Mirror, Mirror on the Wall, What do I Look Like After All?

Everyone has insecurities about their appearance; I know I do. But what separates body dysmorphic disorder (BDD) from a more commonly experienced negative body image is that the former is an obsessive pathological disorder (Discovery Mood & Anxiety Program, n.d.). Try and imagine this: you believe your nose is wonky and completely lopsided. In reality, it’s only slightly crooked and people have assured you constantly that it isn’t something easily noticeable unless you mention it, but you know they are lying. Most days your nose is all that you can think about: in class, at the supermarket, while you’re cleaning. When you’re having a conversation with someone, you’re constantly preoccupied with the thought that the other person is thinking about your nose and how ugly you look as a result of it. You truly believe they’re going to go tell all their friends after you leave. Everytime you look at yourself in the mirror all you see staring back is a deformed monster. Yet, you can’t seem to stay away from reflective surfaces. You walk on the street and have an uncontrollable urge to catch a glimpse of your face on every window you pass, both cars and shops. In fact, just the other day you were all ready to leave for a party but on your way out you ran back in to look at yourself one last time. The next thing you know you had spent 45 minutes obsessing over your nose by holding it in different positions, and you realized that if you saw yourself like this everyone definitely does too. You ended up not going to the party…

This is how someone with BDD feels every single day. You might be thinking how exhausting this must be, and it is. The DSM-V classifies BDD under “Obsessive-Compulsive and Related Disorders” and requires individuals to be preoccupied for at least an hour daily with one or more nonexistent/slight flaws in their physical appearance and to perform repetitive behaviours regarding these flaws. The behaviours can range from mirror checking to picking their skin to seeking constant reassurance from others. Furthermore, clinical significance of the preoccupation (it should cause distress or impairment in day to day functioning) must be established in order to differentiate BDD from more ‘normal’ concerns about appearance (Phillips, n.d.). Features that individuals with BDD commonly fixate on are their face (nose, wrinkles, acne), hair (thinning, balding), veins, size of their breasts, and muscles (Mayo Clinic, n.d.). Muscle fixation is a form of BDD known as muscle dysmorphia, mostly affecting men (Olivardia et al., n.d.). It’s understandable why BDD usually begins in adolescence as it’s a period of development in someone’s life that is typically associated with a lot of physical and hormonal change. BDD doesn’t discriminate between men (40%) and women (60%), race, ethnicity, or socioeconomic class (Phillips, n.d.). While the exact causes are unknown, research has predominantly proposed developmental and cultural factors as potential reasons for its development (Feusner et al., 2010). 

Bullying and childhood abuse are two developmental factors that explain the obsession about one’s appearance due to the negative self-image and self-esteem that both these experiences can cause for the affected individual (Mind, n.d.). Studies have shown support for the notion that patients with BDD report being bullied more often than healthy controls (Buhlmann et al., 2007; Neziroglu et al., 2019). This makes sense, because when someone teases you they make you starkly self-conscious about who you are. Maybe you can recall an uncalled for comment from someone that stuck with you longer than you wanted it to. For individuals with BDD, such comments can manifest into ruminations that distort their self-view, allowing for a negative association to be formed between the physical feature and others’ reaction to it. This then conditions them to be particularly sensitive about that feature. 

Similarly, studies have shown support for the notion that patients with BDD report experiencing childhood abuse more often than healthy controls (Buhlmann et al., 2012; Didie et al., 2006; Neziroglu et al., 2006). The link between childhood abuse and being more at risk for developing a mental health disorder later in life is not a new one (Lippard & Nemeroff, 2020), but there is anecdotal evidence regarding how it connects to BDD. It has been theorized that childhood abuse not only affects the child during that period, but the lasting wounds emerge in unexpected ways later on in their life. The victimization of a child, especially through a trusted caregiver, teaches the child a wrong and destructive message about their self-worth and value which they internalize. Internalization of the abuse then morphs into guilt about their existence and can lead to self loathing, which can ultimately cause this distorted body image (Crossroads Health, 2021; Khiron Clinics, 2021). Of course, individuals can experience bullying and/or abuse and not develop BDD. For instance, personality factors like perfectionism and aesthetic sensitivity have been identified as vulnerability factors that might make individuals more susceptible (Krebs et al., 2019; Lambrou et al., 2011).

In a world where body types and particular physical features have become trends or ideals, it’s not surprising that cultural factors can also play a role in the progression of BDD. The specific portrayal of bodies in the media can fuel dissatisfaction within an individual, especially if they do not recognize themselves in what is being broadcasted. Stangier et al. (2008) conducted a study asking 21 female patients with BDD, 19 patients with disfiguring dermatological conditions, and 20 patients with non disfiguring dermatological conditions to rate the degree of distortion of faces in which a feature like the nose had been changed. Results demonstrated that the patients with BDD were significantly more accurate at detecting minor deviations from beauty standards in the faces presented compared to the other two groups. This is a result of focus on detail processing rather than global processing when viewing others, which is also highlighted in mirror gazing behaviour of BDD patients when they tend to obsess over minor flaws while ignoring their own appearance from a global aspect (Feusner et al., 2010). 

However, there is evidence that different minority groups react to mainstream beauty ideals (that are typically not common within their own community) in different ways, showing that it’s not simple enough to assume that dissatisfaction will arise if individuals do not recognize themselves in what is being broadcasted. Research (Evans & McConnell, 2003) showed that when Asian-American, African-American, and American participants were exposed to mainstream beauty ideals like thinness and Eurocentric features, the African-American participants reported the highest rates of self-esteem and body satisfaction after viewing photos of the models. The administered conformity reports suggested that the African-American participants had the lowest reported need for conformity as a result of focusing on ingroup ideals, protecting them from societal norms. On the other hand, the Asian-American and American participants reported similar very low levels of self-esteem and body satisfaction after viewing photos of the models. The Asian-American participants had the highest reported need for conformity presumably as a result of focusing on outgroup standards and therefore might have internalized the Western beauty norms more (Limpe, n.d.).

Patients with BDD commonly seek out cosmetic treatment in order to fix their flaws because of the perception that this will resolve their appearance concerns. However, only less than 10% of patients with BDD feel satisfied (Priory, n.d.) and in most cases it can be counterproductive. Suicide idealation for individuals with BDD is as high as 80% (Phillips, 2007) and following cosmetic procedures patients can become depressed when they don’t see an improvement in their symptoms or they believe the treatment has made their appearance worse. If you grew up watching Modern Family like me then without a doubt you remember Dylan Marshall, the on-and-off dim but caring boyfriend of Haley Dunphy. Dylan’s character was played by Reid Ewing, an actor who has publicly revealed his struggles with BDD via a self-written letter for Huffington Post. He specifically recounts his numerous attempts at cosmetic surgery, and I recommend reading it to get a first-hand account of why therapy rather than cosmetic treatment is recommended for BDD. Cognitive Behavioural Therapy (CBT) has received attention for its effectiveness in helping patients manage their symptoms of BDD because it helps reduce anxiety surrounding their body by changing their attitude towards body image while also giving them a space to explore their worries about their flaws (Mind, n.d.). 

Last year when I was having a particularly rough time with being kind to myself, my sister said something that really stuck with me: “Your appearance is literally the least interesting thing about you.” There’s a world of truth in that sentence; your opinions, values, passions, feelings, confidence, and kindness are not only what others notice most about you but are also longer lasting. I hope this sentence gives you solace on the harder days too. <<

If you or someone you know is struggling with BDD please know that help is available. The Body Dysmorphic Disorder Foundation’s website contains different supportive resources (check them out at https://bddfoundation.org/support/ or type “BDDF” in Google).