Obsessed with ugliness

For sufferers of Body Dysmorphic Disorder, extreme dissatisfaction with appearance can have tragic consequences.

Research shows that between six and 15 per cent of people who choose to have cosmetic surgery or aesthetic skin treatments are suffering from Body Dysmorphic Disorder.

Beauty is in the eye of the beholder, but what if the beholder and beheld are the same person? Gazing into the mirror some people fall in love with their own reflections, as did the mythological Greek youth Narcissus. Others less enamoured of their own physical appearance recoil in horror, or seek a second opinion such as "do I look fat in this?". And beyond this is the extreme of those people who are so distressed by their own physical appearance that they avoid mirrors, shop windows and reflective surfaces altogether.

Every individual has their own perception of physical beauty as well as their own opinions as to how important beauty is to them. When asked to rate our own physical appearance we often get it massively wrong. Our subjective ratings of our physical appearance can deviate enormously from how the majority of other people see us - a phenomenon attested to by a wealth of social psychological research. The overwhelming message from research looking at "self vs other" attractiveness ratings is that the relationship between subjective and objective ratings is very weak for men and extremely weak for women. As often as not, men and women who see themselves as lowly unattractive 2s are rated by others as highly attractive 8s, and many grandiose self-proclaimed 10s are in consensual reality 2s.

These self versus other attractiveness studies also tend to report that self-attractiveness ratings are related to higher levels of self esteem, even when the objective ratings of physical attractiveness are low. In short, people who think they look good tend to feel good, with the converse being equally true. When the negative misperception of physical appearance is extreme it can result in the diagnosis of a severely debilitating psychological illness known as Body Dysmorphic Disorder (BDD).

People experiencing BDD are extremely uncomfortable with and critical of their physical appearance despite having no obvious imperfections recognisable by others. Also known as "imagined ugliness", the disorder has a long history and has gone through several re-brandings. The Italian psychiatrist Enrico Morselli in 1886 dubbed it "dysmorphophobia", and earlier still it was termed l'obsession de la honte du corp, roughly translating as "obsessive body shame".

In today's appearance-obsessed world many people would like to improve some aspect of their physical appearance. In fact dissatisfaction with the way we look has become so widespread in certain western nations that psychologists working in this area of body image have coined the term "normative discontent", implying that it is actually the norm to be dissatisfied with one's physical appearance. Far beyond normative discontent, the distress caused by BDD is massively disproportionate, to the extent it interferes with important areas of a person's social and occupational functioning. For example, imagining herself hideously ugly, a young woman may avoid virtually all social interaction for fear of humiliation and embarrassment. So extreme is the distress that 50 per cent of BDD sufferers will pursue cosmetic surgery in mostly futile attempts to improve their imagined defects, and tragically, some 28 per cent eventually seek solace in suicide, which is twice the suicide attempt rate of severely depressed individuals and far in excess of that expected in the general population.

Key signs and symptoms of BDD include a preoccupation with one's physical appearance, which may manifest as repetitive, almost ritualistic checking and grooming behaviours such as frequently looking in the mirror, or obsessively avoiding mirrors. There is also a strong belief in the abnormality of one's physical appearance that leads to extreme self-consciousness and to frequent requests for reassurance about one's physical appearance from others. Often a sufferer will engage in camouflaging behaviours, going to extreme lengths to conceal the imagined defect. This can include wearing hats, baggy clothes, sunglasses, gloves and excessive make-up. Probably the most disruptive common behavioural symptom of BDD is the avoidance of activities outside of the home, including social engagements and educational or occupational responsibilities.

To understand which body parts are most commonly the source of distress Dr Katharine Phillips, an internationally renowned expert on BDD, examined the cases of 500 BDD patients. She found that the most common source of distress was skin - 73 per cent of patients were distressed by their perception of freckles, acne and other dermatological blemishes. Hair was the second most common source of distress with at least 56 per cent reporting some hair-related appearance anxiety, and number three was the nose, with 37 per cent expressing distress over its size or shape. It is interesting to note that weight, a common source of distress in the general population, was not among the top three. However it did make the overall list, with about 22 per cent of patients citing weight gain and the stomach as a source of distress. It is important to note that people experiencing BDD commonly have more than one perceived defect and the perceived defect or defects can alter over time.

Epidemiological research suggests that between six and 15 per cent of patients seeking elective cosmetic surgery or aesthetic dermatologic treatments are experiencing BDD. There are also numerous reports of desperate BDD sufferers attempting "do it yourself" cosmetic surgery with horrific results - imagine trying to lighten your skin with sandpaper or to tighten loose skin with a staple gun. Despite the high rate of BDD sufferers seeking elective cosmetic treatments, the evidence suggests that such interventions offer very little hope of relieving appearance anxiety, and in many cases they actually make the situation worse. With the correction of one supposed defect, BDD patients are quick to become preoccupied with another imagined or exaggerated blemish.

Many specialists in BDD advocate that those offering cosmetic surgery and other related elective treatments should screen their patients for BDD to avoid unnecessary and generally unsatisfying surgical outcomes. Such screening tools do exist and are both highly sensitive and specific in their ability to identify individuals experiencing BDD. Treatment options for BDD include psychotherapy and medication, both of which are much more effective clinically and cost-wise than going under the knife. Given the current global surge in the popularity of elective cosmetic interventions, screening for BDD is now more important than ever.

Justin Thomas is a psychologist working within the Department of Natural Science and Public Health at Zayed University in Abu Dhabi. Hafsah al Habsi is a student who recently completed the Psychology of Everyday Life Course at Zayed University in Abu Dhabi.