Monday, December 10, 2018

Body Dysmorphia: It's Under the Skin

Let's talk about body dysmorphia.

I have previously spoken on this blog about other disorders that interest me, such as BPD (accurately and tragically displayed in the show Crazy Ex-Grilfriend).  Body dysmorphia, like bipolar disorder or autism spectrum disorders, has recently become newly popular, in terms of diagnoses, people claiming to have it, and resources and treatment options.  Body dysmorphia sits at the intersection of a number of political issues, giving it a uniquely intriguing personality.  But there's a lot of misinformation out there and so today I'd like to talk about what actually constitutes body dysmorphia and how one can address it.

The subject of body dysmorphia came up recently in a Facebook group.  Someone in the group had bemoaned their body type (overweight) and mentioned self-consciousness, to which another person replied that they, too, were overweight, and suffer from body dysmorphia.

Now, lately, over the last three months, I have seen many, many people claiming to have body dysmorphia.  In the gay community, that checks out; a lot of people are dissatisfied with their bodies and feel pressure to be taller, leaner, more muscular, more or less hairy, et cetera.  Gay culture can be viciously shallow.  But-- and this is a critical but-- and yes, I do recognize the punniness of saying "critical but" in a sentence following one about gay culture-- body dysmorphia is not the same as body dissatisfaction.

Body dysmorphia is characterized as an anxiety disorder and affects only about one in fifty people.  There are clinical criteria to being diagnosed.  It is far rarer than people realize and it's not at all the same as having low self-esteem.

That is not to say that some people who claim to have it don't have it.  But I propose that casually saying you have body dysmorphia without a clinical diagnosis is damaging because it normalizes a disorder which actually has some pretty severe behavioral effects.  This is not dissimilar to how people will exclaim "I have OCD!" because they like having their books alphabetized, without realizing the fairly extreme burden people with OCD live with.  Normalizing disorders like OCD or body dysmorphia means that we are accepting the behavior as common and acceptable, which means that, 1) we are less likely to push those suffering with the disorder toward treatment, and 2) we are less likely to be forgiving of extreme behavior that the sufferer may lack control over.

Interestingly, body dysmorphia (also called BDD, for body dysmorphia disorder) shares quite a bit in common with OCD, which is also an anxiety disorder.

Here are some of the specific traits of BDD.  It's characterized as a perceived flaw in some aspect of one's body, and ritualized behavior to fix or attenuate that flaw.  There's an important word here which I have helpfully italicized for you: perceived.  A person may or may not have any flaw.  A classic example is how a person with anorexia may perceive themselves as having excessive fat.  (The comorbidity of anorexia with BDD is about 25-40%.)

And herein lies one of the other critical features of BDD: it cannot be "fixed."  Because the "flaw" is psychological and not physical, people with untreated body dysphoria will continue to see or feel the flaw regardless of whether or not it exists.  Treatment for body dysmorphia involves therapy and possibly anti-depressants or anti-anxiety medications.  It does not, however, involve surgery.  (Michael Jackson and Pete Burns are two examples of someone trying to "treat" body dysmorphia with plastic surgery, and why it doesn't work.  Most people with BDD overcorrect.  This is why anorexics are underweight and why people with skin fixations end up covered in blemishes.)

One of the reasons I find this point so important is because body dysmorphia is a term often applied to the transgender community, with people saying they need their BDD "fixed" via surgery.  Gender dysmorphia is a subset of body dysmorphia and while it's a valid thing, it is my belief that it is not a criteria for "being transgender."  If it were, this would suggest that being transgender is a generalized anxiety disorder.  (And, indeed, historically, it has been treated as a mental illness, with "gender dysmorphia" replacing "gender identity disorder" in the DSM-V in 2013.)  Another important distinction is that "gender dysmorphia" is not the same as "gender non-conformity."  Transgender people who are out and presenting as the gender they identify as (which is at odds with their biological sex) are by definition gender non-conforming.  But do they have gender dysmorphia?  Not necessarily.  Which isn't to say they are satisfied with their bodies.  They may feel self-conscious or dissatisfied with their bodies.  But they also may not engage in the ritualized fixations that people with BDD do.

Cosmetic surgery is a temporary fix, a band-aid, on a disorder with its roots in a psychological problem.  And make no mistake: I do believe gender reassignment surgery is cosmetic in nature.  This isn't to say it should not be allowed.  If a person wants bigger breasts, they can go get implants without needing to see a counselor.  So, if a person wants gender reassignment surgery, I think they should go do it.  It's their body.  Let them do what they want.  But let's not say it's "necessary."  Because surgery rarely, if ever, cures BDD.

Turning Steve into Captain America cost American taxpayers $516,000 in 1943... 
adjusted for inflation, that's $7,517,433.99 today.

It's no wonder that I've started to see people in the gay community claiming "body dysmorphia," since there's so much overlap between the gay and trans community.  And claiming body dysmorphia has a few silver linings: people flock to reassure you that you're attractive, and it lets you off the hook for actually doing anything about your appearance.  (Take the case of the overweight guy.  If he has body dysmorphia, losing weight won't make him feel any better about it.  But if he doesn't, he could just go on a diet and discover his self-consciousness disappears.) 

I'm not trying to be a gatekeeper.  However, I do think that the excessive claims of "body dysmorphia" are harmful.  Having body dysmorphia is a crippling psychological burden, not just a general lack of confidence or unhappiness with the way you look.  I, for example, have excoriation (also known as dermotillomania).  These are the fancy-pants terms for skin-picking.  And make no mistake: I spend about an hour, on average, and sometimes more, picking at my skin.  It makes me late to most social engagements.  It's an obsessive thing.  

And I don't want people to rush to me and say, "Oh, no, your skin is just fine!"  Reassurances from others are rarely helpful to those with clinical BDD.  Claiming to have body dysmorphia to garner sympathy is a lot like people who claim to be suicidal on Facebook in the hopes that someone will say "Oh, PM me, let's talk."  (I see this more and more often and have always said the same thing: if your friend claims to be suicidal, don't offer to talk to them or ask them to PM you on Facebook. Call 911.)

Over time, constantly requesting reassurance without seeking actual medical intervention (in the form of behavioral therapy or psychiatric intervention) erodes sympathy for the disorder, at the cost of those who cannot control it.
 Please don't go the way of Pete Burns, Steve!  
You're big enough!  You can stop now!

I think that precision of language is a key element to understanding disorders, and casually throwing around medical terms for hyperbolic purposes is at odds with de-stigmatizing psychological and behavioral disorders.

If you suspect you have body dysmorphia, don't just tell everyone about it.  Go and see a licensed mental health professional to get it treated.  Because if there's one thing clincal body dysmorphia and nonclinical body dissatisfaction have in common, it's that they can be addressed.  But identifying which one you suffer from is critical to addressing it properly.  Thanks to G.I. Joe, this is something we've known for years.

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