Organized Chaos - Volume 7
Gosh I Dislike the Way I Look
by Fugen Neziroglu, Ph.D. and Alicia Slavis, Ph.D.
Bio-Behavioral Institute, Great Neck, NY 11021
Sarah[1] is a 15-year-old who was teased about her skinny legs and freckles as a young child. As a youngster, she had been hurt but never showed it; and everyone thought she had forgotten about it. At 15 she looks at the mirror constantly to check out her face and legs. She cannot stop thinking about how she would look with "smooth skin." Sarah cannot stand her appearance and is constantly comparing herself to other girls in school.
She wants to have the face of Danielle who sits next to her in math class. She has asked her mother for dermabrasion for a birthday gift; and although her parents are against it and do not think she needs it, they are thinking of agreeing to it. They will do anything to have her stop obsessing about her complexion. They have already been to several dermatologists and Sarah has used various creams; but Sarah is till very dissatisfied with her appearance. She spends way too much time mirror checking and asking for reassurance from her parents about her face.
Sarah is preoccupied with her legs as well but not to the same degree. She seems better able to camouflage her legs by wearing baggy sweat pants. The other day she was unable to wear a dress that she loved because she could not stand her legs (they do not seem skinny to anyone else). Often Sarah is late to school because she cannot find something that she feels comfortable in and it takes her a long time putting on foundation and cover-ups and getting her face to look just right.
Lenny[1] at age 13 had a few pimples and for the past 8 months he has been upset over pimples, bumps on the face and its redness. He doesn't like to go to gym because he may turn red which would make him look ugly and/or he may develop pimples from sweating. It started with gym. But then, as the weather got hot and there was no air conditioning in the school, he refused to go.
He was too embarrassed to tell his parents what was bothering him so he made up headaches, stomachaches and never seemed to feel quite right. He started avoiding friends and would make up excuses when they called or came by. Initially, he was going out at night but then that became too difficult as well. He complained to his parents about the pimples. Because he was "a typical teenager" who wanted to be liked by everyone, they thought nothing of it and took him from one dermatologist to the next. Lenny was told what products to use and given instructions on how to keep his skin in beautiful condition. Unbeknownst to the dermatologist and his parents, these precise, compulsive instructions made Lenny worse and eventually he stopped seeing his friends and did not return to school.
Lorie[1] at age 11 became obsessed with her thin lips. She heard her mother talking to her aunt about someone who looked awful with those "thin lips" and from that day on she could not stop looking at her own lips. She tried pulling on her lips, wore lipstick, gloss and, in fact, tried keeping her mouth in a particular way to make her lips look fuller. Actually she tried to concentrate and have her lower lip turned downwards. When that became too difficult and she did not get the results she wanted, she just hid her lips with her hand. Lorie, even at such a young age, would carry a mirror with her and keep checking her lips. She asked her mother if she could go for the type of surgery that she read about in "People" magazine. At first her mother did not know what she was talking about; but she then realized that Lorie was really distraught over her appearance. Lorie could think of nothing else but her lips. She no longer wanted to talk on the phone to her friends or have them come over. She kept comparing herself to people on TV, in magazines, and to her friends. This made her more and more depressed.
What do all of these teens have in common? Although they may seem different on the surface, Sarah, Lenny and Lorie all have Body Dysmorphic Disorder, also known as BDD.
Being concerned with one's appearance is extremely common. Many of us dedicate a lot of effort to look a certain way, whether it's spending time at the gym, buying new clothes, or styling our hair. Furthermore, most of us would admit to disliking or wanting to improve some aspect of how we look. This is especially true during adolescence, particularly early adolescence. So what distinguishes this universal concern with one's outward appearance from a diagnosis of BDD?
Body image, like many things, can be thought of as falling along a continuum. It is the intensity, duration, and frequency of one's dissatisfaction with one's appearance and the anxiety, stress, and impairment in personal, social, and occupational functioning, which it causes, that distinguishes BDD from normal concerns about appearance. According to the DSM IV, to receive a diagnosis of Body Dysmorphic Disorder the following criteria must be met:
- Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person's concern is markedly excessive.
- The preoccupation causes clinically significant distress or impairment in functioning.
- The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in anorexia nervosa).
As the definition states, people with BDD experience more concern about their appearance than their contemporaries do. They don't just experience an isolated thought about how they look; they actually obsess about their appearance. They think obsessively about a slight or imagined physical flaw. BDD comes in many forms and varies from one person to the next. The most commonly affected areas of the body are facial features, including wrinkles, scars, acne, redness, paleness, excessive facial hair, size, shape, or asymmetry of any facial features. Other body parts affected are the genitals, breasts, buttocks, abdomen, hands/feet, and shoulders/back. Although, almost any body part could be the source of excessive preoccupation.
The severity of BDD also falls along a continuum. Some with milder BDD can live relatively normal lives, while severe cases of BDD can be life-threatening. The preoccupation with a flaw can lead to behaviors, such as, frequently checking oneself in the mirror, seeking reassurance from others about one's appearance, avoidance of usual activities, camouflaging, skin picking, and even cosmetic surgery. BDD often occurs with Obsessive Compulsive Disorder, Depression, and Social Anxiety.
So where can you turn for help for BDD? Current treatments for BDD include psychopharmacological treatment, exposure and response prevention, cognitive therapy, support groups, and family intervention.
Exposure and response prevention is a form of cognitive-behavioral therapy that has been found to be very useful with BDD. It is the same form of therapy proven effective with OCD. Exposure refers to exposing one's defect in feared or avoided situations. This begins with the creation of a hierarchy of feared situations. Common distressing situations for those with BDD often involve mirrors, shopping for clothes, crowded situations with little personal space, and bright lighting. In conducting exposure exercises, a sufferer gradually exposes him/herself to the area of concern, working from situations that cause low distress up to those causing a lot of anxiety. Use of make-up, clothes, etc. to highlight or exaggerate a defect paired with gradual exposure is another step to this treatment. The idea behind this is that with enough exposure, the anxiety that you experience in a situation will diminish gradually. The second piece of response prevention refers to not performing compulsive behaviors. So, for example, if the compulsive behavior involves checking mirrors, a person with BDD may initially be asked to cover up all mirrors in his/her home.
Cognitive therapy teaches people to change their thoughts and thereby their feelings in a given situation. It is used to address faulty beliefs that one has regarding his/her appearance. Examples of distortions that may be seen in those with BDD include: "I need to be perfect," "If I looked better, my whole life would be better," and "If my appearance is defective, then I am inadequate and worthless." Cognitive therapy also shows promise in lessening strong beliefs about one's fears known as overvalued ideation. Targeting the value placed on appearance may also be an important step in preventing relapse.
Family involvement may be another step in treatment. When families are educated about BDD, they can be brought in to provide coaching for ERP exercises. Helping family members to reduce the frequency of giving reassurance or to change their accommodating styles can also be very helpful.
1 The names of patients in this article have been changed to protect their privacy.
