Do You See What I See?: Body Dysmorphic Disorder and Self-Perception

Sudiksha Miglani

Illustrations by: Natalie Bielat

Imagine that you are visiting a local carnival with your family. You step into the House of Mirrors and marvel at the different reflections of varying heights, shapes, and sizes. As you stand in front of a large mirror and look at your reflection, you can barely recognize yourself. The curved, irregular surface of the mirror alters the angle at which reflected light hits your eyes, making your body appear very different from what you actually look like. Your body seems longer, wider, and strange. Fortunately, because you know the mirror is distorted and the reflection does not display your true appearance, it’s initially easy to dismiss what you see. But if you were to stare into the mirror for a long time, with no other reference for your appearance, you might begin to believe that the reflection is accurate. This overwhelming, dissociative experience can be faced by individuals with body dysmorphic disorder (BDD) on a daily basis.  

For people with BDD, every mirror becomes like the one from the carnival, as the way they see their body is distorted. BDD is a mental health disorder characterized by an individual’s constant fixation on perceived physical flaws. People with BDD are extremely uncomfortable with flaws in their appearance, and they typically try to conceal them by isolating themselves socially, covering themselves with clothes or accessories, or grooming themselves obsessively [1]. Sadly, these actions typically provide little respite. Individuals diagnosed with BDD may also suffer from other mental health issues such as depression, self-harm, or suicidal thoughts [2]. While BDD affects roughly 2% of the general population, the neurophysiological, genetic, and cognitive causes underlying this disorder are not well understood [3]. However, we know that biological factors — such as irregularities in specific brain regions and low neurotransmitter levels — as well as sociocultural standards, may increase the risk of developing BDD. Shedding light on the causes and symptoms of BDD is critical to increase awareness of this serious and under-recognized condition, so that it is better understood by the general public [4].

BDD: A Personal House of Mirrors

Chances are, your morning routine goes something like this: you roll out of bed, brush your teeth, fix your hair, and spend some time choosing an outfit for the day ahead. As you briefly gaze at your reflection in the mirror, your brain subconsciously interprets and processes all the distinct elements of the visual scene in front of you. However, for individuals with BDD, something occurs differently in the brain that distorts this reflection. Why do individuals with BDD see a different reflection in the mirror? 

One answer may lie in abnormal higher-order visual processing. Higher-order visual processing refers to cognitive processes involving the visual system that are more complex than simply perceiving an object, and can include identifying the perceived object or locating it in space [5]. When individuals with BDD fixate on one part of their body, they may be stuck on local visual processing [6]. In contrast to global visual processing — or the holistic interpretation of a visual scene — local visual processing involves focusing on a scene’s smaller details [7]. Imagine you are looking at a picture of the beach. Recognizing that what you are looking at is a beach is an example of global visual processing. Upon further inspection, you may notice a child making a sandcastle or someone tossing around a beach ball in the water, which is due to local processing. Individuals with BDD have slower rates of local processing, which can delay the rate of global processing [8]. One explanation for slower local processing might be that those with BDD fixate on small flaws for a longer period of time. Focusing on the smaller details may cause them to struggle with global processing, or seeing their body holistically. For instance, a person without BDD may not notice that their nose is slightly larger than average; but, for someone with BDD, this same detail would be quite noticeable and distressing. 

Another component of higher-order perception is visuospatial processing. Visuospatial processing is the ability to identify an object’s location in space in relation to other objects, such as when someone throws a ball to you and your eyes follow its movement [9]. People with BDD struggle with visuospatial organization, especially when they are looking at complex figures, such as shapes which contain two or more other shapes. They have a hard time organizing different visual components of an object and placing them in relation to each other, which could lead to an inaccurate understanding of bodily dimensions [10]. For example, a person with BDD may struggle with determining the distance between their facial features in relation to one another; perhaps they think their eyes are too close together or too far apart. Thus, it seems that poor visuospatial skills prevent individuals with BDD from perceiving their features accurately, potentially making their perceived flaws more prominent.

Always in the Spotlight

Not only does an individual with BDD see their warped reflection from the House of Mirrors as their own body, but they also believe everyone else sees them in that way, too. Unlike individuals with other mental disorders related to obsessive tendencies, people with BDD tend to fear that others negatively judge them for their perceived flaws [11]. It's as though your perceived distortions in the mirror follow you out of the funhouse and cause everyone at the carnival to stare at you in disgust. Recognizing negative reactions from others is a necessary social cue that individuals utilize in order to thrive in social settings. In order to “fit-in” socially, we must be able to interpret the unspoken cues given to us by others through facial and body expressions. The amygdala, a brain region involved with emotional processing, helps us navigate these social interactions by allowing us to perceive, recognize, and interpret these facial expressions [12]. 

People with BDD exhibit increased activity in the amygdala when viewing visual stimuli [13]. Interestingly, individuals with social phobia demonstrate the same heightened amygdala activity in social situations [14]. Social phobia is an anxiety disorder that causes individuals to feel uncomfortable in social situations because they are afraid of being judged and rejected by those around them [15]. This heightened amygdala activity supports the idea that people with BDD feel levels of discomfort in social situations that parallel those caused by their perceived flaws when no one is watching. Since individuals with both social phobia and BDD exhibit heightened amygdala activity, this phenomenon may be related to the common symptoms of the two disorders, namely, feeling self-conscious around others and fearing judgment [13]. The aforementioned finding may also explain why individuals with BDD often avoid social interactions, contributing to a reclusive lifestyle.

The amygdala also helps people recognize others’ emotions by interpreting facial expressions, and it is particularly sensitive to expressions that signal fear and anger [16]. During social situations, individuals with BDD are more likely to interpret emotionally neutral faces as expressing negative emotions such as anger and contempt [17]. Negatively misinterpreting facial expressions might reinforce patients' concerns about their perceived ugliness and social undesirability. Individuals with BDD feel as though they are constantly put under a spotlight, judged by everyone simply because of their appearance. On top of this, they are also incredibly harsh critics of themselves. 

A deficiency in the binding of serotonin, a neurotransmitter responsible for stabilizing one's mood, may further contribute to the dissatisfaction felt by those with BDD. While the role of serotonin is unclear when it comes to BDD, low serotonin levels have been linked to body image disturbances and dissatisfaction in other disorders, such as anorexia nervosa [18]. Neurotransmitters like serotonin work by passing chemical signals from one neuron (i.e. brain cell) to another to communicate a particular message. In order for the message to make it from one neuron to another, the neurotransmitters must bind to specific receptor sites. Unfortunately, in patients with BDD, there are less serotonin binding sites. This causes less serotonin to effectively bind and pass on chemical signals [19]. Consequently, low serotonin binding levels may cause BDD symptoms to worsen, causing individuals to possess more negative feelings about their bodies, like discontent or disgust [20]. Furthermore, BDD doesn’t always act alone: low serotonin is associated with other disorders such as depression and anxiety, which can occur in tandem, or be “comorbid” [21]. This overlap in serotonin deficiency means the same drugs used to combat depression can sometimes help with BDD treatment [22]. For example, selective serotonin reuptake inhibitors (SSRIs), antidepressants which increase the effects of serotonin in the body, also aid in reducing symptoms of BDD [23]. While a variety of biological factors can influence BDD, social and cultural factors may also play a critical role in the development of the disorder.

Trying to Meet Society’s Standards

When scrolling through Instagram or TikTok, pictures of models and influencers with idealized and unachievable bodies often flash by. When we are repeatedly exposed to only certain types of bodies, we mentally ingrain them as societal beauty standards, leading us to scrutinize our own bodies and appearances if they do not align. Spending long periods of time on social media platforms such as Instagram and Snapchat has been associated with the development of BDD symptoms [24]. People with BDD were also found to compare their appearances to celebrities on social media more often than those without the disorder, worsening a person’s self-perception and body dissatisfaction  [24]. By comparing themselves to airbrushed and altered images of attractive celebrities, individuals with BDD become more critical of their appearance, a phenomenon known as “priming” [25]. For example, watching a five-minute Sports Illustrated video of swimsuit models primes individuals to be more critical of their own bodies and physical flaws. The effect was reversed when the same subjects watched a “body-positive” video [26]. These “priming” experiences draw attention to physical imperfections and are associated with a pressure to attain the “perfect body” [20]. 

While merely scrolling through social media can be harmful for those with BDD, posting your own photos poses other risks. Choosing the best photo to post on a social media platform may entail fixating on the visual representation of one's own body and amplifying small flaws, which are behaviors associated with BDD  [1]. 

To adhere to society’s beauty standards, some individuals with BDD may even seek out surgical options to address their perceived imperfections. Specific societal beauty standards surrounding body size, weight, height and the desirability of certain features may determine which body parts individuals tend to fixate upon [27] . For example, rhinoplasties, or nose jobs, are one of the most commonly performed surgeries on women in the Middle East [28]. Due to the dress codes that many Islamic women practice, only part of their face is exposed to the public, making the nose very prominent. This causes women to feel pressured to ensure that their nose is “perfect” [28]. On the other hand, one of the most popular surgeries in East Asia and for Asians in the United States is blepharoplasty, or double-eyelid surgery [29]. Interviews with individuals who identify as East Asian or of Asian descent reveal that this fixation over double-eyelids has several motivations: namely, experiencing discrimination for their “small” eyes, or ethnocentric beauty standards being centered around western ideals [30]. Even after such surgeries, there is often no change to BDD symptoms, and individuals may actually seek out these procedures more often [31]. The need to obtain social approval regarding whether one’s body is “attractive” or not is important, especially with young women [32]. Therefore, the promotion of unrealistic sociocultural ideals of female beauty makes women feel dissatisfied with their bodies. Plastic surgeons should be trained to recognize patients who seek out surgical operations as a result of BDD, and the media must make efforts to acknowledge different body types as attractive, instead of promoting one standard of beauty. 

Shattering the Funhouse Mirror: Future Directions in BDD Research and Awareness

BDD has been described as a “secret” obsession [33]. Individuals with BDD tend to end up dealing with their symptoms privately after realizing that others cannot see the flaws that they find so obvious. When people with BDD are told by others that they “look fine” despite what they feel about their appearance, they may begin losing trust in those around them, including mental health professionals. Because of poor understanding of the condition and distrust towards medical professionals, some patients may never know that they have BDD, and if they do, they may refuse to seek help[33]. Therefore, it is crucial to promote greater awareness and understanding of BDD amongst both the general public and medical practitioners. Raising awareness of this disorder will help to ensure that those experiencing symptoms reach out for assistance. Further, if more people are made aware of BDD, those diagnosed with the disorder may be more likely to offer themselves compassion during treatment, as they know they are not alone in their struggle with body image self-perception. Countering the stigmas surrounding BDD with increased research and awareness is essential; with access to proper treatment, those suffering can look beyond the broken mirror and work to accept their perceived flaws.

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REFERENCES

1. Clerkin, E. M., & Teachman, B. A. (2008). Perceptual and cognitive biases in individuals with body dysmorphic disorder symptoms. Cognition & Emotion, 22(7), 1327–1339. doi:10.1080/02699930701766099 

2. Angelakis, I., Gooding, P. A., & Panagioti, M. (2016). Suicidality in body dysmorphic disorder (BDD): A systematic review with meta-analysis. Clinical Psychology Review, 49, 55–66. doi:10.1016/j.cpr.2016.08.002

3. Bjornsson, A. S., Phillips, K. A., & Didie, E. R. (2010). Body dysmorphic disorder. Obsessive-Compulsive Spectrum Disorders, 12(2), 221–232. doi:10.31887/dcns.2010.12.2/abjornsson 

4. Krebs, G., Fernández de la Cruz, L., & Mataix-Cols, D. (2017). Recent advances in understanding and managing body dysmorphic disorder. Evidence Based Mental Health, 20(3), 71–75. doi: 10.1136/eb-2017-102702 

5. Hart, J. (2015). Higher-order visual processing. The Neurobiology of Cognition and Behavior, 107–122. doi:10.1093/med/9780190219031.003.0007 

6. Li, W., Lai, T. M., Bohon, C., Loo, S. K., McCurdy, D., Strober, M., Bookheimer, S., & Feusner, J. (2015). Anorexia nervosa and body dysmorphic disorder are associated with abnormalities in processing visual information. Psychological Medicine, 45(10), 2111–2122. doi:10.1017/s0033291715000045

7. Nayar, K., Franchak, J., Adolph, K., & Kiorpes, L. (2015). From local to global processing: The development of illusory contour perception. Journal of Experimental Child Psychology, 131, 38–55. doi:10.1016/j.jecp.2014.11.001

8. Kerwin, L., Hovav, S., Hellemann, G., & Feusner, J. D. (2014). Impairment in local and global processing and set-shifting in body dysmorphic disorder. Journal of Psychiatric Research, 57, 41–50. doi:10.1016/j.jpsychires.2014.06.003

9. Kravitz, D. J., Saleem, K. S., Baker, C. I., & Mishkin, M. (2011). A new neural framework for visuospatial processing. Nature Reviews Neuroscience, 12(4), 217–230. doi:10.1038/nrn3008

10. Deckersbach, T., Savage, C. R., Phillips, K. A., Wilhelm, S., Buhlmann, U., Rauch, S. L., Baer, L., & Jenike, M. A. (2000). Characteristics of memory dysfunction in body dysmorphic disorder. Journal of the International Neuropsychological Society: JINS, 6(6), 673–681. doi:10.1017/s1355617700666055

11. Fang, A., & Hofmann, S. G. (2010). Relationship between social anxiety disorder and body dysmorphic disorder. Clinical Psychology Review, 30(8), 1040–1048. doi:10.1016/j.cpr.2010.08.001

12. Baxter, M. G., & Croxson, P. L. (2012). Facing the role of the amygdala in emotional information processing. Proceedings of the National Academy of Sciences, 109(52), 21180–21181. doi:10.1073/pnas.1219167110

13. Feusner, J. D., Townsend, J., Bystritsky, A., McKinley, M., Moller, H., & Bookheimer, S. (2009). Regional brain volumes and symptom severity in body dysmorphic disorder. Psychiatry Research: Neuroimaging, 172(2), 161–167. doi:10.1016/j.pscychresns.2008.12.003

14. Etkin, A., & Wager, T. D. (2007). Functional neuroimaging of anxiety: A meta-analysis of emotional processing in PTSD, social anxiety disorder, and specific phobia. The American Journal of Psychiatry, 164(10), 1476–1488. doi:10.1176/appi.ajp.2007.07030504

15. Stein, M. B., & Stein, D. J. (2008). Social anxiety disorder. The Lancet, 371(9618), 1115–1125. doi:10.1016/s0140-6736(08)60488-2

16. Adolphs, R. (2008). Fear, faces, and the human amygdala. Current Opinion in Neurobiology, 18(2), 166–172. doi:10.1016/j.conb.2008.06.006

17. Buhlmann, U., McNally, R. J., Etcoff, N. L., Tuschen-Caffier, B., & Wilhelm, S. (2004). Emotion recognition deficits in body dysmorphic disorder. Journal of Psychiatric Research, 38(2), 201–206. doi: 10.1016/s0022-3956(03)00107-9

18. Riva, G. (2016). Neurobiology of anorexia nervosa: Serotonin dysfunctions link self-starvation with body image disturbances through an impaired body memory. Frontiers in Human Neuroscience, 10. doi:10.3389/fnhum.2016.00600

19. Marazziti, D., Dell’Osso, L., Presta, S., Pfanner, C., Rossi, A., Masala, I., Baroni, S., Giannaccini, G., Lucacchini, A., & Cassano, G. B. (1999). Platelet [3H]paroxetine binding in patients with OCD-related disorders. Psychiatry Research, 89(3), 223–228. doi:10.1016/s0165-1781(99)00102-x

20. Feusner, J. D., Neziroglu, F., Wilhelm, S., Mancusi, L., & Bohon, C. (2010). What causes BDD: research findings and a proposed model. Psychiatric Annals, 40(7), 349–355. doi:10.3928/00485713-20100701-08

21. Phillips, K. A., Siniscalchi, J. M., & McElroy, S. L. (2004). Depression, anxiety, anger, and somatic symptoms in patients with body dysmorphic disorder. Psychiatric Quarterly, 75(4), 309–320. doi:10.1023/b:psaq.0000043507.03596.0d

22. Castle, D., Beilharz, F., Phillips, K. A., Brakoulias, V., Drummond, L. M., Hollander, E., Ioannidis, K., Pallanti, S., Chamberlain, S. R., Rossell, S. L., Veale, D., Wilhelm, S., Van Ameringen, M., Dell’Osso, B., Menchon, J. M., & Fineberg, N. A. (2021). Body dysmorphic disorder: A treatment synthesis and consensus on behalf of the International College of Obsessive-Compulsive Spectrum Disorders and the Obsessive Compulsive and Related Disorders Network of the European College of Neuropsychopharmacology. International Clinical Psychopharmacology, 36(2), 61–75. doi:10.1097/YIC.0000000000000342

23. Ipser, J. C., Sander, C., & Stein, D. J. (2009). Pharmacotherapy and psychotherapy for body dysmorphic disorder. Cochrane Database of Systematic Reviews. doi:10.1002/14651858.cd005332.pub2

24. Alsaidan, M. S., Altayar, N. S., Alshmmari, S. H., Alshammari, M. M., Alqahtani, F. T., & Mohajer, K. A. (2020). The prevalence and determinants of body dysmorphic disorder among young social media users: A cross-sectional study. Dermatology Reports, 12(3). doi:10.4081/dr.2020.8774

25. Bermeitinger, C. (2015). Priming. Advances in Psychology, Mental Health, and Behavioral Studies, 16–60. doi:10.4018/978-1-4666-6599-6.ch002

26. Withnell, S., Sears, C. R., & von Ranson, K. M. (2019). How malleable are attentional biases in women with body dissatisfaction? Priming effects and their impact on attention to images of women’s bodies. Journal of Experimental Psychopathology, 10(2), 204380871983713. doi:10.1177/2043808719837137