Misdiagnosed, Misunderstood & Misjudged: Understanding Body Dysmorphic Disorder
Jasmine Laws / June 20 / BDD
Body Dysmorphic Disorder (BDD), classified in DSM-5’ under the ‘obsessive-compulsive and related disorders’, is a disorder described by sufferers as ‘a living hell’. It is clinically defined with the criteria of appearance preoccupations and repetitive behaviours for appearance concerns, but it is not directly an eating disorder, which is often misunderstood.
BDD is often misdiagnosed as OCD, social anxiety disorder, manic depressive order, eating disorders and many others, making it a difficult disorder to understand. Statistics state that BDD only affects 2% of the population, but this may be an underestimate, given it is often misdiagnosed, and those struggling with BDD are often reluctant to seek help as they want to hide their perceived ‘flaws’ from others. This preoccupation with appearance is often criticised as vanity, or narcissism when in reality it is like living in a mental prison.
The obsessive need to control a person with BDD experiences, with daily rituals to feel even able to leave the house and get through a day, has meant that the pandemic and periods of lockdown have turned this entrapment into suffocation. Having no control of one’s life, severe uncertainty for one’s future, one’s safety, and even one’s survival, those with BDD have found that they manifest their need to feel in control into more obsessively controlling the flaws they see in their appearance.
A study in the International Journal of Women’s Dermatology shows the increase of cosmetic surgery since the start of the pandemic: where 56.7% of dermatologists reported increased demand for cosmetic surgery, with 86.4% of patients explaining video-conferencing and Zoom calls being a reason for their want of cosmetic care. It is undeniable that Zoom, video-conferencing and social media have all played an intrinsic role in worsening the rate and extent of BDD for many people. The worst part is that, even though there is more discussion on BDD in light of the pandemic, there is still a severe problem in people’s understanding of what the disorder actually is.
Given that 70% of cases show the onset of BDD occurs before the age of 18, there is noticeable blame to point towards social media. Social media is a toxic master-mind that influences people daily through appearance-related judgement: how many likes on a post, how many followers, how many comments a person has become obsessive pre-occupations with one’s image online. Questions like: “Am I as pretty as her?” “Why does she have more followers than me?” “Is it because there is something wrong with me?” lead to conclusions like: “I need to be like her if I want to fit in and belong” “There is a problem with how I look” “I need to be attractive under society’s terms in order to be accepted”. As children are getting progressively more involved in social media from a younger age, these questions and conclusions form their mindset of image and appearance, without the rationale of knowing how social media is photoshopped and crafted in ways to make images appear more like society’s ideal of ‘attractive’.
This separates image from reality online and in real life, as people then only see how their body is different to society’s ‘perfect body’, rather than actually seeing their own body. One’s reflection is then no longer a reflection of one’s body, but rather a reflection of what is lacking or ‘not good enough’ in one’s body.
In an interview with the Human Perspective, Caitlin Conmy spoke out about her impression and experience of BDD, and she described the way that social media is a “constant reminder of what you don’t have”, and also leaves you “comparing your worst moments to other’s people’s best”, as while many people in the UK struggled with the lockdown restrictions at Christmas time, many influencers were posting about their holidays to luxurious places like Dubai. She explains how, because of the inescapable influence of social media, that “you forget that that’s someone else’s reality you’re trying to live up to” and that the “perfect body is not achievable for the majority of people”.
Arguably, the impact of social media is not entirely negative. 46% of men and 31% of women claim they are now more likely to open up about personal struggles on social media than before the pandemic, and 42% argue they feel less pressure to represent themselves unrealistically. Although, this is misleading: it suggests that people are more open on social media, implying society has become more accommodating for every individual, every body type, every skin colour, when it has not. This deceives people into thinking that those with BDD will start to feel better, as boosting body positivity movements and awareness online is not what BDD is about. Those with BDD can be misunderstood as having eating disorders, as they are assumed to be pre-occupied with their weight. This is not the case. The boosting of the body positivity campaign does not make someone with BDD feel more accepted online, as it is not about weight, and this is largely where BDD is misunderstood. So, while social media has played a role in creating greater awareness of personal struggles, it has not helped those who suffer from BDD. Instead, during the pandemic, BDD has been more recognised as a disorder that is largely misunderstood and misdiagnosed.
In an interview with The Human Perspective, clinical psychiatrist Dr. Katie Russell has discussed a number of the misconceptions of BDD. She explains how people misunderstand BDD as “vanity”, or being “vain and self-obsessed” when in reality people with BDD report being “riddled with self-loathing, self-hatred, shame, loss, guilt, fear and humiliation”. They will engage in activates like mirror-gazing, skin picking and long rituals of self-preparation that appear self-focused, but the reality of this disorder is that these rituals are the only way they can even begin to attempt to feel accepted by society. This is where there is a misconception of BDD as being an eating disorder. BDD is rarely connected with weight preoccupation alone; BDD is about any flaw a person believes they have that other people will barely if at all, be able to see. The belief system of a person suffering BDD is “rigidly aligned with the obsession that there is a flaw, where there is no alternative other than that being true”. Over time the belief becomes internalised as a fact.
This forms much of the misjudgement of BDD being about vanity, as when someone else tries to re-assure someone with BDD, and they respond still saying they have a flaw in their appearance, people may take that as fishing for compliments. Yet, in actual fact, the person with BDD just genuinely cannot see what other people see, as their self-evaluation is seen through this flawed lens. BDD is not vanity; it is not a vain obsession of appearance; it is an obsession with one’s self-proclaimed flaws, and this makes a huge difference which people cannot understand. It is hard for people to understand, as it is not something that they can make sense of if they cannot see the flaw, or they cannot grasp the fact that they are seeing a different reflection of a BDD sufferer’s body than they see of themselves. This is why it is such a difficult illness. It is all-consuming, it is “like a prison sentence”, and yet it is misjudged on a large scale.
People who suffer BDD experience significant and often deeply rooted self-hatred, insecurity, shame, guilt, humiliation and loss, that manifests themselves in how they physically see themselves in the mirror. As Dr Katie Russell explained in an interview, CBT (Cognitive Behaviour therapy) is the treatment with the biggest research base. This treatment is about transitioning people with BDD from ‘Theory A’ to ‘Theory B’: Theory A is their current reality, that there is a flaw, and Theory B is introducing the idea of an alternative explanation. This introduces the possibility that there isn’t a flaw, but rather a strongly held belief about imperfection, and that the belief may not be the truth. Treatment for BDD may also address the reasons for the underlying problems with self-esteem and self-image, while also working on rationalising, accepting and moving on from all the underlying pain and loss associated with the impact of the disorder. So, BDD is living in a permanent state of belief that you are flawed, unacceptable, disliked, perhaps even hated by others, because of underlying feelings of self-hatred and a lack of self-acceptance. It is hopefully clear how little BDD has to do with weighing scales: eating disorders are not the same as BDD, as they are just a way a person with BDD may respond to their feelings that they have a flawed appearance.
Kitty Wallace refers to one of the members of the BDD foundation’s discussion of how she would go outside for a walk during lockdown, and when people would avoid her in the streets, she believed that this was because there was something repelling, even repulsive about her, that deterred people away, rather than it being because of social distancing measures. This has complicated treatment for people with BDD, because of the experiments BDD sufferer’s will be asked to try in therapy includes walking through the streets and checking to see how many people look, if at all, and how long for, to show them that they are not being judged by others in the way they think they are. However, social distancing measures and the fear factor of the virus, have caused people to avoid others, and perhaps notice them more, meaning that people suffering from BDD fall more into the trap of thinking that they are being personally judged for the flaws they see in themselves. This makes people with BDD undergo rituals even as long as 2 hours in the morning, or 3-8 hours throughout the day, just to leave the house for school, work, or even for a walk. Thus, when they still feel unaccepted when leaving the house, it only taps into their comparative bias more, making them determine that everyone else sees their flaws and judges them for it.
Therefore, you can see that BDD is not about body size, like eating disorders are. It is about the body itself: “my stomach is a weird shape”, “my skin has stretch marks”, “my face is ugly because my features are out of proportion” are some examples of the fixations people with BDD would have, that are not connected to weight. Natalie Olah from Refinery discusses how Zoom for a person with BDD means that they are forced to see a “constant reflection” of “unhelpful feedback” from having a camera pointed directly at their face. Zoom calls do not show the body on the screen, so this is not a question of body size, it is about a person with BDD simply being seen. There is such a great humiliation, and insecurity of their appearance, that being seen by others is hugely difficult for a person with BDD.
Thus, there is clearly a problem with society’s understanding of BDD. BDD is twice as common as OCD, however patients suffering from BDD will be misdiagnosed – in 4 studies every case of BDD in patients was missed by clinicians. This is hugely problematic when nearly 30% of BDD sufferer’s attempt suicide. BDD needs to be understood; it needs people to take the time to recognise that it is not about body weight, it is not about fishing for compliments, it is not vanity: it is a debilitating disorder that is a psychological prison. The impact it has on the daily life of individuals suffering from it is screaming at society to listen and understand, and stop labelling it as just a vainer eating disorder. BDD is linked to trauma, pain, suffering, mistreatment, abuse: it is not vanity. As the pandemic nears its end, with restrictions starting to lift, social media asking ‘what are you going to wear on the 21st June’ and ‘I need to be attractive and ready for 21st June’, means that those suffering BDD are headed from one nightmare to the next. While the pandemic has been a prolonged struggle for many, it has been suffocating for those with BDD. Yet, now, as things start to lift, they are faced with the next challenge: re-entering back into society, and having to face people and their fears of being judged and accepted in social environments.
The thing to take from this is that, unless you have experienced BDD yourself, or listened to people who have openly discussed it, you will probably find that your conception of BDD is misleading because society paints a misconstrued picture of it. What is so important now, is for people to stop being influenced by the misconceptions of this disorder, and appreciate that BDD is a harmful, painful mental disorder. A person suffering from BDD is in a lot pain. Being misdiagnosed, misunderstood, misjudged, only adds to that pain, and so society’s biggest problem is to recognise that, in order to stop the way it falsely labels the disorder.