Sandra Fallman avoided mirrors. Walking down sidewalks during dates, she would avoid bright storefront lights, walking near the curb to stay in the shadows. She put 25-watt bulbs in her apartment lights, not to set the mood, but to provide cover.
Fallman suffers from a little-known mental condition called body dysmorphic disorder (BDD). Sufferers are ashamed of certain aspects of their physical appearance because of exaggerated or imagined defects. But, unlike most of us who have flaws that we live with, these blemishes take over sufferers’ lives, force them indoors, and cause them to shun contact with others.
“We don’t just think we’re ugly. We think we’re grotesque and disfigured,” said Fallman, a Marblehead resident who has been treated at the Massachusetts General Hospital (MGH) Body Dysmorphic Disorder Clinic.
The clinic, one of just a few in the United States, is run by Sabine Wilhelm, an associate professor of psychology in Harvard Medical School’s Psychiatry Department and the clinic’s founder and director.
The clinic provides drug therapy and a combination of cognitive and behavioral therapy that helps sufferers slowly remake their self-image and reform the behavior that goes with it.
“These people worry about an aspect of their appearance that other people don’t notice. It gets in the way of them having a good life,” Wilhelm said.
The condition strikes men and women equally and affects people of all ages, though it most commonly appears at around age 17, Wilhelm said. The disorder is particularly prevalent among college-aged adults, Wilhelm said, and is often accompanied by perfectionism.
Two studies showed that 5.3 percent of German college students and 4 percent of American college students suffer from the disorder. But BDD is quite likely underreported, Wilhelm said, because its sufferers are so ashamed of their looks they often fail to seek treatment. Wilhelm has written a self-help book on body dysmorphic disorder, “Feeling Good About the Way You Look,” set for publication this summer.
While it’s not uncommon to be concerned about one’s appearance, Wilhelm said people who spend more than an hour a day thinking about one aspect of their appearance, or whose lives are curtailed by how they feel they look, should be alert for BDD. The skin – redness, blemishes, moles, and freckles – is the most common focus of concern, followed by hair – too much, too little, or in the wrong places – and noses. But the focus can be almost any body part, including genitalia, and the focus can switch from one body part to another.
Wilhelm said sufferers show a wide range of symptoms. Extremes of mirror behavior – either obsessively staring at their image or avoiding mirrors entirely – are common. Camouflage and masking, like wearing excessive makeup, or avoiding social situations like parties and family gatherings, are also typical symptoms. “Doctor shopping” is another common behavior, requesting procedures from physician after physician and always being dissatisfied with the results.
A significant number of sufferers resort to plastic surgery, but Wilhelm said that is unlikely to help because the physical feature is not the real source of the problem.
Men are prone to particular behaviors, such as obsessive weight-lifting because they don’t believe their muscles are large enough.
Wilhelm said she’s had several patients get into car accidents while staring at their reflections in rearview mirrors. Suicide attempt rates are very high, Wilhelm said, with between 22 percent and 24 percent of BDD sufferers attempting suicide.
Wilhelm said the disorder is no more likely to strike those who might be deemed unattractive than those who might be deemed attractive. One study used independent observers who rated BDD patients at about the same level of attractiveness as the general population. Wilhelm said she’s even had a model as a client.
BDD patients, however, tend to grade others as being more attractive than an objective observer would and themselves as being less attractive.
The MGH clinic offers both medication and behavioral therapy. Wilhelm said both treatments generally work well for BDD sufferers. Wilhelm also said she’s looking for participants in research studies, offering free treatment for those who sign up.
Behavioral treatment consists of carefully facing patients’ fears and gradually dispelling them. Patients slowly expose themselves to situations they would have avoided, such as sitting with others in a brightly lit room or going outside without makeup on a sunny day.
Fallman said the weekly sessions are helpful, but urged anyone seeking behavioral treatment to “do their homework”: little tasks assigned at the sessions to be done on their own, such as spending time looking dispassionately in the mirror.
Wilhelm said the roots of the disorder are poorly understood, but patients sometimes report having parents who never let them go outside unless their shoes were shined, hair combed, and appearance perfect.
Fallman, who also has obsessive-compulsive disorder, traces her BDD to an episode in kindergarten when she had a school photo taken. She recalled thinking that she looked pretty in the picture and rushed home to show her parents. Someone laughed at the picture, however, sowing a seed of self-doubt that flourished in the years that followed.
“I always thought I was bigger and fatter and uglier than my friends,” Fallman said.
Her mother would reassure her about her appearance, Fallman said, but she just explained that away as her mother doing her duty.
Adolescent acne and subsequent scarring led to years of heavy makeup wearing, excessive sleeping, and avoiding social situations. Fallman said her own image was so distasteful to her that she would stand as far from the mirror as she could when she put on her makeup. For close-up application of makeup around her eyes, she used a smaller mirror, but let it get so dirty and smudged that the image in it was unclear.
Today, Fallman is much more comfortable with bright lights and clean mirrors. Like everyone, she has good days and bad, but treatment she began seeking years ago has freed her from the prison of her routines.
“If I didn’t have makeup, I’d wear sunglasses to hide some of the hideousness,” Fallman said. “Now I can go to the supermarket and not have to wear glasses or makeup.”
Fallman realized she had a disorder in the early 1990s after a family member saw a television program on the subject. She went to weekly sessions after the clinic opened and has returned since then whenever she needed additional help.
Fallman said she doesn’t believe she’ll ever be completely cured but said treatment has helped her – and can help others – to live a happy life.
“I do this [speak out] because a lot of people are struggling with body dysmorphic disorder,” Fallman said.