A patient with body dysmorphic syndrome: how to help and not harm?

Nadezhda Tereshchenko , candidate of psychiatry. Doctor of Science, Associate Professor of the Department of Psychological Counseling and Psychotherapy at V. N. Karazin Kharkiv National University, practicing psychotherapist (Kharkov)

Tatyana Kiseleva , dermatovenerologist, histologist, cosmetologist (Kharkov)

Few of us are completely satisfied with our reflection in the mirror. However, there is a particularly painful, extreme degree of non-acceptance of one’s own imperfection - dysmorphophobia. People suffering from this disorder may persistently concentrate not only on real, but also on imaginary shortcomings.

Body dysmorphophobia is a violation of self-esteem, which is manifested by a pathologically unhealthy perception of one’s body and excessive concern about its minor defect or feature.

Example: a person with normal weight, due to an imposed pattern of behavior, may consider himself overweight and not go on a diet, leading himself to physical and nervous exhaustion. Body dysmorphic syndrome is very often associated with complexes or can arise due to an obvious physical defect that worries a person.

Such patients cannot objectively evaluate themselves, so very often they come to aesthetic medicine specialists with not very healthy requests. In such cases, it is very important to defend an adequate position and work with the client psychologically, so as not to provoke the progression of dysmorphophobia.

Nadezhna Tereshchenko: “We are talking about objectively imaginary defects”

In psychology, a person’s attitude towards his appearance is considered in the context of a subjective body image. Body image is mostly an idea of one’s own attractiveness, one’s external characteristics, and the impression they make on others.

Two factors make an important contribution to the formation of body image: characteristics of child-parent relationships and sociocultural stereotypes of perception of appearance. If we talk about the influence of the family, it is important to note the role of non-verbal communication with the child: hugs, kisses, various types of tactile contact. They provide a contribution to the development of a positive body image. Also important is how parents (especially of the same gender) show their attitude towards their own body: they look after, take care of, decorate, etc.

Another aspect of family influence is verbal communication, which gives direct negative attitudes: “Who has such a long nose?”, “Suck your stomach in, it’s ugly!”, “Your cheeks are so plump,” etc. The problem is that a child's body is different from an adult's - it is softer, disproportionate and changes greatly during development. But not all adults understand this, as well as the fact that even harmless “teasing” can become traumatic for the child’s psyche and degenerate into serious problems with self-esteem in the future.

The influence of sociocultural factors is associated with the pressure of the media, offering strict standards of beauty and health, excluding variability in external attractiveness.

Distorting body image or developing a negative body image leads to a range of psychological and social problems. It is interesting that until the age of 5-6, girls and boys feel approximately the same about their appearance, but statistically, as they grow older, it is the girls who become more and more dissatisfied with themselves. It should be noted that according to scientific research, more than half of women are dissatisfied with their appearance, while among men this figure is much lower [1]. This is strongly related to stereotypes and characteristics of upbringing.

A negative body image can lead to exhausting attempts to change one's appearance, which does not lead to long-term satisfaction.

Etiology of body dysmorphic syndrome

Body image distortion can reach the level of a clinical disorder - body dysmorphic disorder. In the International Classification of Diseases, 10th revision (ICD-10), body dysmorphic disorder was considered a type of hypochondriacal disorder; in ICD-11, it is presented as a separate type of disorder. A person suffering from dysmorphophobia is convinced of the presence of defect(s) in appearance, which has an extremely negative impact on his socio-psychological adaptation and functioning. These patients are known to be suicidal and self-harmful, even more so than with depression or bipolar disorder.

Note that we are talking about objectively imaginary defects. Often people with body dysmorphic disorder have an attractive appearance or minimal imperfections, but they believe in their “ugliness” so much that they avoid social contact because of it. Looking at yourself in the mirror for hours, masking imaginary flaws, resorting to dubious cosmetic procedures, even self-harm - all this makes up the routine life of a person with body dysmorphic disorder.

Body dysmorphic disorder “does not come alone” - it is often combined with obsessive-compulsive disorder, depression, eating disorders, anxiety disorders and other mental disorders, ultimately leading to serious somatic disorders.

Tatyana Kiseleva: “Dermatologists often encounter an auto-aggressive attitude towards the body”

An unstable, traumatized psyche from constant dissatisfaction with oneself “pushes” people to undergo unnecessary procedures and operations, and they do not worry that this may pose a threat to their health. It is noteworthy that the maximum number of complaints is related to dissatisfaction with one’s own skin. People suffering from body dysmorphic disorder tend to create hours-long cosmetic rituals that briefly relieve anxiety about their own appearance. In cosmetology, invasive methods are often preferred, since the attitude towards appearance is often characterized by aggression and destructive tendencies [2]. A person cannot stop on his own in “improving” his appearance - working on an imaginary defect turns the patient into a “victim of cosmetology.” There is evidence that cosmetic interventions in patients with a predisposition to dysmorphophobia not only do not improve the patient’s condition, but can also worsen it, satisfying compulsive ritualism and/or confirming auto-aggressive behavior.

Negative body image, regardless of the level of disorder (subclinical or clinical), needs monitoring and treatment. In these cases, psychotherapy is very effective, even with severe dysmorphophobia.

When a person is significantly preoccupied with thoughts about a perceived flaw in his appearance that appears to an outside observer to be insignificant or no more than ordinary physical variations, and if he experiences negative feelings in connection with this for more than 1 hour a day, he may have diagnosed with body dysmorphic disorder or body dysmorphic disorder.

"Alarm signals" of body dysmorphic syndrome

Dysmorphophobia in many cases is concentrated around the face, especially often its manifestations are associated with the appearance and condition of the nose, skin, hair, eyes, mouth, jaw and chin, and sometimes teeth, although it can involve any other part of the body. Moreover, concern often extends to more than one area of the body. Perceived deformity of the face or body and imagined defects can cause a host of repetitive behavior patterns.

In addition to looking at oneself in the mirror throughout the day, other cyclical behaviors have been noted: taking photographs of oneself, touching “ugly” parts of the body or contours of the skin, asking others for feedback on one’s appearance, changing and revising one’s wardrobe, excessive exercise, excessive grooming and the use of makeup, resort to cosmetic procedures, and the use of clothing and other items as a disguise.

Often in such cases, dermatologists are faced with an auto-aggressive attitude towards the body: picking the skin, squeezing out inflammatory elements, tearing out eyelashes and eyebrows, biting off a nail plate or skin fold. For practicing cosmetologists and dermatologists, one of the main symptoms is constant dissatisfaction with their appearance on the part of patients and requests to aggravate and make procedures more aggressive under the pretext of dissatisfaction from previous ones.

How to help patients with body dysmorphic syndrome?

There is a popular opinion in the beauty industry: if a physical disability is somehow corrected, the patient’s emotional state will miraculously transform and he will subsequently be able to improve his life. In the case of a mentally unstable patient, this opinion is erroneous and even dangerous. Various scientific studies indicate that people who have a strong dislike for their appearance often perceive the results of any cosmetic intervention as unsatisfactory, which can also affect the doctor’s reputation.

In one study, 16% of people reported that their condition had worsened as a result of cosmetic procedures, with 9 out of 25 participants surveyed being so dissatisfied that they eventually resorted to performing cosmetic procedures themselves at home [3]. Once the patient reduces or solves one appearance problem, he finds another and focuses on it. Undoubtedly, for this reason, appearance projects for some of them can continue endlessly.

People diagnosed with body dysmorphic disorder often visit many doctors, turning to one specialist after another in search of which one will be willing to perform the required procedure or prescribe a certain drug. And the worst thing is that one of the specialists, due to lack of experience in working with such patients, may decide to “help” with very unpleasant consequences. This again proves the importance of compliance between doctors of aesthetic medicine inside the field and outside – with specialists in mental health issues.

Based on the experience of managing patients with signs of dysmorphophobia: in no case should they aggravate their neurotic state by constantly satisfying its demands for aggressive and drastic procedures. The authors of this article agree that it is better to reorient such patients towards a long-term friendship with a doctor, since under the desire to injure oneself lies a repressed sympathy for oneself and one’s body. A favorable tactic with such patients is: offer them care for themselves, their body and face in the form of a selection of home care, a professional protocol of pleasant care procedures, and not use painful, traumatic procedures, such as injections or aggressive peelings .

It is very important to understand that often the patient’s main problem is not a physical disability at all, but mental discomfort, a feeling of not being beautiful/thin/slender enough, etc., which cannot be corrected by any cosmetic or surgical procedure. Do not forget to remind the patient of his uniqueness and self-love, which largely depends primarily on his mental comfort.

Literature

1. Gender and Body Image, in J. C. Chrisler & D. R. McCreary (Eds.), Handbook of Gender Research in Psychology, Springer, p. 153-184.
Gender and Body Image by Rachel M. Calogero and Joel K. Thompson

[2] Dorozhenok I. Yu., Matyushenko E. N., Olisova O. Yu. Dysmorphophobia in dermatological patients with facial localization of the process // Russian Journal of Skin and Venereal Diseases. 2014. No. 1. - P.42 - 47.

[3] Singh AS, Veale D. Understanding and treating body dysmorphic disorder. Indian J Psychiatry. – 2019 Jan; – 61(Suppl 1): S131–S135.