Imagined Ugliness

Body dysmorphic disorder and assumed defects in appearance

Posted Oct 04, 2016

Body dysmorphic disorder (BDD) is a distressing condition associated with a preoccupation with assumed defects in appearance. These defects in appearance are often imaginary, but if the person does have a physical anomaly, those suffering from BDD will greatly exaggerate its importance. Common complaints include flaws in facial features or facial asymmetry, hair thinning, acne, wrinkles, scars, vascular markings, irregular complexions, or excessive facial hair. Other common preoccupations include body shape generally (e.g. preoccupations with being obese or overweight), and dissatisfaction with specific body parts, such as breasts, genitals, buttocks, etc.

Sufferers will often be so embarrassed about their presumed appearance defects that they will often only talk about them in general terms, and may simply refer to themselves as being “ugly” – hence the condition is sometimes known as “imagined ugliness." As a mental health problem, BDD overlaps with obsessive compulsive disorder (OCD). For example, sufferers will have obsessive, intrusive thoughts about their appearance, and can also develop ritualistic compulsions around their defects, spending many hours a day viewing themselves in mirrors or attempting to deal with their problems with excessive grooming behavior (e.g. skin picking, hair combing, applying cosmetics, dieting, etc.), with such behaviors usually adding to the distress that is experienced.

Concerns about appearance in BDD are frequently accompanied by a host of repetitive and time-consuming behaviors, aimed at verifying, camouflaging, or enhancing the person’s appearance, and one particular repetitive behavior is known as “mirror gazing.” Studies have shown that about 80 percent of individuals with BBD will repetitively check their appearance in mirrors – often for considerable periods of time. Interestingly, the remaining 20 percent tend to avoid mirrors altogether. Mirror gazing can be construed as a “safety seeking behavior,” which briefly acts to reduce distress. However, for individuals with low body-image satisfaction mirror gazing for more than three and a half minutes results in a more negative opinion about their attractiveness, and mirror gazing behavior in the longer term increases distress, maintains negative beliefs about appearance, and reinforces repetitive appearance-checking behaviors (Veale & Riley, 2001).

Individuals with body dysmorphic disorder also develop dysfunctional beliefs about their appearance, and are quite convinced that their own perceptions are correct and undistorted. As a result they may regularly seek cosmetic surgery in order to correct their ‘defects.’ In a study of individuals seeking cosmetic surgery, Aouizerate, Pujol, Grabot, Paytout et al. (2003) found that 9.1 percent of applicants were diagnosable with body dysmorphic disorder. In fact, in those applicants who had no defects or only a slight physical defect, 40 percent were diagnosable with body dysmorphic disorder.

A preoccupation with apparent physical defects often leads to the catastrophizing of these characteristics, and sufferers will frequently comment on their appearance to others in negative ways (e.g. “ I am ugly”, “I am fat”). Nevertheless, regular reassurance from others fails to change these views, and the sufferer can slip into a negative decline which incurs further mental health problems such as major depression, anxiety, social phobia, deliberate self-harm and suicide attempts (Phillips, 2001). In addition, adolescents with body dysmorphic disorder experience high levels of impairment in school and work functioning, with studies reporting disturbingly high attempted suicide rates of around 45 percent (Phillips, Didie, Menard, Pagano et al., 2006).

The exact prevalence rates of BDD disorder are unclear, although a nationwide German survey suggested that the prevalence of BDD at that particular time was 1.8 percent in the general population. This study also indicated that those diagnosable with BDD had high rates of previous cosmetic surgery (15.6%), and higher rates of suicidal ideation (31%). BDD is also relatively common in individuals who already have a diagnosis of OCD, with lifetime prevalence rate for BDD of 12.1% in individuals with OCD (Costa, Assuncao, Ferrao, Conrado et al., 2012) – reinforcing the view that OCD and BBD may be closely related conditions.