By Pulkit Sharma May 2005 Body Dysmorphic Disorder (BDD), a preoccupation with an imagined physical defect in appearance, is on the rise today because of society’s increased emphasis on good looks. However, effective therapies can heal the condition and alleviate the sufferer’s distress. Amit (name changed) is a desi reincarnation of the Greek god Adonis. The beauty of this 22-year-old would inspire envy in most men. He has an athletic built, rippling muscles, beautiful complexion and sharp features, all of which would suggest a good self-image. In reality, however, Amit is constantly tormented about his appearance. He is convinced that he is grotesque. In the past three years, Amit has undergone three surgeries to correct what he believes is his misshapen ‘parrot-beaked’ nose. After each surgery he feels worse. He is considering another nose job this year. Amit doesn’t think he is muscular enough and lifts weights excessively and has taken to anabolic steroid abuse. He prefers staying home and has dropped out of college. Erasing the flaws in his appearance is his only preoccupation. Physical appearance, its perception by self and others, has always held sway over most aspects of human life. Those considered good-looking have an advantage over the rest, particularly in their interactions with the opposite sex. However, the last decade has seen a peaking in society’s obsession with appearances. Beautiful and ugly have become concepts as pervasive as good and bad. In this appearance-obsessed perfectionist society, the media first projects unrealistically perfect images. These convince an individual that something is terribly wrong with his physical appearance and that it needs to be mended. The beauty and fitness industry mints money off their dissatisfaction. To pander to this, we have technology and ample cosmetic procedures that can change a perfectly normal and natural appearance into a ‘designer body’. While some dissatisfaction with an aspect of one’s appearance is warranted, with individuals like Amit, it turns into a torturous obsession with the way they look. In psychological language, this extremely distressing condition is known as Body Dysmorphic Disorder (BDD). People with BDD are preoccupied with slight or imaginary defects in their appearance, creating distress and impairment in daily functioning. BDD is not vanity: the sufferers just wish to be accepted. BDDers feel uncomfortable in public situations. They imagine others are scrutinizing them and laughing at their defects. Many people with BDD are constantly glued to mirrors to find out how bad their defect actually is. BDD exists in people of all ages; it affects young and old, men and women. Any body part can be the area of concern though the most common ones are the nose, lips, face, ears, hair, breasts and genitals. Sudeep (name changed) considers his arms feminine because of their thinness and lack of hair. To avoid embarrassment he always wears long sleeves, even when the mercury soars. He is scared that his fianceé will leave him once she notices his arms. BDDers often resort to cosmetic and surgical procedures to remove these flaws. Though cosmetic surgery is a boon for people with actual deformities, BDD sufferers rarely benefit from it as it only aggravates their dissatisfaction. Individuals having appearance obsessions often buy endless beauty products and clothes in a desperate search for a product that will either hide or end their problems. They inevitably wind up frustrated and depressed as their problem is psychological and not physical. Levels of distress in this psychological condition span a broad spectrum, ranging from those who function relatively well, to those who function below their potential despite sincere efforts, to those who are traumatized enough to commit suicide. Swati (name changed) shares her distress: ‘I had to leave my job as a receptionist because I felt that people were always staring at my ugly face. I remain in my house and worry about my pimples the entire day. My concerns even haunt me in my dreams. I neglect all household duties and my husband is very angry with me. I’m a social isolate. I cannot enjoy my life. At times I feel what is the point in going on like this?’ BDD has recently received a lot of attention from researchers and mental health professionals although it has been recorded for over a century. It was first documented in 1886 by the Italian researcher Morselli, who gave it the initial title Dysmorphophobia. The term was coined from the Greek word dysmorph meaning ‘misshapen’. According to Morselli: ‘The dysmorphophobic patient is miserable; he is always trapped within the doubt of deformity.’ Pierre Janet, the founder of Modern Dynamic Psychology, living in the late 1800s, called this body obsession ‘de la honte de corps’, that translates as ‘obsession with the shame of the body’. BDD seems to be caused by an interaction of biological, psychological and socio-cultural factors. People with a history of frequent teasing, sexual abuse or unfavorable childhood experiences are prone to developing such obsessions. Surabhi (name changed) attributes her appearance concerns to early teasing-‘All the children in my class called me ‘behenji’. I always felt that I had no appeal. Nobody talked to me. I used to sit alone and hate myself for being so ugly.’ Like Surabhi, people with BDD are excessively concerned with how their parents, spouse, friends, boss and significant others will evaluate them. They are extremely self-conscious and hypersensitive to rejection. Sanjeev (name changed) blames the media and society for his obsession with his appearance. ‘I cannot stop myself from hating my appearance. Even if I switch on the television for five minutes I go mad. All the hunks are shown to get love, respect, success and every other happiness in life. Masculinity has to be proven by muscularity. If you are not good looking, you are simply trash.’ It is estimated that around 2 per cent of the general population around the globe suffers from appearance obsessions, but given that BDD is still a closet disorder the figures could be greater. A majority of sufferers never talk about their worries. They fear that others will not take them seriously, will think them shallow and vain or will simply laugh at them. BDD sufferers need not live in panic or silence, as treatment is available. Psychodynamic psychotherapy based on psychoanalytic and existential principles providing insight into the unconscious mind promises relief from this problem. Cognitive-Behavioral Therapy (CBT) is also effective in treating BDD by targeting distorted, unrealistic, or negative attitudes and beliefs that affect behaviour. The BDD Workbook by Claiborn and Pedrick is a step-by-step guide for the treatment of BDD based on CBT. The crucial problem in BDD is how patients view themselves and thus this therapy is designed to change the body image of the person, and not his or her appearance. The patients are encouraged to restructure their cognitions and to examine their assumptions about bodily characteristics in a more objective and dispassionate manner. We all have a perceived body image and an ideal body image. One of the goals of CBT is to help bring about a more satisfying balance between the patient’s ideal body image and perceived body image. Specific behavioural techniques known as exposure and response prevention are also used in treating BDD symptoms. Exposure consists of deliberately confronting a feared or avoided situation such as not going swimming due to the anxiety that one does not have an aesthetic body. With repeated confrontation, the anxiety subsides and the patient begins to feel relaxed. On the other hand, response prevention consists of resisting any compulsive behaviour. While research is on to seek out more effective remedies for BDD, the best approach for the moment would be to combine the existing treatments to suit the need and personality of the patient. The important thing for the patients is to realize that help is available and that they need not live in distress anymore.
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