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Body Image and Body Dysmorphic Disorder

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First published: October 2000

Body Dysmorphic Disorder

by Michael Sones

Dissatisfaction with appearance is very prevalent in our society. Over the past three decades the popular magazine Psychology Today has conducted several surveys on how people feel about the appearance of their bodies. The changing results make for interesting reading. The dramatic changes in American culture have significantly altered peoples' perceptions of themselves. In 1972 twenty-three percent of American women were dissatisfied with their appearance but by 1997 that figure had risen to fifty-six percent. In 1972 fifteen percent of men were dissatisfied with their appearance but by 1997 that figure had risen to forty-three percent. Thirty-eight percent of men are now dissatisfied with the size of their chests compared to the thirty-four percent of women dissatisfied with their breasts. Men are getting pectoral and calf implants. Millions of women have had surgery to change the shape of their breasts or increase their size.

Dissatisfaction with how you look is practically the norm. However, when someone becomes intensely preoccupied with what they believe to be a defect in their appearance, then they may be suffering from a mental health condition called Body Dysmorphic Disorder (BDD). While there may be a real basis for the concern, as for example, where acne is present, the sufferer's preoccupation is intense and excessive. Other times the perceived imperfections may not be obvious to anyone other than the person. They feel intensely tormented and tortured by what they feel makes them ugly to themselves and to those around them. It used to be called dysmorphobia and was first described by an Italian psychiatrist, Enrique Morselli, over a hundred years ago. He was aware of the intense suffering caused by the preoccupation with the imagined defect.

This condition often goes undiagnosed and the sufferer may seek repeated cosmetic surgery to remedy the imagined defects. People with this disorder commonly complain about flaws of the head or face. They may be preoccupied with the size and shape of noses, eyes, ears and mouths, eyebrows, chins, and jaws. People may also agonize over the real or imagined appearance of wrinkles, the shade of their skin, the degree of facial symmetry, or thinning hair. This intensive and time-consuming preoccupation may also focus on other body parts, such as arms, legs, tummy, hips, and genitals. Where the person's obsessive interest is in their weight, body shape and size, a differential diagnosis of Anorexia Nervosa may be made.

People with BDD may find themselves constantly checking their appearance in the mirror. The checking is constant because they never feel reassured. In some cases the level of dissatisfaction in their appearance may lead sufferers to shun the company of other people, in work and social situations. This is partly because being with other people may lead people with BDD to compare their perceived defective parts with others and leads to an increase of anxiety. It can also be because BDD sufferers often feel that others are staring at them, noting their defects and then mocking or criticizing them behind their backs.

BDD usually begins in adolescence, probably because this is a time when young people are having to cope with natural changes in their body shapes and sizes. Issues of sexuality and gender identity also arise at this time, as do impulses to move from the family nest out into the community where future potential mates reside. Many, if not all, teenagers experience anxiety about the many changes that occur within and without their bodies at this time; for most the anxiety is temporary and manageable while for others it is the beginning of a very long course of unhappiness with themselves. This condition occurs at about the same rate in males and females. The current tendency to idealize thinness, as illustrated by images of slender models in the media, has a particular impact upon girls because the development of breasts and hips seems to be in conflict with the cultural ideal. Due in the main to modern nutrition the average woman has become even larger and thus conflicts even more with the cultural ideal of thinness. Puberty seems to be occurring at even younger ages and it may be that younger children will become affected by body image disturbances. The natural change which boys undergo as they become taller and more muscular is more in tune with the cultural ideal for men.

BDD can be very serious and disabling. The disorder is often associated with depressive disorders and social phobia. If someone comes and presents with a depressive disorder it is recommended that the possibility of an associated body dysmorphic disorder be explored. This is because BDD sufferers often find it extremely embarrassing to disclose their worries. The great distress it causes can lead sufferers to serious suicide attempts.

It is difficult to know just how prevalent BDD is as there is such a great cultural preoccupation with beauty and attractiveness and giving lots of attention to the body. This may mask and normalize what might be seen in other cultures to be an excessive interest in one's appearance. For example, what would be a "normal" amount of time to spend doing one's makeup, or a "normal" amount of cosmetic surgery to have?

Treatment with medication, particularly fluoxetine, is effective in many cases but there are also a number of cases which do not respond to treatment. Cognitive behavioral therapy has also been effective.

The author of this article is a qualified and experienced psychotherapist with many year experience working for the NHS in the UK. Information in this article is purely for educational purposes. If you suspect you may be suffering from BDD please seek appropriate help from your doctor or a properly qualified mental health clinician.

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