 years, but it didn't receive acceptance as a formal psychiatric disorder until about 30 years ago,” said David Sarwer, professor of psychology and consultant to the Edwin Fannie Gray Hall Center for Human Appearance at the University of Pennsylvania, at left. “Most practitioners in private practice may only see it once or twice over the course of their careers, and it only affects about 1-2 percent of the general population.”

An Italian psychiatrist, Enrico Morselli, first described the condition in 1891 as someone who is “suddenly overcome by the fear of some deformity.” Today, the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5) classifies body dysmorphic disorder as its own condition, separate from obsessive-compulsive disorder and eating disorders. It is characterized by an extreme preoccupation with slight or imagined defect in appearance.

Aimee Wood, a licensed social worker and full-time therapist at the Center for Growth in Society Hill, has seen a number of patients with body dysmorphic disorder.

“It's usually delusional or imagined,” said Wood, left. “I've heard stories of, 'I missed my breakfast date with my family member because I was in the bathroom fixated on my acne' — and that person will come into my office, and I won't see a damn thing.”

She has noticed certain patterns in her patients over the years, like excessive mirror checking, hours upon hours of time spent online searching for products or procedures designed to “fix” their supposed flaw, and being insistent on getting plastic surgery. Examples of imagined defects include skin complexion, penis size, the size or shape of their nose, thinning hair, and crooked teeth.

“I've had men that are fixated that one person told them that their penis was too small, and they can't get off the whole penis size thing,” she said.

Many patients can very vividly remember the first time someone brought the particular defect to their attention — for instance, being teased about it in elementary school in front of the whole class, Sarwer added.


But such harrowing incidents are not necessarily the root cause of body dysmorphic disorder. One study published by the journal Psychological Medicine scanned the brains of people who had either body dysmorphic disorder or anorexia nervosa using functional MRI. The researchers found they had similar abnormalities in early-stage visual processing, suggesting that such body image distortions may have their origins in neurobiology.

Other studies confirm that it isn't the obsessed-over feature that's the real issue. Another study in the Annals of Plastic Surgery found that, while many who have body dysmorphic disorder end up getting plastic surgery, only two percent of procedures actually reduced the severity of the condition. Many patients even came up with a new imagined defect to focus on.

“Individuals that come in for cosmetic surgery are more likely to have body dysmorphic disorder because they think they'll feel better about their appearance by changing it,” Sarwer said. “We don't really know why this occurs, but it is probably an interaction between things that are going on at a neurological level having to do with brain chemistry and interpersonal or environmental experiences.”

Often times, it is seen with obsessive-compulsive disorder, which is more or less its “cousin diagnosis,” he added. The obsessive thoughts and compulsive behaviors seen with obsessive-compulsive disorder are very similar to those that are seen with body dysmorphic disorder, and a family history of an anxiety disorder could put individuals at greater risk.

The good news is that the condition is treatable, typically with a combination of antidepressant or anxiety medication and cognitive behavioral therapy. For instance, Wood will suggest her patients spend, say, 25 minutes in front of the mirror instead of their usual half hour, and slowly ramping it down from there. She also asks patients to step outside themselves and imagine that a close family member was obsessing about her appearance in this way — does it seem healthy? What would you say to her?

“It is something that can be treated,” she said. “It's a long road, but can be successful if the person sticks with it.”

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