300.7 Body Dysmorphic Disorder

According to the DSM-IV, these are the criteria for a diagnosis of Body Dysmorphic Disorder:

1. Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person's concern is markedly excessive.

2. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

3. The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in Anorexia Nervosa).

I think it is possible that Body Dysmorphic Disorder would be an accurate diagnosis for me. I am not sure I can explain clearly or simply, but I will attempt to explain. Although Bulimia and preoccupation with my body may seem to rule out BDD as a primary diagnosis, I also have issues related to other parts of my appearance: skin (ichthyosis), and face (badly proportioned, difficult to frame well with hairstyle, etc.) The problems with my face make it difficult to deal with photos necessary for ID (at present I have not even a passport - mine expired in early November 2009), and my lack of photogenicness is part of what has driven me away from family functions over the years, or any functions in which people might take snapshots of each other. When confronted with photos that others have taken of me, I often experience an immediate wish to die. It's not so much a feeling of 'panic' as one of utter hopelessness. When I have worked on my body as well as I'm able, I may participate in life more, but my functioning is still greatly inhibited, and the way that I feel about my appearance as a whole and in various parts has an impact.

I think I have a realistic assessment of my appearance.

People are cruel or can be when it comes to judging physical appearance, or singling out 'deal breakers' in this and other areas. I wouldn't call ichthyosis a slight physical anomaly - it certainly wasn't growing up - but my other issues I think are complicated by that early experience of extreme difference.

I am noticeably unphotogenic compared to my siblings, and once I dropped out of life, that difference began to mean something else. It began to represent my character in social situations - or even an explanation: ah, she looks like someone with no character, no focus, no charm, no liveliness.

When it comes to my nose, I think it probably is something that most people discuss amongst themselves, but do not comment on to me. When in my teens, my father said my nostrils were like 'basketball hoops'. As a baby, my nose was clothespegged by my great-grandmother while she babysat me. Now, in spite of this, and other facial imperfections, I do realize that there are occasionally those who have found me 'pretty', or at least acceptably attractive.

When I am fit, I think that many people would be willing to concede that I look fit and even have a certain shapeliness, but that most would also probably add (again, amongst themselves) 'if only her thighs weren't so big' or think to themselves that I am not really fit because I still have cellulite and don't appear to realize it, or think that others don't notice.

For me, it's not really just a few features, it's that I don't really have any positive features, except when I make the effort to be thin and fit. My face is badly proportioned, my hair is too fine for me to be able to find a hairstyle that works with the proportions of my face (and if you don't think I've really tried to find a hairstyle, you haven't looked at much of my website) - from more than one angle, or that doesn't badly damage my hair.

I think that these assessments of myself might have been easier to deal with if I had some kind of recognizable role that had continued from high school into adulthood. Accepting myself came naturally when I was younger, and I did not dwell on the imperfections, but tried to focus on the positives. Unfortunately, when I became a teenager and proved to be exceptionally unphotogenic, it seemed that the most logical thing was to try to have an effect on my body - which theoretically it was within my power to control. And when I tried and failed, this contributed to low self-esteem.

I think I can see the precursors for a pathological preoccupation starting at age 15. When I came to stay with my mother for the summer, my weight had increased by 15 lbs since the last time she had seen me, and she was angry. I went on a crash diet, and exercised for hours a day, losing a significant amount of weight in a week. I then experienced a backlash binge which resulted in me telling my mother that I thought I needed professional help.

My mother died before I ever managed to find my own identity or assert my own individuality. She died suddenly during a time in which many other shocking events occurred, including an incident which may have resulted in posttraumatic stress. I think it is likely that my coping defenses weren't up to the task of dealing with all of the stress, and one of the results was that I began focusing more intensely on defects that before I had been willing to accept and not dwell on. My internal resources were depleted, and my unresolved issues with my mother might have contributed to me (out of guilt related to my mother's death) focusing on my 'ugliness'. She was the pretty one, I was the 'monster' - she was the one who should have lived, it would have made more sense to everyone. People care more about those who are pretty.

During the schoolyear, away from my mother, I was always out of control with food, but I did not have to face her scrutiny or comments regarding my weight. My father and his girlfriend did not comment on my constantly fluctuating weight or on the amounts of food which disappeared. So on the one hand I had too much scrutiny, and on the other I might have been left with too little concern. When I faced my mother, I understood immediately that she was not pleased with my appearance. It became impossible for me to handle the pressure, the stress of staying with her knowing that I didn't think I could control either my eating or my appearance. I felt guilty of how much I had been eating, that I was wasteful and had no self-control. She lived 5-6 hours away. I only saw her a couple of times a year, and once I cut one summer vacation short, I could never manage to stay a whole summer again.

My theory: My physical features reminded both my parents of features in themselves or their families they did not like or wish to see passed on, and likewise with features in each other. If I could be thin, I was closer to 'acceptable', but to please my father, I also had to be fit.

I think I reminded my mother of her sister, and their unresolved sibling rivalry. I look more like her sister than her. Also, with the large thighs, I could remind both parents of my father's sister, who is seen as pretty low on the pecking order. But there is also something odd about the combination, from some angles, exaggerated versions of features they associate with unpleasant traits.

I think it's possible that there was something related to the chain of events that included my mother's death, the funeral in which people compared me and my sister to our dead mother, and possibly to events that I blocked during that one night. In addition, just before I ran away from home, there was a school photo taken at the school I attended for a couple of weeks that was absolutely hideous, and even my father recoiled at the sight of it, and compassionately stated that we did not have to buy it. By this time, it was not just one high school photo - it was 4 for 4. After this point, all ID photos, - I still occasionally went through with getting them through the years, and I still acted normal for family photos, but it was an effort, and I felt increasing distress. When I would see my photo, I would not want to live as the person I appeared to be. The image I saw did not fit with my idea of how I saw myself according to how people treated me. It was like it didn't make sense. The photos didn't make sense to me, and didn't seem 'fair'.

My mother might have even been influenced by 'magical thinking' in this area - that at a certain age I would suddenly develop spontaneously such that I was over my 'ugly duckling' phase, thin and beautiful, my facial proportions having magically resolved themselves just in the nick of time. If this was in fact what she was thinking, in a way it makes sense that as I progressed through adolescence I would lose hope.

Why does this kind of thing get out of hand with some people? Is it just personality type? My best guess is that it might have had something to do with some of the reasons my parents' relationship failed, and with some of the primal violence they hurled at one another through the years. It was like my features, which may have just been normal in another family, represented what they hated about each other, and none of what they liked best in themselves. My appearance became tied not only to their approval, but to earning their love, and ultimately a judgment that someone like me should not live.

My lifelong low level paranoia regarding surveillance cameras, cameras hidden in electronic objects, etc, is probably related somehow to the feeling of being scrutinized constantly by my parents. I understood that in a physical sense I was a disappointment, and even that my appearance resulted in a kind of stress or tension. I also picked up that my mother was always trying to figure out ways to 'solve the problem', which I think resulted in me finding it easier to cope with the outside world when I had done all that was within my power to do to change what I could change. When I see a photo of myself, what my mother saw is emphasized - I feel distress because I understand unconsciously that she was conflicted about my appearance. She could not relate to it, she didn't want to admit to having spawned it, I embarrassed her and destroyed her dreams. I was a symbol of the mistake she had made in giving in to attraction rather than waiting to find out who she was such that she could give herself to someone who was 'right' for her. I was a 'punishment' and constant reminder of guilt and failure. She had thrown her life away, she had 'gone to the devil'. My ugliness was a punishment inflicted upon her for making the wrong choices in life and love. Her efforts to help me control my weight were partly about her own redemption.

This inability to face my mother eventually transferred to inability to face the world. It kicked in for the first time a few months after my mother's death, and then was my most 'normal' way of being from that time on.

As I age, I am finding all of my imperfections harder to deal with. Even when as thin as possible, throughout my life, I have feared the camera. A photo had the power to make me feel suicidal, as if it was not worth living a life if I had to look the way I did.

One thing that occurs to me is that my trouble with my appearance is not just related to how my parents saw me, but also related to how I saw them. If in my features I am reminded of the characteristics of my parents which I do not like or respect, maybe it's difficult for me to like or respect myself. My need to try to find an alternative appearance, my efforts with makeup, clothing and hair, might be one aspect of doing what I can to challenge the idea that genes are destiny.

I definitely have problems with the ubitquitousness of cameras in today's world, and I would guess that this problem is becoming more common, possibly requiring its own diagnosis. But whether at home or at school, we each eventually have to face photos of ourselves. Like it or not, this does constitute some of the feedback which lets us know how we are perceived by others, and where we fit in the grand scheme of things. Photos themselves influence how others see us - they see us firstly according to the impression we make upon them, but a photo is new info, and colours how that first impression is interpreted. Image has an effect, photos are seen as 'truth'. We don't often think about it, but we do form opinions of people we have never met because of photos we have seen of them.

I suspect that one branch of body dysmorphic disorder will increasingly relate to how photogenic a person is in a society where cameras are everywhere.

In my case, I may have felt confused partly because the way others treated me didn't seem to mesh with how I looked in photos. It was like if I really looked as I appeared to in photos, why did people treat me (at least some people) as if I was technically pretty, and not just pretty in the sense of being a nice person? Was it about politeness or not wanting to hurt my feelings? [Note: in case the reader is not familiar with my history, it is necessary to point out that my 'real life' photos Before My Website are the ones I am talking about here. My website photos are about choosing lighting, angles, makeup that change my facial proportions or focus in ways that everyday photos do not.]

...All her life she must drag this body of hers like a monstrous fetter imposed on her spirit. This strangely ardent yet sterile body that must worship yet never be worshipped in return by the creature of its adoration...

Radclyffe Hall, The Well of Loneliness

I don't think I fear ridicule or humiliation, and I think if someone tried to ridicule or humiliate me, I would probably stand up to them. The way it affects me is that I would think it's unlikely someone could be attracted enough to me to be obsessed with me, or to fall passionately in love with me. For more than a decade, I think I have come to the conclusion that my most satisfying relationships would be mental - e.g., mainly email - as meeting in person does seem to reduce the intensity.

It is possible that body dysmorphic disorder is under-diagnosed. It has only relatively recently been included in the DSM. Those with body dysmorphic disorder may be embarrassed by their symptoms, or find it difficult to be thought vain. Many of those who have it seek physical (cosmetic) treatment rather than psychological help - however, I would argue that cosmetic procedures should not be ruled out as part of treatment in all cases, and that they may be an effective or essential part of the whole.

Changes like plastic surgery don't always change the problem, and those with anorexia may still feel 'fat' even when emaciated. However, in my case, when I am thinner and fitter, I do find it easier to cope with the outside world. In my opinion, this is because lacking occupational and intellectual status, lacking the heterosexual validation of marriage and kids, one way I can have a kind of status is to appear to be fit. The majority of people in Western societies either struggle with or cannot attain this, and so a degree of respect goes along with it. Also, it is in my conditioning: when I change what is within my power to change, I cannot be beautiful, but I am making the most of what I have been given, which is a quality that makes me more deserving of love.

I think the latter is an important point, and one which has had a major impact on my life. I reject everyday life in part because my 'natural' state is not 'deserving' of love. I think this probably developed through an excessive scrutiny that began when I was quite young, but which may not have become pathological without a long series of stressors.

On a daily basis, in my 'normal' state, or the state that I tend to revert back to, I just wouldn't want to be seen. It is not just the weight, it's the combination of the weight and the rest of my appearance.

In some cases, cosmetic treatment may solve the psychological problem. In the cases where it doesn't work, isn't it possible that the results aren't what was hoped for? Cosmetic/plastic surgery is far from an exact science, and outcomes can be unpredictable. If the person is a perfectionist, it may make sense that they keep trying to achieve a slightly different effect that others would not concern themselves about. It may be that the people involved do not want to appear 'normal' or 'average', but 'perfect' or to stand out in some way - and that this is the root of the psychological problem. It could be that the combination of features that a person associates with 'I' is very difficult to achieve.

To suggest that appearance does not significantly affect our place in life and our interactions with others is to be out of touch with reality. In other words, society and professionals alike may lack insight into the importance of one's physical appearance. People with BDD may actually be more perceptive than average.

One 'symptom' I find interesting:

Seeing slightly varying image of self upon each instance of observal in a mirror or reflective surface.

Wikipedia

But isn't this what people would normally see, if they were perceptive?

Due to self-consciousness about their defects (or embarrassment related to their preoccupation), those with body dysmorphic disorder may avoid describing them in detail, referring only to their 'ugliness' (fatness?).

I can relate to the above. I think also there might be a fear that the power of suggestion intensifies the perceptions of others, compounding the problem.

Human beings gossip about other human beings. Could it be that when those with body dysmorphic disorder think others discuss their 'flaw'/s, others actually do discuss their flaws? But that those with this disorder dwell on it more or for some reason are more aware of this aspect of human nature? Could the preoccupation be related to bullying of some kind, teasing?

I think the issue was, and remains, that I have a chance for a kind of attractiveness, but only when below a certain weight. And if I was not as attractive as it was theoretically within my power to achieve, what was the point of living, or going out, or seeing anyone? It's one thing to be physically unappealing, but another to possess unappealing character traits - and lack of self-control is unappealing. Sloth and gluttony are unappealing. And if all you think about is death, then you are also a quitter and an overall negative person. If you aren't supporting yourself, you are a parasite. Rationally, you can either try to do something about these things (I was unsuccessful), or you can decide that these judgments aren't acceptable - but I found that I could not force myself to actually enjoy being out in the world, even if I did not share its judgments.

I think that in me it's a complex issue, and that while it may always have been lurking, it could be that a combination of events triggered it or emphasized it. I may have been able to hide it or function adequately if I'd had a little less to deal with in other areas, if I had achieved academic and occupational success.

People with BDD may be preoccupied with more than one area. This is definitely true with me. I suppose the distinction lies in extent. I think all people will be self-conscious about a few of their features. Most people have experienced some form of teasing at some point in their lives. Most people are not perfect. At what point does self-consciousness cross over into a disorder?

Just being aware of the possible influences is not enough to help me shake them off. I don't fit anywhere in life: to psychiatrists and psychologists, I may be considered noncompliant - whatever the story, they ignore me or have never seemed to think it was worth it to talk in more detail (until the meds had kicked in and my thinking was 'cleared up' perhaps), in the eating disorder community I don't fit with those who are pro-recovery or with those who are pro-ana, -mia, I'm not someone who fits in any New Age, wiccan, pagan, spiritual community, tarot community, I'm not someone who fits in with a natural/animal-focused community, I'm not a writer, not an artist, I'm not a website designer, I refuse to be a symbol of hope regarding heterosexual monogamy, I don't even fit in a suicide discussion newsgroup, feminists would probably dismiss me as refusing to take responsibility for my own existence, environmentalists and the politically aware would probably dismiss me as apathetic and empty because I am focused on myself rather than doing something for others and the world I live in, it goes on and on.

When I talk to anyone, how can I describe who I am and what I do with my time? It's extremely difficult not to connect that unpleasantness and vagueness of appearance with who I am intrinsically. In a way it makes sense that I isolate myself from having to deal with that.

I think it is likely that I am still acting out now something that happened when my mother first took me to a professional photographer, except that I act it out in exaggerated form. My 'pretty' photos now are prettier than the ones in which I looked like a normal baby, and the scary or 'ugly' ones are scarier or more dramatic than my horror movie baby photos. I have a kind of control. I am expressing the original conflict, but exercising a kind of creative control over the situation that gives me more power over the adults - I am fighting back against their opinions, challenging them.

Ultimately, though, I have been unable to accept myself. I cannot walk freely in the world, I cannot even kill myself in part because of my issues with my appearance. It would be natural for me to feel a murderous resentment toward my parents, and I admit now that finally, after all these years, I can recognize that I sometimes do. But my thoughts cannot rest there, stay there, because that is not 'authentic' - if I follow the ideas further, and incorporate more of what I have learned in my life, there is eventually conscious choice involved in how I am to process the realization of resentment. If I go down the path of outwardly expressing anger, there may be consequences. The way that I choose to express anger matters. Perpetuating a cycle of hostility doesn't make sense to me. Offering a whitewash doesn't make sense to me. The only thing that makes sense to me is to offer the sides of the issue that I am capable of perceiving, and to remain open to the possibility of discussion.

Otherwise, I suppose that it is about what society has reflected back to me about my appearance. There are occasionally people who have been attracted to me, but there have also been (always) some extremely negative comments about my appearance, and I either might have been overly sensitive (although I did actually hold up to early teasing better than most kids, or appeared to), or the range of reactions was unusual, and it was a difficult job to constantly process too many different kinds of reactions - for most people, it is not that complicated, the way they come across is very similar to all people. A series of traumatic life events might have triggered a more neurotic response.

At age 21, I was extremely lucky to get ID that I didn't mind so much. But I find applying for ID traumatic, for reasons of dealing with the photos alone. There is no way I want to live in a world in which being filmed every day is a given. When I see people on the street interviewed for various news programs, for surveys, for comments on various topics, when people are interviewed in regard to tragedies or in order to share important insights about a disease, or a social problem, I realize that I could not do such a thing, that I am too afraid of the camera, that if I had to look at myself, or let others look at me, I would wish to die immediately. When I was young, I wasn't sure that there wasn't a way to share something closer to what I saw in the mirror with others. Maybe if I actually was filmed in a certain light, with higher resolution cameras, I would actually look better than the ones I had seen so far. That idea has never been explored or tested - I have never been filmed speaking, moving, etc, with a variety of video cameras, lights, angles, etc, and so I don't know for sure if there might be some ways that do not horrify me. However, I suspect that most would.

I can identify with the need to generalize, rather than call attention to the exact details of the ugliness. It's like the power of suggestion is so strong, and in addition the feeling of shame is very strong. Through my years of writing it has become easier to write some of the details, but my obsession with taking photos of myself I think also represents the problem: I try to focus on things that don't call as much attention to what bothers me, I try to see other aspects, but at the same time it is difficult to overcome the fear that the other things are 'more' true and that the situation is hopeless. Definitions of 'slight' defects can vary enormously from person to person. I keep repeating myself, but I think I have more range between ugliness and attractiveness than most people, that some of the ugliness is startlingly ugly (specifically, that I possess features that in modern society are considered unsightly), and that on the whole it makes for a confusing impression.

When it comes to photography, choosing clothing, hairstyles, etc, I doubt that anyone is completely uninfluenced by the impression their image makes upon their own minds, and upon others'. It may be largely unconscious for some people, it may be stressful in varying degrees for many people, but how accepting you are of your appearance depends on a lot of factors. What if some people develop certain personality traits and pursue certain lines of work because unconsciously they have picked up that they look like someone who fits the image? Even an image of someone who doesn't care about appearance and just throws anything on? Even people's judgments about how much other people care about their appearance and how much effort they put into it depends on how those people look, how they 'strike' others, the summing up of visual, vocal, physical, personality cues. Maybe I picked up the idea that no matter what I wore, how I styled my hair, what my facial expression was, I came across as a vague person who was not going to accomplish anything, and who looked like the kind of person who didn't fit anywhere, except maybe eventually a mental institution or the streets, once the civilized grooming was abandoned - because that (grooming) did not help, it just added to the odd impression. But not even there, not 'right' enough, which would lead me to suicide?