By Steven Gregor, InPsych production editor

Think for a moment what it must be like to go to the mirror every morning (and perhaps, compulsively, several times throughout the night) and not like what you see; to feel ashamed; and refuse to leave the house because the thought of others seeing how hideous, how deformed, you are is just too much to bear. Think of the self-loathing, the fear. Think then what it must be like to repeatedly examine your “defects” throughout the day, in mirrors or any suitable reflective surface, perpetuating the cycle of discontent.

Imagine what it must be like to tunnel such intense feelings at a single, and often perceived, flaw; and to be so preoccupied with that perception that personal relationships break down, and social environments are, quite simply, no-go zones.

For someone who does not suffer from Body Dysmorphic Disorder (BDD), these feelings are hard to imagine – maybe impossible.

We live in the age of “nips” and “tucks”, facials, manicures and pedicures (and any other “cure”, really, as long as it makes us look better). As a result, it is reasonable for us, from time-to-time, to feel unsatisfied with our appearance – to have, as they say, a “bad hair” day. This is considered normal by most.

BDD, however, is much more serious a problem.

What is BDD?

BDD is a mental illness and detailed in the DSM–IV as “a preoccupation with a defect in appearance. The defect is either imagined, or, if a slight physical anomaly is present, the individual’s concern is markedly excessive.” It continues by highlighting the preoccupation that can “cause significant distress or impairment in social, occupational, or other important areas of functioning.”

Psychologist, Dr Don E Jefferys, an Associate, Department of Psychiatry, Austin Hospital, University of Melbourne and The Melbourne Clinic, describes the core feature of BDD as a preoccupation with imagined ugliness; so much so, the disorder severely impairs and compromises the patient’s quality of life and general wellbeing.

“Patients undertake a whole range of ritualistic behaviours. They go around comparing themselves to others and grooming activity increases. Patients will check (the “defect”) in the mirror or in other reflective surfaces. It is a preoccupying disease; it dominates their life.

“I was once called out to a home in the western suburbs of Melbourne to treat a girl who had only left the house three times in seven years. They thought she was severely agoraphobic. She described the three occasions when she had left the house – twice was by ambulance for surgery (for an unrelated condition), on the third occasion she had to go to an evening function and she left the house with her face under a raincoat.”

Concerns among BDD sufferers often target the complexion or the overall size and shape of facial features (such as nose, lips or ears) or other body parts (such as arms, legs or buttocks). However, any feature or body part can become the focus of the disorder.

“The facial features are the most common focus but BDD can target any body part and most patients focus on two or three,” says Dr Jefferys.

Why me?

The disorder, by its very nature, often goes unreported and untreated. However, estimations suggest that one per cent of the population may be affected by BDD.

“I don’t think we know the exact figures but, in a clinical setting, I’m seeing more and more of it.” As the disorder achieves greater media attention, Dr Jefferys believes more people will come forward as patients.

Symptoms often first appear during adolescence and its onset is most often gradual; but, it can have an abrupt onset, possibly triggered by a traumatic event. Research has shown that 30 per cent of those with BDD also have Obsessive Compulsive Disorder (OCD).

Research detailing gender ratios among patients offer differing conclusions. Undisputed, however, is the fact that depression is a trademark of the disorder and suicide attempts among patients are alarmingly high. Self-surgery is another common characteristic of the disorder but, Dr Jefferys says, “we just don’t have the figures. This has been a secret illness for a long period of time despite the fact that 100 years ago it was actually formulated.”

A number of environmental factors have been identified as possible triggers for BDD among patients – a child who is the victim of school yard taunts due to his or her appearance, an overemphasis on appearance from family members, or sexual abuse and a subsequent feeling of self-worthlessness, are all situations that could promote the disorder’s development within a patient.

Dr Jefferys acknowledges the environmental stresses that can contribute to the development of BDD in a patient, but believes these stresses often work hand-in-hand with a genetic disposition; he has identified psychiatric histories within patients’ families.

How is BDD treated?

While those with BDD may first seek physical solutions, such as cosmetic surgery, for their “defects”, evidence suggests BDD patients respond best to tailored Cognitive Behavioural Therapy (CBT) sessions (in a group or as an individual) coupled with the option of antidepressant medication – namely, selective serotonin reuptake inhibitors (SSRIs).

Many have traditionally considered medication to be the most effective way to treat the disorder. More recently however, CBT has offered a promising alternative. Exposure and Response Prevention CBT sessions identify and expose the defect (perceived or otherwise), and then offer restraints to future compulsive behaviours.

Dr Jefferys believes a combination of supportive therapy, including CBT, and pharmacotherapy works best in the treatment of the disorder.

“Many of these people also have social anxiety problems; this is often a predisposing factor in this illness.” Dr Jefferys continues by saying practitioners, when making a diagnosis of BDD, should look for “the shy person, the sensitive person, the person who looks away, and the person who may sit in such a way so that their imagined side of ugliness is not directly obvious.”