What Causes Unreasonable Obsession Over Physical Appearance?

One of my family members has a serious obsession with her skin. She is constantly asking if her skin looks “normal.” Sometimes she won’t even leave the house if she has a blemish. I know this behavior isn’t healthy. Do you have any suggestions for how I can help her get over this obsession?

A man thinks his nose is too large. Others don’t share his perception. He has seen two plastic surgeons and it has been apparent to both that his description of his nose is so out of keeping with what they see that surgery has been refused. He avoids being seen in profile and often cups his hand over his lower face.

A woman thinks, unreasonably to her sisters and husband, that her breasts are too large. She wears loose unrevealing clothing and jackets (even in hot weather), and refuses to wear bathing suits. She thinks of going to a surgeon for breast-reduction surgery but has not because of the opposition of her relatives.

Another man, like the “family member” above, is very self conscious about his skin. He has only a small area of mild post-acne pitting of his face but regards himself as “disfigured.” He spends much time before the mirror studying himself, uses creams to hide the blemished area, but then worries that the cream is “too obvious.” He has consulted dermatologists and is scheduled for a planing of the skin.

Such are the sufferers of body dysmorphic disorder (BDD) (dysmorphophobia) — a disorder in which there is an obsessive concern and preoccupation with the appearance of a body part. Usually, the body part in question is wellwithin the range of normal appearance. In cases where there is some abnormality, the person’s reaction is out of proportion to the reality. BDD is more extreme than normal adolescent preoccupations about minor defects in appearance (although the difference may be difficult to see).

It is also different from the kind of concerns a person can get about the body when they are suffering from depression, an eating disorder, or schizophrenia. For example, in depression, a person can feel that nothing about her body looks very nice, or she can feel convinced that she has a serious and undiagnosed medical illness. People with eating disorders have a distorted image about their bodily weight, while some people with schizophrenia experience strange bodily sensations or the feeling that their body is under the control of an outside force.

BDD is believed to be related to obsessive-compulsive disorders (OCD) — and is thus called an OCD spectrum disorder. Instead of having a recurring image, thought, or compulsion, as happens in OCD, the person has a persistent, recurrent conviction about a body part. Current research indicates that the OCD spectrum disorders are linked to dysfunction in the parts of the brain that are related to the regulation of very basic stereotyped, repetitive behaviors. Commonly, there are other people in the family who have BDD or OCD.

Since social and occupational function may be affected and the individual is in considerable distress, BDD should not be passed off as wilful vanity. There can also often be a concurrent depression, as the person feels trapped and hopeless about what he or she perceives as a terrible physical defect. People with BDD often respond well to an SSRI antidepressant medication, and occasionally also require a trial of other kinds of psychiatric medications.

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