“What is the reason for your perceived attractiveness?” – addressing the overlooked issue of body dysmorphia.
On a regular day, Eve* would wake up and begin examining her body while still in bed. She would purposely avoid looking at herself while showering or when choosing clothes to conceal her body.
During my work day, I would often contemplate my food choices and fret over my appearance to others. I constantly made sure to suck in my stomach and position myself behind objects. Every reflective surface I encountered – such as shop windows, bathrooms, cars, and mirrors – became an opportunity for me to check my appearance.
Afterwards, she would return to her empty home to prepare a meal, a task she disliked. She would eat quickly, wanting to finish it quickly. Then, she would spend an approximate hour examining her physique, poking and prodding at it.
I used to go to sleep feeling sad and frustrated about the way I looked, despising it and hoping I could magically transform into a different body, believing my life would be much simpler.
Eve has struggled with body dysmorphic disorder (BDD) from a young age, causing it to constantly affect her thoughts. While she was once praised for her appearance as a child, she now receives backhanded compliments from boys and men suggesting that she would be more attractive if she were thinner.
“Once I hit puberty, I noticed a change within myself, almost like I transformed into a different being.”
Believing her body was flawed, especially her stomach, thighs, and buttocks, she began intense workout routines in an attempt to alter her naturally curvy figure. At the age of 16, Eve developed bulimia.
Her motivation stemmed from a combination of shame, self-loathing, and wishful thinking – the belief that if she could simply alter one aspect, she could achieve all her desires.
In her fifties, Eve reveals that she was in a few relationships, but her condition ultimately caused her to distance herself from others. As time passed, she became less social in order to avoid the anxiety of being scrutinized.
This was a difficult situation for me as I craved connection, but when others complimented me on my appearance, I couldn’t understand why they would find me appealing when I viewed myself as repulsive.
“I thought I would never be able to engage in physical intimacy again because I believed my body was too unattractive. I was afraid that if a partner saw me naked, they would reject me. So, I accepted the idea of living a life of solitude.”
Eve was unaware at the time, but she would soon learn that no matter how much she exercised or underwent surgery, her perception would remain unchanged.
Extreme body dissatisfaction
While BDD is gaining more recognition, professionals suggest that it is frequently mistaken for low self-esteem or narcissism, leading to detrimental consequences. This condition entails an obsession with perceived imperfections, even if they do not actually exist or are minor, resulting in significant distress and repetitive actions to conceal or correct the flaw.
Approximately 80% of individuals with this condition contemplate taking their own life, and about 25% make an attempt to do so.
Research shows that approximately 2% of the overall population is affected by this, which is a larger percentage than the combined prevalence of anorexia and schizophrenia. Some experts believe that the actual number may be even higher and increasing.
Susan Rossell, a globally recognized expert on BDD, is conducting a survey to gain insight into its prevalence in Australia.
According to Rossell, a professor of cognitive neuropsychiatry at Swinburne University, those prevalence figures are outdated and derived from data in other countries.
In the past decade, we have observed a growing trend of individuals experiencing high levels of dissatisfaction with their body image, which can lead to Body Dysmorphic Disorder (BDD). However, during the pandemic, various factors meant to assist us in our daily lives have been found to be particularly triggering for those who are at risk of developing BDD.
During the pandemic, Rossell and his team discovered that 33% of 335 adults who participated in video calls had new worries about how they looked, leading them to consider cosmetic procedures. This phenomenon is commonly referred to as “the Zoom effect.”
Dr. Katharine Phillips, a psychiatry professor at New York-Presbyterian and Weill Cornell Medical Center in the United States, acknowledges that both genetics and the environment play a role in the development of BDD.
According to Phillips, the most recent survey that represents the entire US population, conducted in 2015, discovered a higher prevalence rate of 2.9% compared to previous studies.
However, I believe that BDD (Body Dysmorphic Disorder) is growing in prevalence, potentially due to the widespread adoption of image-focused social media. This platform often showcases unrealistic notions of beauty, allows for alteration of one’s appearance, and fosters comparisons with individuals who are considered highly attractive, such as celebrities.
“We did not receive any forms of treatment.”
While completing her medical residency, Phillips developed a fascination with patients who were suffering from severe illnesses that prevented them from functioning normally and engaging in social activities. Some of these patients had even resorted to attempting suicide due to their belief that they were unattractive. BDD, a condition that she and her supervisors were unfamiliar with, was the underlying cause.
Phillips explains that it had been overlooked by contemporary psychiatric practices.
“Despite being acknowledged for over a century, BDD remained largely unexplored by the scientific community. There were no established measures or evaluations to diagnose or measure its severity, and treatment options were non-existent. This prompted me to embark on a journey to acquire this knowledge.”
The term BDD was initially referenced in the commonly used Diagnostic and Statistical Manual of Mental Disorders in 1980. Phillips, whose research has influenced the diagnostic standards and descriptions in subsequent editions, acknowledges that there has been progress in identifying the disorder since she began her research in the 1990s, but further efforts are necessary.
There is a lack of research on BDD compared to other psychiatric disorders, and more studies are needed to explore all aspects of the disorder. It is particularly important to gather data from various populations and in younger individuals.
Although it is often viewed as less significant than other severe mental illnesses, this condition is actually strongly linked to thoughts of suicide and attempts at suicide, even more so than many other serious mental disorders.
Frequently, it is accompanied by other psychological problems, but a lot of those who experience it refrain from talking about their signs due to feelings of embarrassment.
Research conducted by Rossell and her team, which includes David Castle, a psychiatrist and professor of psychiatry at the University of Tasmania, has revealed alterations in the structure and connections of the brains of individuals with BDD.
According to Castle, although both obsessive-compulsive disorder (OCD) and body dysmorphic disorder (BDD) encompass obsessional thoughts and ritualized actions, there are significant differences that set BDD apart.
The majority of individuals with OCD are aware that their worries are extreme, but in BDD, approximately 50% have strong beliefs that their appearance is unattractive and cannot be changed.
Individuals with BDD may have difficulties with visual processing, specifically in interpreting facial expressions. They are more likely to perceive the expressions of others as hostile or angry instead of accurately understanding them.
Rossell explains that individuals with BDD have brains that do not alternate between focusing on small details and the overall picture, unlike those of healthy individuals. Instead, their brains become fixated on the details, causing distortion when focusing on one aspect of their appearance for an extended period of time. This is believed to be a contributing factor in BDD.
According to Dr. Toni Pikoos, a clinical psychologist based in Melbourne, approximately 75% of individuals with Body Dysmorphic Disorder (BDD) turn to cosmetic or dermatology treatments. However, these treatments are not likely to be beneficial and can pose additional risks to both patients and providers.
“They have the potential to be susceptible customers. Frequently, they are in a state of desperation, which leads them to pay for solutions to feel relief… Regrettably, in as many as 90% of BDD cases, individuals do not see any improvement in their symptoms following treatment.”
Many times, Pikoos encounters patients who were initially content with a cosmetic procedure, but after months or years, they believe the “imperfection” has returned or worsened.
Individuals with body dysmorphic disorder (BDD) may experience intense feelings of sadness and obsession with a specific aspect of their appearance, potentially resulting in anger towards the surgeon. In the United States, approximately 29% of BDD sufferers have filed complaints or pursued legal action against their cosmetic practitioner.
In July 2023, Australia’s medical regulator, Ahpra, conducted an investigation into the cosmetic industry and implemented stricter guidelines for doctors who offer cosmetic procedures. Additional modifications are anticipated for those who offer non-surgical procedures, such as nurses, dentists, and Chinese medicine practitioners.
The modifications mandate that doctors who administer cosmetic surgery or prescribe cosmetic injectables (like botulinum toxin and dermal fillers) must evaluate patients for BDD and refer those at risk for an outside assessment.
Pikoos, a co-founder of an organization that aids cosmetic practitioners with psychological evaluations and a consultant for the Ahpra review, reports an increase in referrals for evaluations since July. Some of these referrals have required additional treatment or assistance.
Access to treatment
According to Castle, targeted treatment is necessary for improvement of BDD symptoms. This typically includes high doses of SSRI antidepressants in combination with cognitive behavior therapy that addresses avoidance and safety behaviors, such as working with mirrors.
“You can change people’s lives completely. The tragedy is, often people are coming to us very late and having gone through a lot of cosmetic procedures.”
Rossell approximates that there are twelve mental health professionals in Australia who are trained to address BDD. She trained many of them herself, but expresses disappointment that there is no specific focus on this area of expertise.
The Royal Australian and New Zealand Royal College of Psychiatrists (RANZCP) and the Australian Psychological Society (APS) do not have BDD listed as a searchable issue in their clinician directories. However, the APS does have body image listed as a subcategory under “personal” issues. Rossell emphasizes the importance of improving searchability.
She is worried that patients and those looking to refer them have difficulty locating available specialists. She encourages practitioners with experience in BDD to inform RANZCP and APS, as they rely on practitioner-provided information.
Dr. Elizabeth Moore, the president of RANZCP, states that research indicates a lack of understanding about the disorder and suggests that its prevalence may be higher due to cases going undiagnosed.
There is worry among healthcare professionals about potentially overlooking symptoms of Body Dysmorphic Disorder (BDD) in patients, or mistakenly diagnosing individuals with BDD as having depression, social anxiety, or OCD.
Eve believes she consulted with 10 mental health professionals before being diagnosed with BDD three years ago. She has been receiving specialized therapy for nearly a year, which has been life-changing.
I start my day with a positive mindset and have reduced my obsession with my physical appearance.
It also has a mix of emotions.
Having someone who truly comprehends my situation feels almost surreal. It confirms my feelings, but it also frustrates me that it took so long to receive assistance and that I have had to deal with it on my own for most of my life – the embarrassment, judgement, and lack of understanding.
Nonetheless, she credits this improvement for her current healthy relationship – which is also the first instance of her sharing her BDD struggles with a romantic partner.
“I have experienced significant changes… and I have fallen in love. I have allowed myself to be vulnerable to the most compassionate and empathetic individual I have ever encountered.”
Eve is currently pursuing a degree in psychology and intends to focus on treating BDD.
The name has been altered.
Please reach out to Prof Susan Rossell at Swinburne University’s Centre for Mental Health via email at [email protected] if you have any concerns regarding body dysmorphic disorder.