Mirror, Mirror on the Wall – Body Dysmorphic Disorder

I actually started writing this with every intention of doing a Sunday post, but wouldn’t you know, I got distracted and ended up doing something entirely different. So here it is for Monday.  Since this is something that is constantly on my mind and has been the subject of my latest therapy session; let’s talk about Body Dysmorphic Disorder. I’ve talked about dysmorphia before but not about the extent of the disorder.

So what is it?

Body Dysmorphic Disorder (BDD) is a kind of mental illness or somatoform disorder where a person is exclusively concerned with their body image. It manifests as excessive concern and preoccupation with a perceived defect of one or many physical features; or even vaguegly complains about appearance in general to the point where it causes psychological distress that (and this is important) impairs either occupational or social functioning, or both.

Snow White had it easy.
I’m going to reiterate this because as something that I’ve noticed a lot with self-diagnosing … you can run through the checklist of criteria for any disorder and say ‘yes’, ‘yes’, ‘no’, ‘yes’, ‘yes’ to any number of qualifications and on the surface it may look like you’re a good candidate for the illness or disorder, BUT, and this is a big ‘but’, if the problems do not create a SIGNIFICANT problem of functionality in some form of your life for an EXTENDED period of time, you may not actually have the disorder or illness, just passing symptoms of it that may be something else entirely. Being generally self-consciousness does not mean you have Body Dysmorphic Disorder. Being a cutter with mood swings does not make you Borderline (Yeah, I’m looking at all the pre-teen emo attention whores out there).

For years, starting in middle school, high school, and college… I could not go out in public. I could not do anything in a crowd of people. I would lock myself away in my room, wear baggy clothes (fortunately skater goth was a look that worked with my sense of style), and refuse to see anyone because the thought of anyone looking at me, seeing the “flaws” that I perceived induced a paralyzing anxiety. And I do mean panic attack, hyperventilating, dissolving into a puddle of self loathing kind of social anxiety. I could make myself go to work and school, but I would bundle myself up in shapeless clothes, avoid any kind of social contact, and steal myself away as soon as it was done.

BDD can occur to a degree that causes severe emotional depression and anxiety, and even may lead to the development of other anxiety disorders, social withdrawal, or social isolation. It sucks.

I remember having plans for events that I’d been looking forward to for months. For weeks I’d be even more strict about my diet and exercise so I would feel in control enough of my body to go out and enjoy myself. I would get all dolled up and decked out. Then an  hour before I was suppose to leave I would freeze. Literally on the threshold of my house, incapable of moving another foot out of the door because the thought of going out in public where people could see me felt like the world would come crashing down around me. I’d cancel my plans at the last minute, disappoint my friends, disappoint myself, strip off all the pomp and fancy and hide in bed for the rest of the night.

Like many mental disorders it’s caused by a variety of different things and is different for each person; biological, psychological, and environmental factors can all contribute. Maybe you’re predisposed to this kind of mentality, have suffered mental or physical abuse, or emotional neglect can be the cause. As you’d probably suspect, dysmorphic symptoms usually begin in adolescence or early adulthood when it’s common for self-criticism of a persons appearance to begin. From here it goes further than just criticism to an atypical aesthetic standard created from some internal perception of beauty or perfection between the persons ‘actual self’ and the ‘idea self’. What a person actually sees versus what you want to see.

However, what a person actually sees may be entirely different from what actually is.

According to the DSM patients are so overly concerned, or convinced, that they are misshapen or deformed in some way, despite all evidence to the contrary. Patients are generally concerned about some aspect of their appearance or with the possibility that they have some deformity. The specific “deformity” depends completely on the person. Maybe their facial or scalp hair is not right, maybe their nose is too big, their breasts are uneven, or their eyes are too far apart. Seeking help is actually common, but not by a psychiatrist. Because the person is so convinced that this is a legitimate problem they’ll go to their primary physician, dermatologist or even eventually to a cosmetic plastic surgeon. After being examined the physician usually finds no abnormality at all, or if one is present, it’s so trivial that no one would ever notice it. Reassurance does nothing though.

“Only a small minority recognize the groundlessness of their concerns; the vast majority are more or less convinced, and in a significant proportion the conviction becomes a delusion. Patients are often in torment over their “defect,” and the majority repeatedly check themselves in mirrors: in some cases such “mirror-checkers” may be so distressed by what they see that they may avoid mirrors, or cover them up. Most patients avoid contact with others, and a minority become housebound; ideas or delusions of reference may appear.”

I’m a mirror checker. Oddly I often avoid looking at my face, but I constantly check other aspects of my body that I perceive as out of proportion or that need to be hid. Constantly. It’s a compulsion. With me it’s my upper arms, thighs, and jaw. I have a very specific idea of what I need to look like and any deviation from this is a monstrosity.

Therapist has commented on more than one occasion that I have a beautiful figure and that my clothes are very professional and flattering (I go to session straight from work). I’m a master of disguise. A chameleon. I know exactly what I need to do to hide my flaws, create the illusion that they aren’t there, and appear in a way that is acceptable to the environment that I am forced to interact in. I wear a very specific cut of pant, I wear tailored jackets that emphasize other features and draw the eye to other areas like my tiny waist. It’s all a matter of tricking the eye of the beholder into seeing what I want them to see. This is often how I manage my Borderline issues as well. I draw the eye to positive attributes that I want people to focus on and gloss over the areas that I need to keep in shadow.

When I was younger my dad used to accuse me of vanity. He would see me looking in the mirror and say something like ‘you’re beautiful, quit checking yourself out’. Sort of a compliment I suppose, but he never understood. It’s not vanity. It has nothing to do with being vain. I hated how I looked. I NEED to see what other people see though. I need to be prepared for how others will look at me. What they will see with their own eyes. I needed to make sure that I was taking care to only show them what I wanted them to see. I needed to make sure I was perfect so there would be nothing to criticize.

“People with BDD say that they wish that they could change or improve some aspect of their physical appearance even though they may generally be of normal or even highly attractive appearance. Body dysmorphic disorder causes sufferers to believe that they are so unspeakably hideous that they are unable to interact with others or function normally for fear of ridicule and humiliation about their appearance. This can cause those with this disorder to begin to seclude themselves or have trouble in social situations. More extreme cases may cause a person to develop love-shyness, a chronic avoidance of all intimate relationships. They can become secretive and reluctant to seek help because they fear that seeking help will force them to confront their insecurity. They feel too embarrassed and unwilling to accept hat others will tell the sufferer that he or she is suffering from a disorder. The sufferer believes that fixing the “deformity” is the only goal, and that if there is a disorder, it was caused by the deformity.” (Thanks, Wiki.)

This is certainly how I think. If I could just fix these 3 things, everything would be perfect. If this was just a little more streamlined, if that was just a little more toned, if that was just a little more concave, I could be the marble statue I’ve always wanted to be. Roommate doesn’t believe this. She thinks that even if these things were “fixed” then my focus would just shift to something else.

Last session Therapist asked me to name 5 words that described how I view myself. 1) Ugly, 2) fat, 3) uncomfortable. I couldn’t’ actually think of two other words. I’m 30 years old, though I look like I’m 22. I’m 5’3”. I have a 24.5” waist. I’m athletic. In college I would be stopped on the streets by modeling recruiters. Professional photographers routinely seek me out at the many costuming events I attend to post for them. No, I’m not bragging. But since I’m maintaining a relative anonymity and won’t post my pictures on this blog I’m relaying my experiences to give you an idea of the massive discrepancy of what I see and what others do. Therapist looked like I broke her heart when I told her those words. I just don’t understand how others can see me and see someone that is attractive.

Another important thing to note is my weight obsession. Body Dysmorphic Disorder and Eating Disorders are not interchangeable. In fact, a preoccupation with weight and the development of eating disorders is something that is specifically taken into consideration in diagnosis. If a persons symptoms are better accounted for by another disorder: weight concerns are usually more accurately attributed to eating disorders: then BDD may not be the problem.

My eating disorder is incredibly psychologically complicated. In regards to BDD it’s almost opposite. I developed this disorder as part of my attempt to control my flaws. But there are many other facets to it as well; like my need for structure and control, as an attempt to fill the void of loneliness that I can’t otherwise fill at the moment, etc. So I’m one of those with both.

In fact, co-morbidity is common with BDD.

         76% will experience major depressive disorder at some point
         36% may develop agoraphobia
         32% are affected by obsessive-compulsive disorder
         But the most common disorders found are Avoidant Personality Disorder, Social Phobia, Social Anxiety Disorder, and Dependent Personality Disorder
         Eating disorders are also sometimes found in people with BDD.
I’m curious about the Avoidant and Dependent Personality Disorders. It makes me wonder if there isn’t a higher ratio of Borderline Personality Disorder with Body Dysmorphic Disorder as well.
Here’s the part where I list the symptoms and expressions and see just how neurotic I am!


Common symptoms of BDD include:

         Obsessive thoughts about (a) perceived appearance defect(s). <~~~~ And how.
         Obsessive and compulsive behaviors related to (a) perceived appearance defect(s) (see section below). <~~~~ I can  hardly wait
         Major depressive disorder symptoms. <~~~~ Gee, let’s think…. Yeeeaaah.
         Delusional thoughts and beliefs related to (a) perceived appearance defect(s). <~~~~ So I’m told, of course it could just be that everyone else is wrong.
         Social and family withdrawal, social phobia, loneliness and self-imposed social isolation. <~~~ Years, and years of this. Though admittedly I’m working hard despite my ridiculous anxiety to push through this, it is still always in the background of my mind bullying the happy thoughts off the playground.
         Suicidal ideation. <~~~~ Been there, done that.
         Anxiety; possible panic attacks. <~~~~ Possible? Can you say understatement?
         Chronic low self-esteem. <~~~~ Not that I’d let anyone see this.
         Feeling self-conscious in social environments; thinking that others notice and mock their perceived defect(s). <~~~~ I wish I could be social without people looking at me.
         Strong feelings of shame. <~~~~ I just want to be perfect.
         Avoidant personality: avoiding leaving the home, or only leaving the home at certain times, for example, at night. <~~~~ When it’s harder to see me.
         Dependent personality: dependence on others, such as a partner, friend or family.
         Inability to work or an inability to focus at work due to preoccupation with appearance.
         Problems initiating and maintaining relationships (both intimate relationships and friendships). <~~~~ It’s hard to be close to someone when you don’t want them to look at you.
         Alcohol and/or drug abuse (often an attempt to self-medicate). <~~~~ You can’t worry when you’re passed out.
         Repetitive behavior (such as constantly (and heavily) applying make-up; regularly checking appearance in mirrors; see section below for more associated behavior). <~~~~ Mirror mirror on the wall ::SMASH::
         Seeing slightly varying image of self upon each instance of observing a mirror or reflective surface. <~~~~ This is maddening.
         Perfectionism (undergoing cosmetic surgery and behaviors such as excessive moisturizing and exercising with the aim to achieve an ideal body type and reduce anxiety). <~~~~ I just want to be perfect, and redundant.
Note: any kind of body modification may change one’s appearance. There are many types of body modification that do not include surgery/cosmetic surgery. Body modification (or related behavior) may seem compulsive, repetitive, or focused on one or more areas or features that the individual perceives to be defective.

Compulsive behaviors

Common compulsive behaviors associated with BDD include:
         Compulsive mirror checking, glancing in reflective doors, windows and other reflective surfaces. <~~~~ Vanity is its own problem, but has nothing to do with this.
         Alternatively, an inability to look at one’s own reflection or photographs of oneself; also, the removal of mirrors from the home. <~~~~ We literally have a hall of mirrors.
         Attempting to camouflage the imagined defect: for example, using cosmetic camouflage, wearing baggy clothing, maintaining specific body posture or wearing hats. <~~~~ It’s really not that hard.
         Use of distraction techniques: an attempt to divert attention away from the person’s perceived defect, e.g. wearing extravagant clothing or excessive jewelry. <~~~~ You can see what I want you to see.
         Excessive grooming behaviors: skin-picking, combing hair, plucking eyebrows, shaving, etc.
         Compulsive skin-touching, especially to measure or feel the perceived defect. <~~~~ Hey, maybe I just like how my jaw feels.
         Becoming hostile toward people for no known reason, especially those of the opposite sex, or same sex if homosexual. <~~~~ In my defense, my hostility towards other people is usually because they’re dicks. And I’m irrationally angry.
         Seeking reassurance from loved ones. <~~~~ If I sought reassurance they’d know there was something wrong.
         Excessive dieting or exercising, working on outside appearance. <~~~~ 6 days a week, 15 hours in the gym, constantly monitoring everything I eat… Excessive? Nah.
         Self-harm <~~~~ I like to think of it as keeping myself on track.
         Comparing appearance/body parts with that/those of others, or obsessive viewing of favorite celebrities or models whom the person suffering from BDD wishes to resemble. <~~~~ Who doesn’t compare themselves to others.
         Compulsive information-seeking: reading books, newspaper articles and websites that relate to the person’s perceived defect, e.g. hair lossor being overweight. <~~~~ Maybe I just like to be in the know.
         Obsession with plastic surgery or dermatological procedures, often with little satisfactory results (in the perception of the patient).
         In extreme cases, patients have attempted to perform plastic surgery on themselves, including liposuction and various implants with disastrous results. <~~~~ Holy crap, if I ever get this bad I’ll just have myself locked up.
         Excessive enema use (if obesity is the concern). <~~~~ Um, Ew. Just, ew.

Now I certainly recognize a lot of these symptoms in myself but I don’t know if I attribute them all to BDD. Some of clearly a byproduct of my Borderline Personality Disorder or aspects of other problems I have. Where’s the line though? Often these things overlap and collide like a maelstrom of emotional turmoil.

Surprisingly in my research I found that this actually affects men and women equally. It sounds like it would be another ‘female problem’, but apparently not. As many as 1-2% of the world’s population might even meet the diagnostic criteria for a diagnosis of BDD.

My final thought: Not just in physical appearance but in every aspect, I’m obsessed with how people perceive me. Not because I have some need to be complimented or anything like that. But I need to know how others see me, what they think, so I can gauge how different it is from how I think of myself.