Body Dysmorphic Disorder
My day job involves countless interactions with emaciated anorexics arguing “I’m so fat! I know I’ve gained way too much weight. I’m healthy now. I don’t need to gain anymore weight. I’m the fattest one here!” And boy do they believe it, as much as they do that grass is green. To them, it’s true. It’s their reality. While I sit across from them trying to understand how a 60 or 70 lb adult can be fat, they sit across from me trying to understand how I can’t see that it’s true! While I see an emaciated and undernourished individual, they look in the mirror and literally see an overweight individual.
This phenomenon is called body dysmorphia and it runs rampant among individuals who suffer from eating disorders. Body dysmorphia is when an individual obsesses over some “flaw” in their appearance. This can be over a specific body part or over one’s overall weight and shape. This “flaw” is typically over-exaggerated or not even present at all. If left untreated, body dysmorphia usually worsens over time and leads to compulsive behaviors such as body checking, eating disorder behaviors, excessive grooming, comparisons to others, social avoidance, low self-esteem, and numerous cosmetic surgeries with little satisfaction.
In my opinion, body dysmorphic disorder falls in the camp of an anxiety disorder, and more specifically, an obsessive compulsive disorder (OCD). OCD involves some sort of obsession which is followed by compulsions, attempts at reducing the anxiety produced by the stimuli, or obsession. For example, in the case of body dysmorphic disorder, one’s obsession might be weight. The stimuli is highly exaggerated and blown out of proportion so that the affected individual literally sees a much larger representation of themselves in the mirror than is reality. A healthy person from the outside would be able to see that they are extremely thin, not fat at all. But the affected person truly sees and feels fat. Consequently, this arouses extreme anxiety. In attempts to lower the anxiety, the individual will engage in compulsions, most probably weight loss behaviors such as restriction, purging, and/or compulsive exercise.
As in any manifestation of obsessive compulsive disorder, the issue is not about the reported obsession. The issue is about the underlying anxiety. In other words, the issue is not about being overweight, no matter how much the individual feels it’s so. The issue is about the underlying anxiety. In OCD behaviors, anxiety gets placed on, or manifested in, some sort of concrete worry, thought, rumination, or body obsession. In the case of body dysmorphia, the underlying anxieties literally get embodied. This is where therapists have to become detectives. They have to uncode, so to speak, what emotions and beliefs are getting acted out in what the client sees reflected to them in the mirror.
As a therapist, my job is to help my clients extract their feelings from their body and free them up to experience their emotions for what they are. Most of the time, body dysmorphia is caused by a mix of shame, low self-esteem and perfectionism. Many times, there are feelings of fear and disgust. Sometimes these feelings stem from a violation that has occurred against the body. Rather than confronting and experiencing these emotions, which may feel overwhelming and lethal, individuals have somaticized them into body obsessions. It’s a way of saying “if I can change and perfect my body then I can change and perfect these feelings. I can make these feelings go away.” Of course this is not a conscious thought transaction, but it is an unconscious protective mechanism that may have served to help them survive a real or perceived threat. With a lot of work and persistence, recovery is possible.
Many people who suffer from body dysmorphic disorder also suffer from anxiety, depression, obsessive compulsive disorder, or eating disorders. Treatment includes a mix of cognitive behavioral therapy to change the negative thought patterns, exposure and response prevention (ERP) to treat the obsessive compulsive component, and medication.
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