The Broken Mirror

by Mary Allen and David M. Edwards

Painting by Roger Casier
courtesy of NARSAD Artworks; Art by and on behalf of persons with mental illness.


In an episode of "The Twilight Zone," a young woman, her face totally obscured by bandages, is in a hospital full of caring, sympathetic doctors and nurses. The young woman is there in an attempt to correct her hideous, congenital ugliness. As she waits anxiously for the bandages to be removed to find out if the procedure has been successful, we witness the agony she feels because of her perceived freakishness. We also overhear the doctors and nurses privately express their sympathy, though unable to mask their revulsion. Finally, the bandages are removed, and we see what is, to our eyes, a beautiful, perfectly normal-looking young woman.

In rapid succession, we see her horror at her reflection in the mirror, hear her anguished cry that the procedure has failed and see the faces of the staff (which have been artfully hidden from view till now), all of whom look to us like horrible monsters. This television episode says much about the cultural perception of beauty and ugliness. But what about people in the real world who, although they appear absolutely normal to others, are so preoccupied with some perceived physical defect that their lives are seriously affected? Such people may suffer from Body Dysmorphic Disorder (BDD).

Dr. Katharine A. Phillips is recognized as the country's most experienced researcher and clinician in the area of BDD. Her recently published book, "The Broken Mirror," provides a wealth of information for the mental health professional as well as for others interested in learning more about this disorder. Treatment Today recently spoke with Dr. Phillips regarding the current state of knowledge about BDD and what the future holds.

The origin of BDD is obscure. "The clues we have suggest it results from a variety of factors," according to Dr. Phillips, including biological/genetic factors, psychological factors, teasing and societal factors that emphasize the importance of appearance. "It's probably a combination of all these things." As for the incidence of BDD, again information is scarce. "This is definitely not a rare disorder," Dr. Phillips said. The best estimate is that it may affect as much as 2 percent of the population. "What we need in order to know how common it is are large-scale epidemiological surveys, which haven't been done."

A similar problem that comes to mind when discussing BDD is that of eating disorders. "There are some interesting similarities between them because people with eating disorders have a lot of concern with their bodily appearance," Dr. Phillips said. "There are even similar compulsive behaviors, such as checking mirrors a lot or weighing themselves or exercising too much." Though related, these are nevertheless distinctly different afflictions. "The most common concerns with people with BDD involve the face -- facial skin, nose, hair. The focus of concern is somewhat different."

BDD is often misdiagnosed. "Patients will often talk about the associated depression but not the BDD," according to Dr. Phillips. Other common misdiagnoses include social phobia and obsessive-compulsive disorder (OCD). "In fact, it's probably related to OCD, but I don't think it's exactly the same disorder," Dr. Phillips said. "You don't see a lot of depression with OCD." Unfortunately, confusion with other disorders is only part of the misdiagnosis problem. "I think the biggest problem is that it is totally missed," she said. "The clinician looks at the person and the person looks fine. And they say, 'Oh don't worry about it. You look fine.' "

The seriousness of BDD is underscored by the prevalence of suicidal thoughts and attempts. Dr. Phillips speculates that this is related to co-occurring depression. "BDD is really characterized by feelings of worthlessness and rejection," she said. "With these very deep-seated feelings of low self-esteem, shame and worthlessness, people often end up feeling very isolated from others. I think all of those feelings can easily lead to feelings that life isn't worth living." One area that needs more research is the link between BDD and adolescent suicide.

"I have data on 15 to 20 cases at this point," Dr. Phillips said, describing what she says is the largest group of adolescents with BDD studied thus far. "There is a fairly high rate of suicide attempts among those individuals," she said. "The disorder needs to be studied in adolescents, and a link with suicide attempts really needs to be studied. It's very important."

Based on her work with people suffering from BDD, Dr. Phillips has some informed opinions on what type of therapy works best. She believes the two kinds of treatment that appear most effective are serotonin reuptake inhibitors (SRIs) and cognitive-behavioral therapy. SRIs are a class of antidepressant medications that have anti-obsessional properties. "They really seem to help people obsess less and feel more comfortable going out, and it lessens their depression. Interestingly enough, the medications help to 'stay out of the mirror' and help them resist the compulsive behaviors."

Cognitive-behavioral therapy, on the other hand, "is a very here-and-now treatment focused very much on the symptoms," Dr. Phillips said. "The therapy helps the patient resist and ultimately stop the obsessive-compulsive behavior, like mirror-checking, and helps them go out and do the things they are avoiding."

The first step in treating any disorder is to recognize it. To that end, Dr. Phillips' book contains questionnaires and diagnostic instruments which can be used by clinicians and other readers to help determine if someone has BDD. "There was nothing out there on this disorder, and I had gotten so many requests from so many patients and from their families to give them something they could read," she said. "I really wanted the public to know and professionals to know, including the medical profession, that there is such a disorder and the people really suffer and that there are treatments that appear very, very promising."

What should be done if you think you or someone you know has BDD? "I think the best advice is to find a qualified professional who is familiar with BDD and who treats patients with OCD," Dr. Phillips said. "I recommend to people that they contact the Obsessive-Compulsive Foundation in Connecticut." They can help people find clinicians who are familiar with BDD and will provide the names of people in a particular area of the country.

"There is hope, and in the coming years I feel we are going to learn so much about this disorder," Dr. Phillips said, sounding an optimistic note. Although more research on this disorder is sorely needed, there are effective treatments for people who suffer from BDD. "That's the good news about BDD -- I think a lot of people can be helped."

For more information, contact the Obsessive-Compulsive Foundation, P.O. Box 70, Milford, CT 06460-0070; 203/878-5669.

© 1997 Quest Publishing Company, Inc.

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