Killer Looks — Body Dysmorphic Disorder
By Matthew Robb, MSW, LCSW-C
Social Work Today
Vol. 5 No. 3 P. 36

When people see Jennifer, they see a striking beauty seemingly lifted from the cover of a fashion magazine.

But when Jennifer gazes into a mirror, the image reflected is a grotesque caricature responsible for hijacking her life, undermining her confidence, and seemingly dooming her to neverending misery. While other people go on with their lives, the Boston secretary grapples with chronic depression and wrenching feelings of rejection and shame. Her last best hope for relief, she believes, lies in the gilded promises of cosmetic surgery.

Jennifer is no stranger to the scalpel. At 37, she’s already undergone eyelid lifts, chemical peels, facial contouring, and injections of Botox and collagen. Last year’s rhinoplasty merely opened the door to this year’s “corrective” rhinoplasty. Yet having exhausted her savings, she feels not 1 inch closer to satisfaction.

The focus of her dissatisfaction? Her “wrinkles, sagging skin, and a crooked nose,” she says.

Others do not see these features, but they glare at Jennifer like a light tower on a moonless night. On bad days, she might peer into a mirror 75 to 100 times, each time hating what she sees, who she is, and what her life has become and seemingly will always be.

Chances are, you have met or heard of someone like Jennifer. She (or he) could be a neighbor or new client. Things seem fine until their idiosyncrasies start bubbling up. It’s tempting to downplay their complaints, dismissing them as molehills given prominence by our appearance-crazed culture. But experts stress that body dysmorphic disorder (BDD) is a serious condition with potential life-and-death consequences.

According to researchers, BDD is a silent epidemic, affecting an estimated 1% to 2% of Americans (approximately 4 million adults), nearly one-half men and most undiagnosed. Among them is Hollywood celebrity Uma Thurman, star of Quentin Tarantino’s Kill Bill cult series and John Travolta’s costar in the 2005 flick Be Cool. That a stunning Lancome spokesmodel would struggle with BDD may be surprising but also captures the disorder’s paradox. To paraphrase the Bard, beauty may be only skin deep, but the perception of ugliness is to the bone.

And perception, in the twisted logic of BDD, is everything.

Who Is Obsessed?
Dissatisfaction with appearance runs deep—and is getting deeper—in the United States. According to the American Society for Aesthetic Plastic Surgery, in 2003, Americans underwent a record 8.3 million cosmetic procedures, representing an annual spike in surgical and nonsurgical procedures of 12% and 22%, respectively. Of these, nearly 300,000 females (some in their mid-teens) opted for breast enlargement while another 2.3 million people (a 37% hike over 2002) got Botox injections.

Against a sociocultural backdrop that sees the rise of Botox parties, breast implants as graduation gifts, and a popular television makeover show that hails the curative powers of plastic surgery, curious observers are left to wonder: What separates the disordered few from the discontented many? And where does the pathology of the individual end and the pathology of society begin?

Body worry on a national scale may provide grist for social commentators but has no place in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, which defines the disorder as a preoccupation with a defect in appearance, be it an actual (minor) flaw or imagined. Over time, obsessions beget clinically significant distress or impairment in social, occupational, or other areas of functioning. Notably, BDD cannot be accounted for by another mental disorder. The fraternity president who obsesses over his receding hairline may have BDD, whereas his emaciated twin sister who ruminates about her broad hips may (or may not) instead have anorexia nervosa.

Seemingly uncontrollable compulsions are a classic signature of this obsessive-compulsive spectrum disorder. People with BDD typically check and recheck their imagined flaw (or try to camouflage it) sometimes all day long. The preferred means are mirrors, but any reflective surface will do.

Identified body parts run the gamut, typically centering on the face. Among the top concerns: a big or misshapen nose, wrinkles or freckles, blotchy skin, acne, hairiness, or hair loss. Perceiving themselves as ugly and defective, people with BDD typically suffer rock-bottom self-esteem and fear rejection. Some understand that their thinking is skewed but cannot stop their preoccupations and compulsive mirror-checking.

For years, experts have relied on a general rule of thumb that said emotionally well people reported increased self-esteem after cosmetic procedures, whereas persons with BDD generally did not. But a recent study by U.S. and Finnish researchers casts doubt, finding women with breast implants three times more likely to commit suicide than the general population—during the early postoperative years. Future research needs to shed light on how many of these women had BDD.

In recent years, researchers have documented a “males-only” variant of BDD: muscle dysmorphia. Coined “reverse anorexia” by some, this disorder finds untold tens of thousands of bodybuilding “gym rats” obsessing over muscles that no steroid, human growth hormone, or extreme training regimen can ever make big enough.

Beyond Madison Avenue
Pioneer researcher and noted authority Katharine A. Phillips, MD, says much of BDD remains shrouded in mystery, despite the American Psychiatric Association having first recognized it nearly 20 years ago. Phillips, director of the Body Dysmorphic Disorder and Body Image Program at Butler Hospital and professor of psychiatry at Brown Medical School in Providence, RI, has written widely on BDD. Her landmark book The Broken Mirror is set for a July update.

Asked which mechanisms give rise to and sustain BDD, Phillips says, “our research isn’t there yet; we can only speculate.” Current thinking, she says, points to a complex interplay of genetics, upbringing, and pop culture. “Some people appear genetically predisposed to worry, obsess, and focus on the way we look. Some, but not all, of my BDD patients have been taunted and teased in childhood and adolescence.”

Societal forces likely play a contributory role by “increasing our expectations that we can be perfect,” she says. “People who have the biological and psychological predispositions to develop BDD may be tipped over the edge by television shows. One patient I’m working with watches these makeover shows and afterward feels a lot worse.”

But Phillips cautions that the root causes of BDD are complex and multidimensional and do not lend themselves to crisp answers. She adds that this disorder is hardly new and existed a century ago, though today’s incidence is probably much sharper. Addressing another myth, she says, “BDD patients are everywhere, absolutely everywhere in America. This isn’t a Hollywood or Madison Avenue problem.” Translation: The high school pom-pom girl in rural Iowa is as likely to have BDD as her Miami counterpart.

Might BDD be thought of as an obsessive-compulsive disorder (OCD) that attaches to body image? Phillips nods, but says the fit isn’t perfect.

“BDD mimics OCD in terms of the tendency to obsess and do compulsive behaviors,” she says, “but people with BDD tend to be more depressed, more suicidal, more socially anxious and socially phobic, and have much worse insight.” Calling BDD “an often-secret disorder,” Phillips says it often masquerades as OCD, social phobia, social anxiety, or depression. “While the OCD patient typically understands [his or her] fears are not based in reality,” she says, “many BDD patients are absolutely convinced that they are ugly.” Pausing, she adds, “I think it’s harder to work with BDD patients.”

“The No. 1 problem is that BDD is typically missed in clinical practice,” Phillips says. “Patients do not get the right treatment because therapists do not know they have it and do not ask about it.”

San Mateo therapist Scott Granet, LCSW, agrees. Granet, 50, knows BDD well, having lectured on it internationally, lived with his own BDD issues for 30 years, and run OCD-BDD groups at the Palo Alto Foundation’s department of psychiatry. Having interacted with thousands of therapists in workshops worldwide, he estimates that no more than 30% to 40% are familiar with the diagnosis. “Surgeons and dermatologists tend to be more aware of BDD than mental health workers,” he notes.

Granet says therapists should ask about BDD, noting that patients typically do not volunteer critical information due to shame. He also notes that persons with BDD typically withdraw socially, creating clinical impressions of social phobia. The risk finds therapists pressed for quick results by managed care formulating treatment plans that go nowhere. Phillips agrees. “Most patients really want their therapists to know, but they’re too embarrassed to say themselves,” she says.

Therapist Stacey Kuhl, MSSA, of the OCD Center of Los Angeles, says that while BDD might seem like one of the more obvious disorders, those who have it typically “look normal” and defy attempts by others at guessing the identified problem body area.

Failing to pick up on subtle clinical cues carries considerable risk, Granet says. “I try to stress to therapists just how serious [BDD] really is. The suicide attempt rate is anywhere from 25% to 30%. BDD is not vanity. BDD involves people desperate to look in a way that makes them feel acceptable to the world.”

Effectively, individuals with BDD feel so fundamentally flawed and undeserving of society’s embrace that they opt for self-exile, becoming imprisoned by destructive obsessions and compulsions.

Treatment Issues
According to Phillips, the most efficacious treatment for BDD focuses on cognitive behavioral therapy and psychotropic medications, such as Lexapro, Prozac, and Paxil. The cognitive-behavioral component should be practical and symptom-focused. “Therapists need to help people develop more accurate beliefs about their appearance, help get their rituals under better control so they aren’t checking a mirror all day long, and help them feel more comfortable in social situations,” she says.

People with BDD typically need reassurance, but Kuhl urges caution, noting that reassurance can fuel obsessions. She cites a young female preoccupied with freckles. The girl constantly asked family members for reassurance, whose calming words temporarily decreased her anxiety “but actually validated that her obsession about her face was an important thing to worry about,” she says. Unraveling this damaging feedback loop demands clinical finesse. “Telling a client there’s nothing wrong isolates them and makes them feel you’re not hearing what they believe to be true,” she says.

Granet says psychodynamic psychotherapy is typically contraindicated, noting that people “can waste years in therapy without treating the BDD itself.” He agrees with Kuhl’s observations about getting swept up in reassurance-giving. “Patients need to develop the skills to reassure themselves that everything will be OK no matter how they feel they look,” he says.

“Talk therapy alone is not effective for BDD,” Phillips says. “Having said that, BDD patients have a lot going on in their lives that may benefit from it as adjunctive treatment.” More research is needed, she says.

Kuhl’s work often focuses on cognitive restructuring and “modifying the way a patient overvalues a particular body part.” The behavioral component involves exposure and response prevention, wherein the therapist and client outline a hierarchy of compulsions and then the client slowly stops the compulsions. “We generally start with cognitive therapy,” Kuhl says, “as most people aren’t ready to do behavioral exposures.” One behavioral exercise might find a client walking down the street while making eye contact with strangers.

Treatment for BDD can be complicated by the constant bombardment of print and broadcast images that declare imperfection unacceptable and human flaws worthy of shame and self-punishment.

Sad but true, many patients fail to grasp that fashion icons are products of the surgeon’s knife, trick photography, editorial airbrushing, eating disorders, cosmetic concealment, and consumer gullibility. The bottom line finds vulnerable people chasing a ghostly mirage that can wreck lives and push families to the brink.

As her work week draws to a close, Kuhl tells of a relatively new patient (and college student) preoccupied by imagined blemishes on her face. “She feels people are staring at her in public,” Kuhl says. “She thinks they are disgusted by her. She checks mirrors all day long, hoping she will see something different, something better.”

The truth, the Los Angeles social worker says, finds a young woman blessed with killer looks but tormented by a BDD mindset. “Her BDD is really lying to her, telling her she has a flaw when she doesn’t.”

Reflecting on this patient’s struggle, Kuhl sighs, “What’s so tragic is that she is beautiful—simply beautiful.”

— Matthew Robb, MSW, LCSW-C, is a social worker and freelance writer residing in suburban Washington, DC.

When East Meets West: Integrative Healthcare and BDD
Traditional Western therapists typically recommend medication and cognitive-behavioral therapy for persons with body dysmorphic disorder (BDD). But what path might an East-West holistic practitioner extol?

For answers, we asked Ted Cmarada, LCSW-C, director of the Maryland-based Center for Integrative Healthcare. For more than 20 years, he and his colleagues have blended practices from both worlds, yielding a “heart-centered” psychotherapy that embraces body work, meditation, exercise, and nutrition.

According to this longtime student of Vietnamese Buddhist Master Thich Nhat Hanh, helping relieve symptoms is laudable, but therapy should ultimately deepen awareness and address key developmental and existential issues.

“The guiding premise of integrative healthcare,” Cmarada says, “springs from the realization that we are not body alone. We are body, mind, emotions, and spirit. Using cognitive-behavioral techniques to help a patient not focus on her nose or on his thinning hair is fine, but it doesn’t bring him or her closer to self-acceptance and self-love. We believe deeper work is needed. We want to support patients in developing a sense of their integrated selves … into complete beings who can have pleasure and enjoy a vital, robust life in every dimension.”

Noting BDD’s maelstrom of body identification-preoccupation/image distortion that “cycles and swirls” until it leads to rejection of body, mind, and spirit, Cmarada believes a deepening of awareness and compassion can give rise to inner peace and happiness. “With awareness,” he explains, “we see things as they truly are. With compassion, we open our hearts to them and accept them.”

Yoga, he says, helps people develop a different kind of relationship with the body. While typical exercise programs such as aerobics or weightlifting tend to focus on physical manifestations, “yoga teaches a sensitive awareness and bodily experience within which the mind can rest. It also introduces a sense of pleasure coming from the body, rather than self-hate.

“Meditation,” Cmarada says, “also calms the mind and body. It helps us find that locus of control again and shows that we have some capacity to determine where our consciousness is focused.”

Promoting a disciplined mind, compassionate heart, and healthy new relationship with the body, he says, helps patients move toward becoming a “whole and functional human being.”

— MR