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| Sabine Wilhelm, Ph.D., is the founder and director of the Body Dysmorphic Disorder Clinic and Research Unit at Massachusetts General Hospital. She is the author of a new book entitled, "Feeling Good About The Way You Look: A Program for Overcoming Body Image Problems." (photo by Tom Croke) |
(June 2006 Issue)
By Jennifer Chase Esposito
It's been called "imagined ugliness," a disorder that causes its sufferers to obsess over perceived body defects that exist in their minds but are rarely a reality on their bodies.
Sufferers - and people diagnosed with Body Dysmorphic Disorder (BDD) are that - are addicted to anything that offers them a reflection by which some sit for hours, scrutinizing aspects of their bodies to extreme depths of desperation and hatred for what they think others see in them.
They stare, obsess, pick and plastic surgery-away at their perceived problems.
Some don't drive cars because the urge to stare in the rearview mirror is too great.
Others don't leave their homes because they think they are too ugly.
Twenty-four percent of sufferers are so tormented that they kill themselves.
Going far beyond the worst "bad body image day," BDD prompts seemingly attractive people to internally despise what most see as healthy, beautiful individuals. It's a disorder that breeds secrecy among its patients and can at first mimic symptoms of depression.
But thanks to increased research and media attention in the last decade, clinicians are learning to pick up on the warning signs of a disorder that quietly disassembles the teachings of good parents: it's what's on the inside that counts.
"It was probably about 15 years ago when I saw some people who presented with complaints that confused me at first, but which became more understandable when understood as BDD," says James Claiborn, Ph.D., ABPP, a licensed psychologist practicing in South Portland, Maine.
Claiborn has used cognitive behavior therapy to treat anxiety disorders such as obsessive-compulsive disorder, posttraumatic stress disorder, depression and BDD. Like many clinicians, he learned of BDD by associating behavior and symptoms with other anxiety disorders like obsessive-compulsive disorder.
But it's the depression caused by BDD that can bring patients from the point of no return to the doctor's chair.
Sabine Wilhelm, Ph.D. is the founder and director of the Body Dysmorphic Disorder Clinic and Research Unit at Massachusetts General Hospital and associate professor of psychology (psychiatry) at Harvard Medical School. She remembers a patient who entered her practice and began his session with his hand over his mouth. When Wilhelm asked the patient his reasoning for the gesture, he replied, "Oh Dr. Wilhelm, I can't believe you asked me about it...But I decided before I came that I wasn't going to bring it up" during the session, which, according to Wilhelm, was booked to address his recent depression.
"I'm so ashamed ..." continued the patient, "about my mouth and teeth."
For Wilhelm, an instant BDD red flag rose as the likely cause of his depression. But if she hadn't asked about it, he likely wouldn't have brought it up. That's because patients with BDD are so secretive, says Wilhelm, that they often won't tell their doctors their issues.
"At the same time, they're really worried people will think they are superficial...But people with BDD zoom right into one specific thing - a scar, a pimple. What we try to teach them at the clinic is to see the whole face, not only small parts," she says.
At Massachusetts General's BDD clinic, where Wilhelm and her staff receive hundreds of calls per year from people seeking BDD treatment, she prescribes both cognitive behavior therapy and medicating with Serotonin Reuptake Inhibitors (SRIs). Countless psychoeducation exercises like "perceptual retraining," "mirror retraining" and other cognitive behavior techniques are among a variety of treatments the clinic uses to teach patients to learn to accept and most importantly, tolerate their imperfections.
Some say it's more about vanity than reality, that it's "all in the heads" of patients. And in fact, it is in their heads and therein rests the heartbreak for men and women who seek plastic surgery to even out a scar, level off their nostrils or eyes, attempting to fix a malady that doesn't exist.
James Rosen, Ph.D., is professor emeritus of psychology at the University of Vermont and a former clinical psychologist for more than 20 years. Having begun BDD treatments at a time when some of his eating disorder patients were presenting with non-weight excessive appearance concerns, Rosen says there is one looming fallacy about BDD: that body concern is limited to unusual, isolated physical features like those of the nose, eyes and hair.
"The truth is, it doesn't matter where in the body they see the defect," Rosen, who now lives in California, says in an e-mail. "The nature of BDD is excessive and unrealistic concern with appearance, regardless of where. Therefore, people with large body area concern, like being too fat or too large, can meet the criteria for BDD."
Claiborn adds that common misconceptions are that the disorder "is rare and that it's not a serious problem."
But another misconception could be that women are more often patients than men. In his 28 years of practice, Claiborn has seen a 50-50 balance in male-to-female patients. "This is a fact that surprises many people," he says.
According to the Web site, www.bddcentral.com, there are fewer than 70 clinicians and programs world-wide specializing in BDD. New England has two major centers offering treatment for patients and guidance for their families: Wilhelm's and that of Katharine A. Phillips, M.D., director of the BDD and Body Image Program at Butler Hospital in Providence, R.I..
Phillips is also professor of psychology and human behavior at Brown Medical School and is regarded as a foremost authority on BDD. Since publishing countless research papers and the 10-year-old-book "The Broken Mirror," Phillips has witnessed an increase in BDD research and public awareness.
"Everything I wrote in 1996 was accurate, but now there is more treatment research ... on medicine and cognitive behavior therapy," says Phillips. "That's probably been the most important advance in the last 10 years....But at the same time, it's so much less than other mental illnesses.
"I think the reality is clinicians have seen these patients and are struck by how ill they are."
Another reality is the boom in exposure BDD has received from mainstream media. In the last 10 years, Phillips has done some 350 media interviews ranging from print media to media mega-shows like the Today show, Good Morning America and an episode of Oprah dedicated to BDD. "The public is now awash in information," she says. "The efforts of the media have genuinely been terrific," she says. "To have them present information in an accurate way has been helpful to us as clinicians with research getting done."
Phillips' book, "The Broken Mirror," since its first edition in 1996, and has become known to some as the bible on BDD. Written for families of people diagnosed with the disorder, patients and clinicians, it's part handbook, part self-help guide and part dictionary.
"People have said things like 'it's lifesaving,' 'I had no idea that what I have had a name.' I think a lot of people have suffered in silence," she says.
Another positive that's come from BDD's greater exposure is an emergence of patients now able to self-diagnose. "I saw someone last week - a 16-year-old - who made her own diagnosis," says Phillips. After going through her preliminary questioning, Phillips deduced that the patient was right.
Still, she says, too many clinicians aren't familiar with the disorder. Her remedy is simple. "Get familiar with it. Ask each patient about it. If you don't screen for it, you might not find it. These are very secretive patients," Phillips says.
"It's very important that psychologists directly ask about the disorder, because patients may not say it," Wilhelm says. "The biggest fear patients have is that people will assume they are vain."
Clinicians can start by asking questions like "Are you worried about the way you look?" or "Does it preoccupy you?" But the trick is to respond as they would to any other answer. "Unfortunately, I think sometimes people have the tendency to say, 'What? You look fine!'" Phillips says. "But you wouldn't respond like that to any other symptom. Curb that impulse." "The burden is on the psychologist," Phillips adds.
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