Ed*, a freelance computer graphics artist, was so embarrassed by his appearance that he refused to attend most parties and social gatherings. Instead he spent his days alone, indoors, working on various assignments. At night he would venture out in a large hat covering most of his face and an overcoat to shop for groceries and other essentials. When friends or strangers observed him, they merely saw an average-sized, ordinary-appearing white man in his 30s who was slightly balding. When Ed stared into the mirror, which he did with increased frequency and horror, he saw a hairless, fat troll.
One day Ed was required to go to a meeting at one of the companies that employed him. After procrastinating, he managed to propel himself out of his apartment to the company. There he enjoyed the meeting and actually responded to an attractive woman who engaged him in conversation afterward. When they said goodbye, she gave him her email address and encouraged him to contact her.
Ed really wanted to email her and ask for a date, but he looked into the mirror again and feared rejection based on what he thought was his grotesque and disfigured appearance. In the past, Ed had been in two significant relationships. The first one, when he was in high school, had lasted two years. That girlfriend had continually reassured him that he looked fine and that she loved him. Of course, her reassurance and vows of love did nothing to overcome Ed's distorted view of himself that he never disclosed to anyone. The next relationship, when he was in college in his early 20s, followed the same pattern of his lover constantly confirming that Ed was normal and that she loved him. He broke off the last one when he lost so much hair that he was too ashamed to take the vacation the two had planned for months. His lover could not understand his last minute cancellation and refusal to see her anymore.
Realizing that he was reaching dead ends everywhere he turned, and that his behavior was irrational, Ed resolved to try psychotherapy. The psychiatrist diagnosed BDD, body dysmorphic disorder, and recommended an antidepressant and psychotherapy. Ed complied with the treatment plan. His medication was raised over a period of three months, but he still couldn't stop obsessing about his receding hairline or call the potential date. During the course of the treatment, Ed tried Zoloft, Celexa, Luvox and Paxil, at average-to-high levels for adequate time periods with little results.
Finally, he experienced some relief when he switched to an old-fashioned tricyclic antidepressant called imipramine. But he was not able to stop the checking and rechecking of himself in the mirror until the doctor added an antipsychotic, risperidone. In therapy, Ed learned that his narcissistic mother was over-involved with his appearance while his depressed father neglected and avoided him. Ed also realized that he'd been depressed and anxious himself throughout most of his childhood and adolescence, but instead of focusing on his feelings, he concentrated negatively on his body. After 18 months of treatment, Ed emailed the woman whom he had met at the company meeting, but she was in a relationship by then. Not losing his courage, even though he looked in the mirror first (and saw a less atrocious-looking man), Ed went to a single's mixer the next night. It was extremely difficult for him, since he felt self-conscious throughout the ordeal. He decided to attempt socialization once per week with his therapist's support.
BDD, body dysmorphic disorder, a preoccupation with an imagined defect in appearance when only a slight physical anomaly is present, causes patients significant distress or impairment in social, occupational or other important areas of functioning. Ed was able to maintain employment since a computer graphics artist can work at home, but he was failing on a social level. Although BDD has been recognized for over 100 years (Kraepelin and Freud both described it), it has been poorly studied. Many patients consult plastic surgeons and internists rather that psychiatrists. Usually women are more affected than men, and the onset is in adolescence. Co-existence with other mental disorders is common, with depression and anxiety being the most prevalent. It is believed that the pathology of the disorder may involve serotonin, a neurotransmitter, since more than 50 percent of cases are responsive to SSRI's. However, Ed was not responsive to any SSRI, and he needed to take a TCA and an antipsychotic before his condition improved.
Cultural and social effects on BDD patients need to be studied further. Psycho-dynamically speaking, BDD may be displacement of a sexual or emotional conflict onto a non-related body part through repression, symbolization and projection; Ed's balding head representing castration anxiety, as an example. Distortions of body image also occur in anorexia nervosa, gender identity disorders and specific types of brain damage, in which cases BDD cannot be diagnosed. Ed's beliefs were almost delusional, but not quite. He was always able to understand that his concerns were bizarre.
*Ed is not this patient's real name.
Carol W. Berman, M.D. is a writer, psychiatrist and artist who lives and works in New York City. When she's not listening to patients, she's writing or painting. As an undergraduate she attended the University of California at Berkeley; she went to medical school at NYU Medical Center. Presently she is an Assistant Clinical Professor at NYU. She has practiced psychiatry for 25 years and is a member of the APA, ASJA and NWU. Her two books, "100 Questions and Answers About Panic Disorder" and "Personality Disorders," have helped thousands of patients deal with mental disorders. Read her blog on Red Room.