Many of us are embarrassed by or dissatisfied with some body part or other. I recall that from about age 11 through my early teens I sat in class with my hand over what I thought was an ugly bump on my nose. And I know a young woman of normal weight who refuses to sit down in a subway car because she thinks it makes her thighs look huge.

But what if such self-consciousness about a perceived facial or body defect becomes all consuming, an obsession or paranoia that keeps the person from focusing on school or work, pursuing normal social activities, even leaving the house to shop or see a doctor? What if it leads to attempted suicide?
Such are the challenges facing tens of thousands of Americans who suffer from body dysmorphic disorder, or BDD, a syndrome known for more than a century but recognised only recently by the official psychiatric diagnostic manual. Even more recently, effective treatments have been developed for the disorder, and its emotional and neurological underpinnings have begun to yield to research.

New findings
A pioneering researcher, Jamie D Feusner, and his colleagues at the David Geffen School of Medicine at the University of California, Los Angeles, recently found patterns of brain activity in people with BDD that appeared to differ from those of others. The differences showed up in areas involved in visual processing.

 The more severe the symptoms, the more the person’s brain activity on imaging scans differed, on average, from normal levels, the researchers reported in the February issue of The Archives of General Psychiatry.

These brain changes may help explain how people can become overly focused on a perceived defect of their face, hair, skin or facial or body shape that others may not notice — indeed, that may not even exist. Some turn to alcohol and drugs to try to cope with the extreme distress. Others seek cosmetic surgery — which fails to relieve anxiety and can even make the problem worse, leaving scars where nothing was apparent before.

Some men have a form of BDD called muscular dysmorphic disorder, thinking they look puny and weak when in fact their muscles are highly developed through compulsive weight training.

Dr Katharine A Phillips, a professor of psychiatry at Brown Medical School, is perhaps the best known authority on BDD and the author, most recently, of “Understanding Body Dysmorphic Disorder: An Essential Guide” (Oxford University Press, 2009).
In an interview, Phillips described how crippling the disorder can become for those who spend hours in front of a mirror trying to ‘fix’ their ‘ugly hair’ or disguise a facial blemish only they can see. Some pick at an unnoticeable mark on their skin until they do indeed have a visible lesion. Some won’t leave the house unless they can totally cover their face and hair. Those who do go out without masking the area of concern sometimes suddenly flee and hide when they think someone has noticed it or is staring at them.
Many trace their problem to a childhood emotional trauma, like being teased about their looks, parental neglect, distress over parents’ divorce, or emotional, sexual or physical abuse. But Phillips says most people survive such traumas without developing BDD, especially if other factors in their lives lift their self-esteem.Rather, she explained, the disorder seems to have a combination of genetic, emotional and neurobiological underpinnings.

“It’s likely that the genes a person is born with provide an essential foundation for BDD to develop,” Phillips wrote. She noted that in about 20 per cent of cases, a parent, a sibling or a child also had the disorder. Imaging studies done by Dr Feusner, Dr Phillips and others suggest that some brain circuits may be overactive in people with the disorder.

One presumed factor — societal emphasis on looks — is far less important than you might think. Phillips said the incidence of BDD was nearly the same all over the world, regardless of cultural influences. Also, unlike eating disorders, which mainly affect women seeking supermodel thinness, nearly as many men as women have body dysmorphic disorder.

Which treatments work?
The good news is that even though research into the causes of the disorder is in its relative infancy, treatments have been found to help a large percentage of those affected, as long as their problem is recognised and they manage to overcome their embarrassment long enough to get to a qualified therapist.
The two most effective approaches are cognitive behavioural therapy and treatment with serotonin-enhancing drugs, either alone or in combination. In cognitive therapy, patients gradually learn to reorder their thinking, expose their ‘defect’ to others and view themselves more realistically as whole individuals rather than seeing only the presumed defect.

In studies using serotonin-enhancing drugs, half to three-quarters of people with BDD have improved, although Phillips warned that it can take as long as three months to see the benefit of a proper dose. (Moreover, there is still controversy about how many people achieve long-lasting benefits from the serotonin drugs.)

What does not work is plastic surgery and other cosmetic treatments. Even if the treatments modify one presumed defect, the person is likely to come up with another, and another, and another, leading to a vicious cycle of costly and often deforming as well as ineffective remedies.

Most important, Phillips said, is not to give up. Effective treatment is out there and it can make a tremendous difference — even a lifesaving difference. Her new book lists centres around the United States that specialise in treating BDD