The problem started with the mirror.
As I was doing my hair one morning before work, I studied my face in the mirror. Something just looked… wrong. I moved my head closer, swiveled from side to side, and was immediately flooded with alarm. The face that stared back at me looked crooked and malformed in a way I’d never noticed. I ran to another mirror in the house, hoping for a different result, but to no avail: no matter where I looked, the same thing. Overwhelmed with anxiety, I checked and re-checked my face for six hours. Engulfed in a desperate need to fix the problem, I started making calls to plastic surgeons.
Six months later, emerging from surgery for a chin implant and rhinoplasty, I was more devastated than ever. I hated the results, and immediately wanted the implant removed. I was having debilitating panic attacks accompanied by around-the-clock obsessing. I struggled to go to work and take care of my young daughter. I was in deep psychological pain, but had no insight into what was happening.
The plastic surgeon told me I needed to give it more time — that it could take months to see the actual results, but I didn’t know how I’d make it through the day, much less the unforeseeable future. Neither of us had any insight into the real issue.
I desperately wanted to ask my parents for help, but I’d kept the surgery a secret from everyone, including them. I didn’t want them to worry or to question me about the loan I’d taken out for the surgery — which we both knew I couldn’t afford to pay back. I was ashamed and didn’t want to draw additional attention to my new appearance.
Then came the night of my parents’ anniversary, where our family gathered at their favorite restaurant for a celebration. Halfway through the evening, as the table was bursting with laughter and conversation, I struggled to share in the revelry; rather, I felt anxious and terrified. My mother noticed and shot me a concerned look. “I need to go to the hospital,” I whispered.
Soon, I found myself in the emergency room, and then, a day later, in the office of a psychiatrist. I listened as he diagnosed me with a mental illness I had never heard of: body dysmorphic disorder.
“He constantly peers in the mirror, feels his forehead, measures the length of his nose, examines the tiniest defects in his skin, or measures the proportions of his trunk and the straightness of his limbs.”
As defined in the DSM-V, the so-called bible of psychiatric diagnosis, body dysmorphic disorder (BDD) is classified as an obsessive-compulsive disorder involving a preoccupation with one or more perceived defects or flaws in physical appearance that are not observable to others; or, if they are, they appear inconsequential. The preoccupation causes significant distress or impairment in social, occupational, or other areas of functioning. Untreated, BDD can lead to devasting effects, including major depression and suicidal ideation.
The condition was first coined by Italian psychiatrist Enrico Morselli in 1891, when he described his patient’s excessive worry over imagined defects as “dysmorphophobia” — a Greek word meaning misshapenness. In a paper published by Morselli, he wrote, “The condition consists of the sudden appearance and fixation in the consciousness of the idea of one’s own deformity.” He reported the typical behavior of one of his patients: “He constantly peers in the mirror, feels his forehead, measures the length of his nose, examines the tiniest defects in his skin, or measures the proportions of his trunk and the straightness of his limbs.”
Later, Sigmund Freud and American psychologist Ruth Mack Brunswick treated patient Sergei Pankejeff, also known as the “Wolf Man” after a childhood dream he had in which he was confronted by wolves. Pankejeff was obsessed with his nose, which he believed was deformed. According to Brunswick, Pankejeff “neglected his daily life and work because he was so engrossed, to the exclusion of all else, in the state of his nose.”
Now, we live in a world in which images of strangers’ and celebrities’ bodies flicker constantly across our social media feeds, inviting critique and mockery, self-absorption and obsession over minutiae. Social media’s celebration of the self has spawned an industry around body- and face-altering filter, some with algorithms so subtle that they appear real and thus leave viewers feeling inadequate in comparison.
An estimated 3.6 billion people use social media, meaning that it has a concomitant social effect on about half of the human population — including how we view ourselves. Continuous exposure to unrealistic images through various interfaces has a significant effect on body image. Cosmetic surgeons often see the results of this in their practices, such as when patient bring in highly-edited images of themselves and ask for surgery to make them look more like the photos.
Plastic surgeons are trained to change appearance, but for the BDD patient, that change might not match what they see when they look in the mirror.
Patrick Byrne, the Director of Facial Plastic and Reconstructive Surgery at John Hopkins University School of Medicine told USA Today his patients are requesting “absurd and unrealistic” body alterations based on images altered by Snapchat filters.
Plastic surgeons are trained to change appearance, but for the BDD patient, that change might not match what they see when they look in the mirror. As a result, plastic surgeons and other cosmetic professionals should be aware of body image issues and take special care to talk with their patients prior to performing any body altering procedures.
Mathew Schulman, a plastic surgeon in New York, says that filters are having a trickle-down effect on the plastic surgery industry. “Patients have been coming in with Snapchat filtered selfies to show what they want done to their body,” he told me. Studies have found that continuous exposure to unrealistic images creates pressure to change the body which can contribute to body dysmorphia. (How Social Media Contributes to Body Dysmorphic Behavior, Alyce Adkins).
According to Katherine Miller, MD., BDD expert and author of “The Broken Mirror, Understanding and Treating Body Dysmorphic Disorder,” 5 to 10 million people are diagnosed with BDD every year in the United States. Yet the numbers are believed to be much higher due to a lack of reporting. Though the exact cause of BDD is unclear, several factors are thought to have an impact, including a family history of BDD or a similar mental disorder, abnormal levels of brain chemicals, personality type, and life experiences.
Celebrities are not exempt from BDD, and many have come forward to talk about their struggles with body dysmorphic disorder. Singer Billie Eilish opened up about her diagnosis in an interview with Rolling Stone. She described the point when her preoccupation with her appearance reached a breaking point. “I couldn’t look in the mirror at all,” she said. “That was the peak of my body dysmorphia.”
Actor Reid Ewing, who played Dylan on the popular TV show “Modern Family,” penned an article for the Huffington Post chronicling his struggles with BDD. “My looks were the only thing that mattered to me,” he wrote. Unhappy with his appearance, he underwent his first cosmetic surgery in 2008 after a plastic surgeon recommended he get cheek implants. When Ewing, then 19, saw the results of the procedure, he was horrified and wanted another surgery to fix it. When the doctor refused to operate, he found another doctor who would. Several surgeries later, Ewing wrote, “all the isolation, secrecy, depression, and self-hate became too much to bear. I vowed I would never get cosmetic surgery again even though I was still deeply insecure about my looks.”
Those who have BDD often labor under the misconception that surgery or another cosmetic procedure will cure BDD. In an interview, two BDD experts from Harvard and Massachusetts General Hospital — Dr. Sabine Wilhelm, the Director of OCD and Related Disorders Program, and Hilary Weingarten, a Clinical Fellow in Psychology — stated that “76.4% of individuals with BDD seek cosmetic treatment, and 66% of adults with BDD obtain cosmetic treatments.” (Phillips, Grant, Siniscalchi, & Albertini, 2001). But for those with BDD, “cosmetic treatments rarely (i.e., in only 2.3% of cosmetic surgeries or procedures) improve BDD symptoms in the long term.” Hence, they advise against cosmetic surgeries or procedures as a BDD treatment.
Understanding that BDD is a mental illness and not simply a desire to be more attractive is critical in recovery. A young Korean-American man who suffered for years with what he believed was his “hideous” appearance wrote of his personal struggle for the Massachusetts General Hospital: “To understand BDD as a psychological disorder was essential for me to finally shed the blinders that the illness had put on me that kept me from knowing what my values were, what activities made me happy, and putting myself out there to love and be loved,” he wrote.
Though there is no cure for BDD, cognitive behavioral therapy (CBT) and medication have been shown to decrease symptoms, helping individuals to live fuller, happier lives. CBT is a type of talk therapy (psychotherapy) where negative patterns of thought are challenged by the therapist. It is based on the premise that psychological problems arise from faulty thoughts that lead to unhealthy behavior and psychological suffering. Therefore, CBT focuses on changing thought patterns.
After his BDD crisis that ultimately brought him to therapy, the aforementioned pseudonymous young man said that this type of therapy was what really helped him recover. “It was through CBT that I discovered how far-reaching of an influence my BDD had, and it was through CBT that I was able to radically alter my life. Undergoing CBT, I learned very tangible skills to properly address my anxiety and my BDD.”
Cognitive Behavioral Therapy was part of my treatment as well. After my trip to the emergency room and subsequent visit with a psychiatrist, I started therapy sessions twice a week along with taking a prescribed low-dose SSRI (selective serotonin re-uptake inhibitor) — a medication shown to be effective in helping control negative thoughts and repetitive behaviors in BDD patients. Two months later, my panic attacks and obsessing had decreased, but it would be another two years before I stabilized.
Over those two years, as I inched towards recovery, I did extensive self-work. I read dozens of self-help and mental health books seeking out information and practices that might be helpful. One technique I found particularly helpful was known as the Circle of Influence and Control, as described in Stephen Covey’s “The 7 Habits of Highly Effective People.” It is also a technique also used in psychotherapy. The practice involves focusing our energy on what we can control as a means to increase our ability to affect those areas outside our control. With BDD my life felt out of my control, but when I worked on my circles of influence and control I was able to shift my mindset from, “I am a victim of mental illness” to “I am an active participant in my recovery.” The simple practice was invaluable in my recovery.
I started meditation after reading the work of mindfulness experts like Jon Kabat-Zinn and Richard Davidson, whose research clearly demonstrated the benefits of meditation on mental health. Though meditation has been used for centuries, we now have science to back up what has long been suspected: meditation decreases anxiety, rumination, and depression, and increases feelings of calm, self-worth, and emotional well-being.
Specific to treating BDD, which is classified as an obsessive-compulsive disorder (OCD), meditation helps by placing our attention in the present moment and interrupting the obsessive cycle. Most exciting is the newest research that demonstrates how mindfulness meditation can physically change our brains by reprogramming them and creating new patterns of thinking.
Though meditation didn’t initially come easy to me, it got better with time. More importantly, I started to see the benefits. Disciplining my mind to stay present helped me remain calm throughout the day when intrusive thoughts threatened to send me spiraling.
Over two decades of living with body dysmorphic disorder, I’ve encountered many setbacks, but none as debilitating as the onset. Though my anxiety and obsessive thoughts occasionally resurface, they are manageable. Most of the time, I live from a place of peace and acceptance. Through therapy, medication, and self-work, I have learned that healing can only be found in addressing my emotional well-being, and not in fixing my face.
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