In this article, we will have a deeper look into what might be called, so to speak, “major” body dysmorphic disorder. In this case, we are dealing with people who pursue a concept of “beauty” or “perfection” understood as being “more beautiful,” or as maintaining and preserving beauty so that it does not deteriorate, or enhancing it in order to reach a higher level of attractiveness.
This is often not an obsession in the strict sense—that is, a thought experienced as unpleasant but nevertheless controlling—but rather a dominant or prevailing idea. In other words, the person becomes absorbed or fascinated by the idea that their life depends on enhancing their appearance, correcting an aesthetic feature that may not even be particularly problematic, in order to achieve an ideal of aesthetic success.
For this reason, they generally develop theories about beauty, about the importance of physical appearance in determining a person’s fate, and about the impossibility of freely choosing how to relate to others unless one is aesthetically “qualified,” meaning that one does not immediately receive social approval on the basis of one’s appearance. Many therefore feel inexorably destined to belong to a human “second tier” if they do not possess certain characteristics.
If they can obtain those characteristics, they usually pursue that route: cosmetics, surgery, nutrition aimed at reshaping the body, including, naturally, exercise, and so on. Some prefer procedures because they are rapid and definitive; others prefer body shaping because it allows them to maintain active control over their appearance and learn how to preserve it.
If the underlying motive is dysmorphic, however, the typical course is that corrections and procedures of any kind eventually cease to be satisfactory, or are judged insufficient. The person therefore repeatedly insists on modifying their appearance, with the inevitable consequence that further complications arise in order to maintain harmonious proportions with other parts of the body or to improve the overall aesthetic result.
It is not uncommon for the focus to shift from one detail to another: once one feature has been corrected, attention moves to another that now needs correcting. Skin tightening, enlargement of the lips, chin augmentation, reduction of the nose or ears, and alteration of the cheekbones tend to follow two reference models. One is the “mannequin” model: smoothed out and stripped of protrusions and indentations. The other is an exuberant, “swollen” appearance, which becomes particularly noticeable with age, when other tissues become less taut and the artificial features stand out more clearly.
Patients with this problem may see a psychiatrist for various reasons. Some do so because they are depressed or distressed, but they believe that being depressed will prevent them from achieving the desired changes, or from correctly understanding which changes are essential to resolving the aesthetic issue. Others seek psychiatric help because they have become demoralized by “paradoxical” failures in their social or romantic lives.
The patient’s tendency is to defend their position, despite recognizing that it is not fully under their control, and to deny that their unhappiness stems from body dysmorphic disorder. Instead, they maintain that the solution to the dysmorphic problem would be to have “a good appearance,” or a perfect appearance.
Some patients, particularly those with fewer resources or with aesthetic defects or peculiarities that cannot be modified, adopt a position of depression and hostility. They hate “beautiful people,” those who are “successful,” who have been favored by nature rather than condemned to unhappiness because of an unfavorable appearance.
These patients may ask for help and then approach the doctor with open distrust and condescension, arguing that treatment is pointless because, ultimately, their appearance is what it is. Some may even fantasize about killing or ruining other people because those people represent the beauty that has been denied to them, and are living proof of their own perceived inferiority.
In this form, body dysmorphic disorder therefore takes on the characteristics of a conviction—however logical and well argued it may appear—but one that is essentially impossible to resolve because it arises from a concept of aesthetic defect that reproduces itself indefinitely.
The most severe cases are those in which the person has experienced a period of success associated with their youthful beauty, or has felt “beautiful” in the sense of being appreciated during a particular phase of life. They subsequently develop a fear of moving too far away from that model and therefore resort to practices or procedures intended to regain their former appearance or prevent themselves from becoming less attractive.
Some, naturally, when they feel that they have “become uglier,” adopt a position resembling social phobia. Fundamentally, however, they remain attached to their idea, without questioning it or being willing to redirect their efforts toward correcting the underlying idea rather than the appearance itself.
There is a famous fairy tale that serves as a useful reference point in this regard: Snow White. The enchanted mirror that Snow White’s stepmother speaks to repeatedly tells her how beautiful she is, yet the more this happens, the more the objectively beautiful queen feels that she is not beautiful enough. Consequently, any potentially greater beauty—even that of a child who could grow into an exceptionally beautiful woman—becomes a threat.
The solution in the fairy tale is to eliminate those who are more beautiful, in order to avoid having to think of oneself as less beautiful than someone else. Ultimately, the queen’s beauty is not a social issue; it is a problem within herself. The mirror echoes her own thinking, but eventually “betrays” her by telling her that there is a girl more beautiful than she is. The dysmorphic mind that theorizes about and guides the person toward perfect beauty is the same mind that ultimately betrays them, because the more it reasons about beauty, the less beautiful enough the person will feel, and the more frightened they will become by the idea that someone else might possess greater beauty.
The moral of the fairy tale should therefore be taken as a principle of psychotherapy: the problem lies in the mirror. The queen, despite possessing all her power, can only lose because she remains blinded by her body dysmorphic preoccupation. No matter how beautiful a person with body dysmorphic disorder may be, they will never feel that it is enough. And no matter how unattractive a person with body dysmorphic disorder may actually be, the source of their suffering lies in the beauty upon which they have become fixated.