Imagined ugliness

New study offers hope for sufferers of body dysmorphic disorder.

Published October 29, 1999 4:00PM (EDT)

No matter what surgeons did to Theresa Ramirez's breasts, it was never
quite right. After losing a breast to cancer, she had a plastic surgeon put silicone implants in both so they would match. But she didn't think they did, so she had them reshaped, taken out, and reshaped again. Over the course of eight years, she had 13 breast reconstruction surgeries. Nothing doctors did assuaged her fears that they were imperfect.

So on July 3, 1997, Ramirez went to one of her surgeon's clinics and shot
and killed him. Despite her lawyer's argument that Ramirez suffered from a
debilitating mental illness that causes those afflicted to have a distorted
view of themselves, she was convicted of first-degree murder.

Called body dysmorphic disorder (BDD) -- or imagined ugliness -- the illness affects an estimated 2 million to 3 million people in the United States, causing an obsession with an
imagined or slight defect in their appearance. Because many people don't even know they have it, one doctor studying the disease believes it is America's "hidden epidemic."

Ramirez's ire is not representative of the condition. Most BDD sufferers disrupt their own life more than others' -- spending hours and hours just staring in the mirror at what might be a minor blemish.

Now a new study, published in the November Archives of General Psychiatry,
shows that clomipramine, a selective serotonin reuptake inhibitor (SSRI), is effective in treating BDD. Dr. Eric Hollander and his colleagues at New York's
Mount Sinai School of Medicine found that out of 29 patients who went through the
16-week study, two-thirds were helped by the medication, which is commonly used to treat obsessive-compulsive disorder, a closely related condition.

"It caused them to have less distress and it was easier for them to resist doing the rituals -- so they didn't have to look in the mirror over and over again for long periods of time; and they didn't have to put as much makeup on [to conceal the defect]," says Hollander, director of Mount Sinai's compulsive, impulsive and anxiety disorders program. "It was also
easier for them to go to school, to be involved in relationships, to go to
work, and they had less suicidal thoughts."

While clomipramine has long been prescribed to patients with BDD, this is the first double-blind study showing how well it works. Hollander says the study's results also suggests that people with BDD might respond well to other SSRI medications, like Prozac or Luvox (although that hasn't yet been proved).

BDD is difficult to diagnose; because the average time of onset is adolescence, it can be confused with normal body-image insecurities. "On college campuses, you find high rates of people obsessed or concerned with their buttocks or thighs, but it's different than BDD because they're not obsessed about it 24 hours a day and it doesn't result in secondary depression or social phobia," says Hollander.

What is happening now, Hollander says, is that many people are being
treated in the wrong order. They are often being given medications for secondary
conditions like depression or social phobia, which are caused by the BDD, rather than being treated for the disorder itself.

Patients with the disorder find plenty of targets for their obsessions.
One of the patients in the Mount Sinai study thought he had fatty deposits in his buttocks and didn't want his pants to rub up against them, so he put cardboard in his underwear as a barrier. Another person was initially obsessed with his nose, but then thought that his penis was being retracted into his body, and had surgery to correct that.

Because patients with BDD see themselves differently than those around
them do, physicians discourage them from getting plastic surgery. (Surprisingly, only 5 to 7 percent of the people who visit cosmetic surgeons have BDD, according to the Center for Human Appearance at the University of Pennsylvania Medical School.) Patients with BDD who do have surgery are usually unhappy with the results, or may just move
their preoccupation onto another area of their body.

In fact, at the Center for Human Appearance, they turn away many patients who have imagined ugliness. "One patient came in who did have a small bump on her nose and the surgeon really thought that she was [too] particular about how it had to be corrected and how it was going to look in different light conditions," says Dr. Michael Pertschuk, a consultant to the Center for Human Appearance and associate professor of psychiatry at the University of Pennsylvania Medical Center. "She never actually got the surgery, because there's no way that any surgeon would work so exactly that it would be the perfection that she was looking for."

The patient in this case ended up having therapy instead -- a treatment that Hollander says should always accompany a medication like clomipramine for someone who has BDD.

By Dawn MacKeen

Dawn MacKeen is a former senior writer for Salon, and author of a forthcoming book about her grandfather’s survival of the Armenian Genocide, "The Hundred-Year Walk: An Armenian Odyssey" (Houghton Mifflin Harcourt, January 2016).

MORE FROM Dawn MacKeen

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Mental Illness