Don't Look At Me!

K was diagnosed with Body Dysmorphic Disorder about 10 years ago, but she's had it much longer than that, I'd guess since she was a pre-teen.  Body Dysmorphic Disorder is a mental illness characterized by distorted body image and obsessions about perceived physical shortcomings.  A person with BDD is extremely concerned with their appearance, and this manifests as a preoccupation with a perceived defect of their physical features.  Simply put, K's obsessed with how she looks, because of her (self-declared) flaws.  This causes psychological distress that impairs occupational and/or social functioning.  The person complains of a defect in either one or several features of their body, or vaguely complains about their general appearance. (K complains both generally AND specifically.)   The disorder is generally diagnosed in persons who are overly critical of their mirror image, physique or self-image, even though there may be no noticeable disfigurement or defect.  In other words,  K sees an ugly (read=imperfect) reflection upon looking in a mirror, even though no one else sees anything wrong with her appearance.

BDD is often misunderstood as a vanity-driven obsession, whereas it is quite the opposite; people with BDD do not believe themselves to be better looking than others, but instead feel that their recognized "defect" is unforgivably ugly or not good enough. People with BDD may compulsively look at themselves, or do the opposite-cover up and/or avoid mirrors. They typically think about their appearance for at least one hour a day  (usually more) and, in severe cases, may drop all social contact and responsibilities as they become a recluse.  K positively must look at herself in any mirror she comes across, and spends hours making herself "presentable" before she will leave her house.  We haven't dropped social contact altogether, but do go through periods in which I'll avoid people for days or weeks at a time.

Common symptoms of BDD include:

• Obsessive thoughts about a sensed defect(s)
• Delusional thoughts and beliefs related to sensed appearance defect(s)
• Chronic low self-esteem
• Seeing slightly varying image of self upon each instance of observing a mirror or reflective surface
• Major depressive disorder symptoms
• Suicidal ideation 
• Strong feelings of shame
• Social withdrawal, isolation or social phobia
• Perfectionism 
• Alcohol & drug abuse
• Feeling self-conscious in social situations; thinking that others notice/mock their perceived defect(s)
• Repetitive behavior (such as constantly applying makeup or checking reflection in mirror)
• Compulsive/repetitive body modification (such as multiple plastic surgeries)

I exhibit all of these symptoms.  I must point out that K has never had plastic surgery however.  Instead, my body modification rituals include tattoos, multiple body piercings, cutting, and branding.  One therapist told me that my tattoos and piercings were another form of self-injury, and that my methods had evolved from cutting with razor blades to piercing with needles.  I guess I could believe either explanation.  I am trying to permanently alter my appearance to distract from our flaws (BDD), but K very much enjoys the pain and gets pierced to help her deal with reality or emotional distress (SH).

A person with BDD may exhibit obsessive and compulsive behaviors related to perceived appearance defect(s). (K does all of these things.) Some of these include:

• Compulsive mirror checking OR avoidance of mirrors-- I can't walk past a window or a reflective surface without looking at myself;  I'm not vain, I'm checking my flaws.  On the opposite end of the spectrum, there is a K who hates to see herself in a mirror and tries to avoid it (she also doesn't like to get her picture taken)
• Attempts to camouflage perceived defect (such as wearing lots of makeup, hats, or baggy clothing)--A couple of the K's wear little to no makeup, but most of us use a good deal of concealer and liquid foundation, and a bright red lipstick to draw the eye away from our flaws. (The Kellie loves to be dramatic and wears heavy eye makeup as well.)  All of the K's wear hats (K collects hats) and most of us wear baggy clothing to hide our body.  However, The Kellie will wear fitted clothing, and she loves to wear corsets. Note that corsets also alter the appearance of the body.
• Use of distraction techniques (such as wearing extravagant clothing or excessive jewelry)--Each of the K's has a different style, but almost all of them stand out in a crowd and are over the top with accessories-hats and scarves and tons of jewelry.
• Excessive grooming behaviors (hair-combing, eyebrow plucking, skin picking)-- Throughout the day, most everyday, K smooths or touches her hair, plucks her eyebrows and also picks at her skin. I'm not sure if this counts, but she also paints and repaints her nails and toenails.
• Seeking reassurance from loved ones-- I seek constant reassurance from my husband, friends, and family about how I look.  "Do I look OK?" comes out of K's mouth dozens of times a day.
• Comparing appearance to that of others--Not only do I compare myself to every female over the age of 16, but I almost always feel that every other girl I see is more attractive than I am.
• Compulsive skin touching (to feel the perceived defect)--I catch myself constantly touching the areas of our face and body which I feel are unacceptable; I don't know why...maybe to see if the flaw is still there or has grown larger?
• Self harm--My first memory of self-harm is from 4th grade, and it's gotten worse over the years.  I intend to do a blog post soon about my experiences with self-injury.
• Obsession with plastic surgery--As I said earlier,  I've never had plastic surgery,  but I do constantly think about which procedures I'd  have done if I could afford it. (breasts reduced and lifted, tummy tuck, forehead lift, butt lift, facelift, all-over liposuction...) In extreme cases, patients have attempted to perform plastic surgery on themselves, including liposuction and various implants with disastrous results.  I have to admit that I have done some minor work with a scalpel, but certainly nothing drastic. 

The three most common areas of which those suffering from BDD are critical are the hair, the skin, and the nose.  For K, the obsession focuses on her skin, especially that of her face, and she's particularly critical of her chin/jawline/profile.  She's been obsessed with her teeth for as long as she's been seeing a dentist.  She's also obsessed with her overall body, mainly the legs;  to a lesser degree she obsesses about her nose and hair.

In most cases, BDD is under-diagnosed.  It is often associated with shame and secrecy; therefore, patients often fail to reveal their concerns about their appearance for fear of seeming vain or superficial.  BDD is also often misdiagnosed because its symptoms can mimic that of major depressive disorder or social phobia.  K, like most people diagnosed with Body Dysmorphic Disorder, is shy, introverted, and neurotic. Certain personality traits make people more susceptible to BDD.  Others include perfectionism, sensitivity to rejection or criticism, unassertiveness, and social phobia.  K is bothered by all of these things.  Treatment for Body Dysmorphic Disorder includes both cognitive behavior therapy and medication, namely SSRI's.  K is currently being treated with both of these.  Writing about it now, and seeing everything in black and white, the diagnosis seems so simple and easy-to-see.  If only it had really been that easy for our doctors! Perhaps then K would be living a different life now, with more confidence and fewer mirror checks.