Mirror, Mirror on the Wall…You Are the Ugliest of All Says Body Dysmorphic Disorder (BDD)

Mirror, Mirror on the Wall…You Are the Ugliest of All Says Body Dysmorphic Disorder (BDD)

Eda Gorbis, PhD, LMFT

Member Since 2008

Dr. Eda Gorbis, PhD, LMFT is the Founder and Executive Director of the Westwood Institute for Anxiety Disorders in Los Angeles, California and a Clinical Assistant Professor (V) at the USC Keck School of Medicine. The Westwood Institute is often called an intensive center of 'last resort' for Obsessive-Compulsive Disorder (OCD), Body Dysmorphic Disorder (BDD), and other anxiety disorders. By integrating treatment methods with a multidisciplinary team of experts, Dr. Gorbis has brought hundreds of people with prior treatment failures to normal functioning. Her expertise was prominently featured on programs, such as "20/20," "60 Minutes," and "MTV's True Life.”  She has given over 170 conference presentations on topics related to her intensive treatment of OCD, BDD, and anxiety disorders around the world.

Dr. Gorbis and ADAA

"Back in 1994, I applied for a poster presentation for the ADAA annual conference based on my observations that there is a certain group of patients whose onset of OCD began after a certain level of trauma/PTSD. ADAA's committee accepted my presentation for a symposium which was supervised and led by one of the leading experts in the world on OCD and PTSD: Dr. Edna Foa (also an ADAA member). 

Once the poster was accepted, an unbelievable buzz went through the OCD and anxiety disorder community at UCLA. This incredible association not only accepted my paper but also found it to be important enough to be presented at the conference. Had it not been for that day at ADAA, my career could not have skyrocketed the way it did, and I would not have achieved the same levels of success. The acceptance that I felt at that conference and the sense of exuberance that rushed over me means more to me than any other peaks that I have experienced in my career. Not even the appearances on documentaries and TV shows nor the multiple awards I received could surpass the moment my supervisor passed a quiet remark that today marked the day I was accepted within the anxiety disorders community. Ever since then, I have given hundreds of presentations, and I have never missed one with the ADAA conference.

For me, ADAA was the first step in my professional journey and helped me gain the confidence to step onto other big and bright stages later in my career. I believe that ADAA can be that same stepping-stone for other young professionals. ADAA offers an incredible professional stage for anyone looking to begin their career."

Mirror, Mirror on the Wall…You Are the Ugliest of All Says Body Dysmorphic Disorder (BDD)

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Peggy, an attorney in her late 30s, establishes rituals to protect herself from aging and in her mind, becoming ugly. These rituals include 20 to 30 facial wraps a day, washing her face 40 times from morning until night, applying her cosmetics in a ritualized order, and constantly standing in front of mirrors to scrutinize the symmetry of her legs. These rituals last 8 hours a day every single day and cost over $10,000 a month to maintain.

Over the course of her life, Peggy has had over 20 car accidents as she has been so distracted checking her face for wrinkles in her rearview mirror. She has had 17 reconstructive surgeries and over 25 facial corrections. Peggy is so self-absorbed and obsessed with her appearance that she cannot maintain any type of relationship for more than one month at a time. 

This is the story of “imagined ugliness” where a person hyper-focuses on a flaw in appearance and will go to extreme, often dangerous lengths, to “fix” the flaw. This is the story of a person suffering from body dysmorphic disorder, or BDD.

BDD is a serious, debilitating disease that afflicts approximately 1-2% of the general population, which is about 5 million people.  This illness has existed throughout the ages and has been documented all the way back to the medieval times. Ironically, the patients I have seen with BDD were above average in their looks. They are high in delusion and impulsivity but low in insight.

BDD is characterized by obsessions, or preoccupations, of one or more self-perceived flaws, or defects, in appearance.  Usually, the “defect” is minimal or practically invisible to the naked eye. However, according to some research studies, compared to individuals without BDD, individuals with BDD have abnormal visual processing. Thus, their flaws are magnified 100 times, and it is all they ever focus on.

Common Obsessions:

  • Nose
  • Skin
  • Hair
  • Chin
  • Ears
  • Penile size and muscle tone (in males)
  • Symmetry of breasts (in females)

BDD is also characterized by compulsions, or repetitive behaviors or mental acts, in response to their appearance obsessions. These compulsions can be time-consuming and can interfere with daily functioning, such as occupational, social, and school.

Common Compulsions:

  • Checking the mirror
  • Grooming
  • Skin picking
  • Seeking medical procedures (e.g. dermatological, plastic surgery)
  • Comparing/contrasting self to others
  • Seeking reassurance from others

Individuals with BDD oftentimes end up having social phobia as a second diagnosis. They avoid social interactions, such as dating and interacting with peers, as they feel too ugly to interact with anybody. They may also cover themselves up with glasses and hats to cover their appearance, and since they are ashamed of themselves, they may have awkward behaviors around others, which could further isolate them from people.

When seeking treatment, those with BDD tend to be at the offices of dermatologists, plastic surgeons, or cosmetologists but rarely appear at the psychiatric office. No matter how many times they undergo plastic surgery corrections, they will never be fully satisfied with their looks as it is common for the “defect” to move to another part of the body. It is the self-image that needs the “surgery” and the adjustment; it is the inside that must be changed.

When individuals do show up for psychiatric help, appropriate assessments should be administered to determine severity of obsessions and compulsions and their insight level. Sometimes the patients will need to be convinced for treatment.

The primary treatment modalities for BDD include medications and exposure and response prevention (ERP). Medications, such as selective-serotonin reuptake inhibitors (SSRIs) and atypical antipsychotics, have shown to be effective in patients when medication does work.  Crooked mirrors are the mirrors that are found in fun-houses in carnivals. When looking into these mirrors, one sees a distorted view of themselves. Repeated and prolonged exposure to these mirrors is effective in treating BDD because it helps the patient habituate both internally and externally to this distorted view of themselves.

In sum, BDD is a treacherous disease of self-perceived ugliness, and it must be detected as soon as possible to ensure proper, effective treatment from a trained professional.

For more details, please visit these resources:

Eda Gorbis, PhD, LMFT

Member Since 2008

Dr. Eda Gorbis, PhD, LMFT is the Founder and Executive Director of the Westwood Institute for Anxiety Disorders in Los Angeles, California and a Clinical Assistant Professor (V) at the USC Keck School of Medicine. The Westwood Institute is often called an intensive center of 'last resort' for Obsessive-Compulsive Disorder (OCD), Body Dysmorphic Disorder (BDD), and other anxiety disorders. By integrating treatment methods with a multidisciplinary team of experts, Dr. Gorbis has brought hundreds of people with prior treatment failures to normal functioning. Her expertise was prominently featured on programs, such as "20/20," "60 Minutes," and "MTV's True Life.”  She has given over 170 conference presentations on topics related to her intensive treatment of OCD, BDD, and anxiety disorders around the world.

Dr. Gorbis and ADAA

"Back in 1994, I applied for a poster presentation for the ADAA annual conference based on my observations that there is a certain group of patients whose onset of OCD began after a certain level of trauma/PTSD. ADAA's committee accepted my presentation for a symposium which was supervised and led by one of the leading experts in the world on OCD and PTSD: Dr. Edna Foa (also an ADAA member). 

Once the poster was accepted, an unbelievable buzz went through the OCD and anxiety disorder community at UCLA. This incredible association not only accepted my paper but also found it to be important enough to be presented at the conference. Had it not been for that day at ADAA, my career could not have skyrocketed the way it did, and I would not have achieved the same levels of success. The acceptance that I felt at that conference and the sense of exuberance that rushed over me means more to me than any other peaks that I have experienced in my career. Not even the appearances on documentaries and TV shows nor the multiple awards I received could surpass the moment my supervisor passed a quiet remark that today marked the day I was accepted within the anxiety disorders community. Ever since then, I have given hundreds of presentations, and I have never missed one with the ADAA conference.

For me, ADAA was the first step in my professional journey and helped me gain the confidence to step onto other big and bright stages later in my career. I believe that ADAA can be that same stepping-stone for other young professionals. ADAA offers an incredible professional stage for anyone looking to begin their career."

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