A while back, singer-actress Miley Cyrus, in a soul-baring interview, made a casual reference to the term ‘body dysmorphia’. The Internet erupted as the interview created a lot of social media buzz. It brought into focus a much-poorer cousin of the infamous eating disorders — Body Dysmorphic Disorder (BDD). Though, at first much of this may sound like describing a person who is vane, but the problem lies much deeper – and it’s one that needs to be addressed.
So, what is body dysmorphic disorder and why should you care?
BDD Foundation describes body dysmorphic disorder as ‘a disabling preoccupation with perceived defects or flaws in appearance’. Don’t dismiss it as a pathetic case of vanity just yet. Dr Bhavna Barmi, clinical psychologist at Fortis Escorts Heart Hospital, New Delhi, explains, “It is a kind of somatoform disorder in psychiatry — usually the person has symptoms of a medical illness or a medical disorder, but the symptoms cannot be fully explained as actual physical disorders. It is basically an exaggeration in the mind of a small defect that a person has.” Common obsessions tend to be facial features — such as the nose, eyes, hair, chin, skin or lips — or particular areas of the body — such as the breasts or genitals, apart from general preoccupation with being too fat or skinny. Giving an example, Dr Barmi says, “I might feel that there is a mole — in actuality a small mole on my cheek — but I have exaggerated it and I have perceived it as a very big defect. I think that those who are seeing me are seeing such a big, black blotch on my face and I must be looking really ugly with it.”
“May be the defect can be ignored, but the person puts too much emphasis on it. It can start by just being a mild concern of body image or a body part. What is important is that it is causing clinically significant distress. So, that means the preoccupation with the imagined defect and the distress or the stress or the depression that it causes is of clinical significance — to the extent that sometimes it also reduces the social and occupational functioning.”
What does potentially distressing preoccupation with appearance look like? Dr Barmi cites a case, “I have a case in which the person came to me saying that, ‘my nose is completely deformed — completely deformed. Because my nose is deformed, I am not going to go to college now because people make fun of me. I will not go to social gatherings. I think my family also makes fun of me now, so I’m not very happy on the family front’. Then, in her house, she started becoming very very aloof. She started removing all the mirrors from the house. Her parents eventually took her for plastic surgery. She came back and again she looked into the mirror and found another small defect. She went back to the cosmetic surgeon to confront him, and even went to the extent of filing a lawsuit against that doctor.
“By that time, her social functioning, her academic functioning had completely gone. She was having comorbid (when someone has an additional disorder co-existing with another) depressive symptomology. Her self-esteem had gone down — she felt nobody understood her, that people were against her, she felt very humiliated, she didn’t have a constructive lifestyle and started putting on weight as a consequence. So, the whole scenario started moving around in a vicious cycle to make her even more confident that this nose of hers has caused her a lot of trouble in life. It can go to that extent.”
The hallmark feature of critical self-talk in BDD occurs at a compulsive level, and the sufferer is often unable to switch off the mind chatter. Seaneen Molloy, in her blog called The Secret Life of a Manic Depressive, says, “I have always had partners who were gentle, loving, complimentary and adoring and who did not put me down and treated me as equal. How I wish I could listen to their real, REAL voices, and not the one in my head which is catcalling me, “your nose is too fat. Your face is bloated. Your nose nose nose nose nose, break your nose, get a new nose…”
In fact, BDD shares comorbidity with a lot of mental disorders. “The comorbidity that body dysmorphic disorder has can be with Obsessive Compulsive Disorder (OCD) — when the preoccupation becomes obsessive and we start doing compulsive rituals. It can become comorbid with intense anxieties or phobias. It can also be correlated with eating disorders,” Dr Barmi explains. In fact, it is estimated that up to 30 per cent of patients diagnosed with some form of eating disorder have BDD as well.
BDD becomes apparent only after it has reached a diagnosable state, by which time a lot of damage has already occurred. “I do accept now that I have body dysmorphic disorder, which, although I had been diagnosed with, I had denied because I was ‘that ugly’,” Molloy explains. How does one recognise the warning signs of BDD, before it snowballs into something so impairing? Dr Barmi says, “Some of the indicators are that one, there is some kind of a mirror checking that increases in our lives. For example, we keep glancing at our reflection, we’ll keep seeing windows and other reflective surfaces to see whether our body image or body part is fine or not. We sometimes even start removing mirrors from our house. We start opening albums and taking out our photographs from those albums — because we don’t want to see ourselves.
“Two, we start camouflaging the imagined defect — by using cosmetic camouflage, or if it’s about the weight we start wearing baggy clothes so the abdomen is not seen. We start maintaining some specific body postures, or we start wearing hats — things which are going to camouflage it. Another thing could be we start diverting our attention from the body part. We suddenly start wearing beautiful and extravagant clothes, we start wearing chunky jewellery to divert our attention from it.”
Luckily, there’s hope. Medical literature says BDD is a ‘highly treatable’ condition. Cognitive Behavioural Therapy (CBT) and Neurolinguistic Programming (NLP) are two approaches Dr Barmi adopts to treat patients with BDD. Resistance to treatment is high, as Dr Barmi explains, “There is stigma about treatment in any case. People feel that taking psychiatric treatment is stigmatic. Secondly, If I’m going through some body image, it is very personal to me. I want to just keep it very very private within me. So, I don’t like to go and share it with other people, because it further reduces my self-esteem.”
Dr Barmi says spreading awareness is extremely important. She suggests, “Teachers should be sensitised, parents should be sensitised, and of course the students need to be made aware. The awareness rates can also go further if the doctors are primed towards it. For example, if a patient is coming again and again to a cosmetic surgeon he should have some concern. Rather than operating or conducting surgery on that person, they should also make the person aware that there may be some kind of body dysmoprphia that they may be going through — that it’s not any cosmetic surgery, but mental health support that you need. They (cosmetic surgeons) don’t focus on it as a psychiatric disorder. The awareness needs to be higher even in the medical fraternity of other associated (disciplines).”