When the mirror holds you captive

They think they're ugly: Treating a debilitating body-image disorder

Dr. Katharine A. Phillips offers hope for sufferers of body dysmorphic disorder, a little-known disease in which people obsess about imagined flaws in their appearance. Antidepressants and cognitive-behavioral therapy may provide relief. (See also release number 97-049.)

PROVIDENCE, R.I. -- When Jennifer sought psychiatric help, she was 22 years old with long strawberry-blond hair, large green eyes and a beautiful complexion. She believed she was magnificently ugly:

I do go out sometimes, but mostly at night when no one can see me. Sometimes I go to a 24-hour grocery store at midnight, when I know no one else will be there. For a long time I've bought most of my clothes through catalogs. I'm too scared to go out - everyone will see how ugly I am.

Jennifer had body dysmorphic disorder (BDD), a debilitating disorder in which sufferers are obsessed with imagined flaws in their appearance. In The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder (Oxford University Press), Katharine A. Phillips, M.D., writes about Jennifer and others afflicted with BDD.

Phillips, a Brown University psychiatrist based at Butler Hospital in Providence, R.I., estimates that as many as one in 50 people may have the disorder, most of them men and women in their 30s. People who suffer from BDD are typically obsessed with their face, skin or hair, but can be haunted by any part of the body.

Knowledge about the disorder in the medical community and the general public may help doctors, sufferers and their families identify the symptoms and seek help, Phillips says. Sufferers sometimes do not turn to psychiatrists because they attribute their obsession to their actual appearance, not their perception. Before visiting Phillips, Jennifer had seen 15 dermatologists, most of whom had refused her treatment.

The severity of BDD varies. Some sufferers obsess about perceived flaws from the moment they wake up. They check mirrors frequently, perform lengthy and elaborate grooming rituals before leaving the house, and frequently seek plastic surgery. Others are prisoners in their own homes, refusing to work, socialize, or even be seen in public. Cases documented in The Broken Mirror include people who missed family weddings, birthday parties and funerals because of their fears. Most sufferers think about their appearance more than three hours a day. In extreme cases, they have committed suicide.

Phillips devotes much of her time now to learning more about the disorder and finding a treatment. She is leading a study on the effectiveness of the antidepressant Prozac in treating adults with BDD. She has treated her own patients with some success, using various antidepressants and cognitive-behavioral therapy.

"Based on clinical experience, cognitive-behavioral therapy and serotonin-reuptake inhibitors [antidepressants such as Prozac] appear very, very promising," Phillips said, "but we need more studies. We are still very early in research on BDD."

Phillips is internationally known for her pioneering work on BDD, which only entered psychiatry's classification manual of disorders in 1987. Yet vivid case descriptions written during the last century testify to its history and presence in a variety of cultures.

There are people like Jennifer, who abandoned her car one afternoon in the middle of a traffic jam because she thought other drivers were staring at her. "All I could think was that they were looking at my face, thinking, `That poor girl; look at how ugly she is. How can she go out in public when her skin looks so bad?' "

Katharine A. Phillips, M.D., is chief of outpatient services and director of the Body Dysmorphic Disorder and Body Image Program at Butler Hospital in Providence, R.I., and assistant professor of psychiatry at the Brown University School of Medicine. She can be reached at (401) 455-6466.