Mandy Rosenberg, 35, from Brookfield, Wisc., has always drawn attention because of her looks. With her long blonde hair, athletic build and large blue eyes, she was called Barbie by some of her high school peers.
But even though people often told her that she was pretty, she didn’t view herself the same way.
She’d spend hours staring at a tiny blemish on her forehead that was barely visible to others. In her mind, it was a large and unsightly scar, and she would climb on top of her bathroom sink to get as close to the mirror as possible while examining it.
“If I couldn’t make that go away, I didn’t want to live anymore,” she said.
Ms. Rosenberg didn’t know it at the time, but she had both obsessive-compulsive disorder and body dysmorphic disorder, or B.D.D., a mental health condition that causes people to spend an inordinate amount of time worrying about their appearance — to the point where they may isolate themselves from others and feel imprisoned in their own bodies.
People with B.D.D. not only think they look unattractive but can become convinced that others will reject them because of their flaws.
“They often feel they’re unlovable,” said Dr. Katharine Phillips, an expert in B.D.D. and a psychiatrist at Weill Cornell Medicine and NewYork-Presbyterian.
What is body dysmorphic disorder?
Those with B.D.D. fixate on perceived cosmetic problems that to others appear unnoticeable or minor. But it’s not about vanity; instead, people with B.D.D. feel extreme anguish that impairs their functioning.
The disorder typically emerges during adolescence and is estimated to affect 2 to 3 percent of the general population, but these numbers may be conservative because the disorder is underdiagnosed.
Studies have shown differences in the brains of people with B.D.D., said Dr. Jamie Feusner, a professor of psychiatry at the University of Toronto Temerty Faculty of Medicine. Some of his research has found that in those who have the condition areas of the brain that help us view things holistically are underactive.
This might be part of the reason that people with B.D.D. have trouble viewing their imperfections as small relative to their entire face or body. It’s akin to looking at a window with a smudge on it, then “thinking that the whole window is ruined,” Dr. Feusner said.
Patients with B.D.D. aren’t always aware that their concerns stem from a mental health problem. Instead, they often believe wholeheartedly that they have physical defects.
Because of this, someone might suffer for a decade or more before seeking help from a mental health provider, said Hilary Weingarden, a psychologist in Massachusetts who studies O.C.D. and related conditions.
Instead, “they’re going to their dermatologist and a plastic surgeon and the dentist and the aesthetician,” she said.
But trying to “fix” their appearance only serves to maintain and exacerbate their anxiety in the long run.
What are the signs and symptoms?
People with B.D.D. may withdraw from relationships, avoid attending work or school, and spend an excessive amount of time on repetitive behaviors like examining themselves in the mirror, attempting to camouflage their appearance or seeking reassurance from others.
Chris Trondsen, a therapist in Costa Mesa, Calif., who diagnosed Ms. Rosenberg with B.D.D., said his patients admit to spending hours chatting with artificially intelligent bots, both seeking affirmation and asking what they ought to fix.
“If you ask a human, people are going to get fed up answering the questions,” Mr. Trondsen said.
Mr. Trondsen was inspired to study psychotherapy because of his own struggle with B.D.D. He used to fixate on his complexion and other parts of his body, too. He worried that his nose was too large for his face and that his body wasn’t muscular enough, a form of B.D.D. called muscle dysmorphia.
“I kept thinking I was getting uglier,” Mr. Trondsen said.
Like many patients with B.D.D., he also spent hours checking his body in mirrors and rarely left his apartment. At 21 years old, Mr. Trondsen became so isolated and consumed by his appearance that he attempted suicide, and might have died had his roommate not discovered him. After that, he sought help and was diagnosed with O.C.D. and B.D.D.
It’s common for those with B.D.D. to also have conditions like O.C.D., major depressive disorder, social phobia and substance use disorder. Studies indicate that people with B.D.D. have high rates of suicidal ideation and behavior, too. One meta-analysis found that, across a patient’s life span, about 66 percent of those with B.D.D. will have thoughts of suicide and around 35 percent will attempt it.
How is it treated?
Cognitive behavioral therapy for B.D.D. has been shown to lead to remission in more than half of patients. It includes exposure and response prevention, which is meant to help patients gradually confront the things that they have been avoiding or the rituals they have become dependent upon, like hiding parts of their body with clothing or makeup.
Therapists try to help patients view themselves more holistically, emphasizing that there’s more to them than the specific parts of their bodies they scrutinize.
The disorder can also be treated with serotonin reuptake inhibitors, or S.R.I.s., often at high doses. For those with severe B.D.D., both medication and C.B.T. are recommended, Dr. Phillips said.
For Ms. Rosenberg, cognitive behavioral therapy with her former therapist, Mr. Trondsen, gradually helped her condition.
Later, as part of her treatment, she created a diagram showcasing all of the things that contribute to her identity: She is a daughter and a faithful Christian, she loves dogs and cats, she is a teacher, she is caring — she is more than just her looks.
My body, she said, “doesn’t get to determine how I go about my day.”
