“Am I OK Today?” — BDD and the Role of Self-Esteem

by Scott M. Granet, LCSW

In years past when giving talks to the public, I always found it necessary to describe Body Dysmorphic Disorder or BDD in some detail as few people really knew what it was. That was even true with other mental health professionals, as they too were more often than not unaware of the existence of BDD. While that is still the case to some extent, there is no question that more people know about the disorder now than even just a few years ago. Certainly, many people now know that BDD is essentially about obsessions pertaining to perceived flaws in physical appearance, and that cognitive behavioral therapy (CBT) and/or medication, is the treatment of choice, just as it is for OCD.

There are many similarities between OCD and BDD, one of which is the strong element of shame that people with OCD and BDD live with. It is widely recognized that BDD sufferers, however, take that many steps further as indicated by using words such as “disgust” to describe how they feel about their appearance, and often about themselves. While some of these people are participating in CBT, they still may stay stuck in therapy without seeing satisfactory results.  This is where I believe the role of self-esteem may need to be addressed more aggressively. Certainly, a skilled cognitive-behavioral therapist will be exploring that through examining a client’s negative thoughts and core beliefs. As it applies to BDD, the latter will generally come in the form of beliefs such as “I’m worthless without my hair,” or “I’m unlovable with skin like this.”

Is this really the way most people feel about themselves? Of course it isn’t. Only people with BDD think this way. Everybody has appearance flaws, but how many contemplate suicide over them? Well, people with BDD often do, and at a rate which is higher than it is for many other psychiatric disorders. In my practice, I have found those who get well are those who come to believe that their obsessive thoughts stem from having BDD, and not from just a desire or need to look better. How many people define themselves based on their appearance? How many would say that their hair, nose, and skin are more important than any other part of their lives?  How many would rather have some terminal disease rather than having to live with a face “this ugly.” I wish I could say that these types of thoughts are rare, but unfortunately I come into contact with them far too often in the clients I treat. If you are someone with BDD and are holding onto thoughts like that, getting well will be very difficult. It is the willingness to think “outside the box” which will propel someone to get better.

In discussing self-esteem, let’s not forget about other important aspects of life such as work, school, relationships, and hobbies. “Nope, too ugly to have any of that,” a BDD sufferer might say. Too often people with BDD think that their appearance has to improve before they can sufficiently engage in these types of pursuits. Think again. If you wait for that the BDD will win every time. You must put those and other meaningful activities into to your life first, and begin to improve your self-esteem that way. No one is just their hair, their eyes, their chin, etc… Everyone defines themselves based on other parts of life, and that shouldn’t be any less true for people with BDD. While building one’s self-esteem in other areas is important, it does not take the place of CBT, which of course needs to happen. It just gives the BDD less of an opportunity to flourish.

Consider this test if you are someone fighting BDD: first, make a decision to go look at the particular body part(s) that concern you. Before you look in the mirror notice what thoughts begin surfacing. My guess is there are thoughts such as “I hope I look OK,” or “I hope I don’t look so bad,” or quite possibly it’s worse with such thoughts as “I know I’m going to look disgusting!” I would ask you to consider something else as you’re having those thoughts. Is this just about how you look? In some way, aren’t you really saying “I hope I’m OK today,” “I hope people will accept me,” or perhaps “I hope I can even like myself.” There is a tremendous difference between “I hope I’m OK,” and “I hope I look OK,” yet most people with BDD equate the two. How we look shouldn’t define how we feel about ourselves, though I realize I would be ignoring the obvious by overlooking that we live in a society that promotes that type of thinking. But, it is also safe to say that people with BDD take that to an extreme.

It is also safe to say that many with BDD are much kinder to others than they are to themselves when it comes to appearance. If you are reading this and are someone with BDD, you probably have friends who are balding, have acne, or have something else like wrinkles or a nose that may appear to be crooked in some way. Do you like these people any less because of that? Probably not. You might actually consider doing so to be unreasonable. If that’s the case, then why not treat yourself with the same kindness? And what about their self-esteem? Do these appearance issues seem to interfere with their daily functioning like it might for someone with BDD? If you are close to these people, asking them may help you with some insight into this issue. While some of these same people may wish the body part looked different, does it seem to change how they feel about themselves? Does it fundamentally change who they are? Again, the answer is, “probably not.”

So what’s the point of all this? The point is self-esteem. People are more than the fullness of their hair, the shape of their nose, or the tone of their skin. If you have BDD and look to “fix” those and other parts in an attempt to feel better, you are likely to be very disappointed and very frustrated, as is well documented in the literature. Self-esteem comes from many sources, and perhaps how we look may be one of them. But aren’t there other factors? Isn’t how we treat others important? What about how we are at being a spouse, a parent, a friend, an employee, a student or whether we are kind, understanding, and compassionate? Most people would probably agree that those roles and qualities are in fact more important than how we look. So while you’re working on your appearance concerns in therapy don’t forget about these other issues. Work on those too, and you just may begin to see more progress with the BDD. You may also have a very different answer to the question, “am I OK today?”

Scott M. Granet, LCSW, has specialized in the treatment of body dysmorphic disorder for many years and in 2008 opened the OCD-BDD Clinic of Northern California, located in Redwood City. In addition to his clinical work, Mr. Granet has presented on BDD at numerous conferences worldwide and teaches continuing education classes on the disorder to mental health clinicians around the country. Scott is the author of Body Dysmorphic Disorder, Mine and Yours: A Personal and Clinical Perspective.