Body Dysmorphic Disorder - BDD

This is one of the mental illness that I have!


When the mirror lies
Patients tormented by body flaws, often imagined, urgently need help

Barbara Yost
The Arizona Republic
May. 30, 2006 12:00 AM

Imagine you're an average-looking man or woman. But when you look in the mirror, you see a monster.

Your nose is grotesque, or your skin has the pallor of a ghost, or your hair is so thin you're certain everyone is laughing at you. You believe you have a defect so horrible you can't leave your house.

So your world shrinks until it's no bigger than the air you breathe.

If you're lucky, you'll find a mental-health professional who will diagnose a psychiatric illness called body dysmorphic disorder, an obsession with an imagined or slight physical defect. And you will be on your way to relief.

If you are not diagnosed, your life will become miserable. Or worse.

"It can be crippling," said Sabine Wilhelm, founder and director of the Body Dysmorphic Disorder Clinic & Research Unit at Massachusetts General Hospital and Harvard Medical School. "This is a real disorder. It's not just vanity."

Those with body dysmorphic disorder, or BDD, have one of the highest suicide rates among people with mental illnesses, 22 to 24 percent. BDD is not a new disease. Accounts of patients tormented by imagined physical flaws go back more than a century. Sigmund Freud documented a patient obsessed with his nose.

But BDD only now is being addressed by the mental-health community. It has been listed in the Diagnostic and Statistical Manual of Mental Disorders, the psychiatrist's bible, only since 1987.

Research is in its infancy, said Jamie Feusner, a research fellow in the University of California at Los Angeles Department of Psychiatry and Biobehavioral Sciences. Feusner is conducting studies on brain activity in people with BDD. But "it's being recognized more and more."

In the meantime, the mirror is telling ugly lies to millions of people around the world.

BDD usually begins to surface in adolescence or in the late teens, but cases have been reported in children as young as 4. When diagnosed, many patients had been suffering for years, their world narrowing day by day.

Patients are evenly divided between men and women. Though no racial studies have been conducted, experts believe that the illness cuts across all ethnic lines and affects about 1 to 2 percent of the general population. Most patients are average-looking, but even fashion models have sought treatment.

The cause of BDD is unknown, but scientists believe that a genetic component is involved and that life events can trigger its onset. Perhaps a child is teased and begins to focus on a slight physical flaw. Or the child's parent is overly critical of his or her appearance. The obsession festers.

The illness can be misdiagnosed as depression, social anxiety, agoraphobia or obsessive-compulsive disorder, which is a closely related illness but not synonymous with BDD, said Arie Winograd, director of the Los Angeles Body Dysmorphic Disorder Clinic.

The clue to BDD is patients' irrational focus on one or more "defective" body parts. Most commonly, they are concerned with the nose, skin, hair, eyes or breasts that are too small or too large. Some become obsessive body builders, convinced they are too thin, even when their muscles are large. This is known as muscle dysmorphia.

Wilhelm treated a patient so disturbed by a small pimple on his neck that he irritated it until he had created a bullet-size hole dangerously close to his carotid artery. One man spent hours cutting his sideburns trying to make them perfect.

In a paper published in the American Journal of Psychiatry, BDD pioneer Katharine Phillips reported a woman who slashed her breasts because she thought they were ugly.

James Claiborn, a Maine psychologist who works with BDD patients and is a consultant for a BDD Web site, treated a man unable to attend a job interview because he was convinced his hands were unsightly. A woman was repulsed by flakes in her skin - flakes Claiborn was unable to see. He's encountered people who have taken a knife to try to reshape their noses or contemplated getting into an accident to justify surgery.

"It can be a fatal disorder," he said. "It can take over and ruin a person's life."

Many patients spend hours staring into a mirror or other reflective surfaces and engage in excessive grooming.

"They describe it as being mesmerized by the mirror," Wilhelm said. "They seem to lose touch with what's going on around them."

Tragic obsession

In 2000, Kathleen Powley's 26-year-old daughter, Neysa Jane, was diagnosed with BDD. For months, she had suffered from depression after breaking up with her boyfriend and suffering other personal disappointments. BDD symptoms began to surface.

Neysa Jane believed that her skin was bad and that her head and chin were misshapen. All were imagined, her mother said, but the young woman believed her "ugliness" was the cause of her problems.

"We tried to play up other things than her appearance," Powley said, but her parents' reassurances had no effect. "They (BDD patients) are in another world. They block out what you're saying."

Neysa Jane began going out only after dark. She took a job where she didn't have to encounter the public. Finally, a psychiatrist who had just returned from a BDD conference diagnosed her symptoms.

"It was a relief that you could put a name on it," Powley said. "We thought love could cure all things."

But Powley could find no in-patient BDD center in her town of Naples, Fla., and watched helplessly as her daughter slipped further into depression. After attempting suicide several times, Neysa Jane took her life Feb. 19, 2000.

A week later, Powley founded the Neysa Jane Foundation to help families dealing with BDD.

"We do a lot of education outreach," she said. "The public doesn't recognize what they have."

Powley's hope is to save lives, as no one could save her daughter. She takes phone calls from parents around the world, parents with fear in their voices. "I don't want anyone else to go through this."

Under the radar

In the 1980s, when Phillips became interested in BDD, there was even less known about an illness that flew under most clinicians' radar, she said from her office as director of the Body Dysmorphic Disorder and Body Image Program at Butler Hospital in Providence, R.I. Still, "I was fascinated by it," she said.

But she found few studies into its nature. What characterized BDD behavior? Did it affect men or women? What body parts were involved?

There was no treatment protocol, but "I took my major clues from OCD and depression," she said.

In 1996, she wrote her own book, The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder (Oxford University Press, $19.95 paperback).

In the book, written for clinicians as well as the public, Phillips details the history and nature of BDD, its treatments and possible causes, and covers the spectrum from normal concern over appearance to the painful illness. Phillips updated her book last year to include new information from professionals and researchers.

Winograd, of the Los Angeles BDD clinic, said dermatologists often have been at the forefront, wary of patients complaining about undetectable skin flaws.

Angela Kenney, a certified physician's assistant with Allergy & Dermatology Specialists of Phoenix, believes that as many as 12 percent of dermatology patients could have BDD. But confronting those patients is a challenge, she said.

"You're telling someone they don't have this defect they spend hours a day 'correcting.' "

Persuading them to consult a psychiatrist takes diplomacy. Some patients shop for doctors who will confirm their fears.

"Not everyone is open to treatment," Kenney said. "We still have a stigma against mental disorders and seeking help."

Plastic surgeons' duty

Plastic surgeons also should be picking up on BDD, but many don't, Winograd believes, saying, "Surgeons are not 'getting' it."

Wilhelm, of the Massachusetts clinic, says about 27 percent of BDD patients undergo cosmetic surgery to improve their imagined defects. But surgery is rarely successful.

"They're so disappointed with the results," she said. "Plastic surgeons need to request a psychiatric evaluation."

During more than 15 years in practice, Scottsdale cosmetic surgeon Ron Caniglia has seen many patients with BDD. One man despaired over a scar on his upper lip that was nearly invisible to Caniglia.

"You look at it, and you don't see much of a problem. But they obsess," he said. "You have to back up and talk to the patient . . . If there's something I think isn't right for the patient, I won't do it."

Caniglia believes that his colleagues are likewise aware of BDD and won't perform unnecessary surgery just for profit.

"I think most guys in this (profession) are familiar with the term," he said.

But some aren't skilled at picking up on it, and some cases may slip past even a savvy doctor.

"The more severe cases you pick up on right away," Caniglia said.

For those, he keeps a list of psychiatrists for referral.

Modern treatment

As BDD becomes recognized, more treatment protocols have been developed. Most therapists use a combination of drug therapy, including antidepressants such as Prozac and selective serotonin reuptake inhibitors, along with cognitive behavior therapy, which gradually acclimates patients to situations that make them uncomfortable.

In Feusner's study, the UCLA researcher performed functional MRIs, or magnetic resonance imaging tests, on the brains of 12 BDD patients and compared them with 12 healthy control subjects as they studied pictures of faces. He discovered that healthy people used parts of their brain that process configurational aspects - the shape of the face, where the eyes and nose are located. When people with BDD looked at the faces, they used parts of the brain that process details and failed to get the bigger picture, suggesting functional differences in the brain.

Further, when the faces were enhanced for detail, the BDD patients used parts of their brain that process threat and fear, though they reported only low levels of anxiety.

In another phase of Feusner's research, test subjects will look at their own faces. He hopes his work will lead to better therapies.

Although BDD is a severe illness, success rates are high. Treatment is more specific than it was a decade ago, and promising new medications are becoming available.

"I'm quite optimistic. People get better with the right treatment," Phillips said. "We just need to do a lot more to get the word out to dermatologists and plastic surgeons. They need to use the term, give it a name. It's common, it's treatable. It's like diabetes . . . "

The battle against mirrors that tell lies is not over.

"BDD has come so far in the last 15 years," Phillips said. "But we have much farther to go."

Reach the reporter at or (602) 444-8597.


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