Body dysmorphic disorder is a disorder characterized by distress related to the belief that one is ugly. Over time, this fear evolves: it becomes the conviction that one is not attractive enough to be free from distress. One moves from being afraid of something to believing that one actually is that thing.
Someone with this type of problem in an advanced stage will usually describe themselves in these terms: “I am depressed and distressed because I am ugly; if I were different, if I were ‘beautiful,’ the problem would certainly not exist.”
Behavior alternates between the idea of improving oneself and the idea of correcting or concealing perceived defects, but in neither case is there ever satisfaction at being sufficiently beautiful; at most, there is satisfaction at being sufficiently less ugly. What matters is how far the person perceives themselves to be from a state of aesthetic unacceptability.
Alternatively, if the person does not consider themselves ugly, they may nevertheless be terrified of becoming ugly—that is, of becoming less attractive or growing old.
In the final stages, perception becomes markedly distorted, in the sense that a person who considers themselves ugly ends up seeing other people as increasingly beautiful. If someone thinks they have a crooked nose, they will see other people’s noses as increasingly straight, and will tend to construct a “myth” of beauty, regularity, and proportion. They become, in other words, an expert on and advocate for the beauty they do not possess but would at least like to approach.
At times, changing one’s physical features seems to be the only way to protect oneself from ugliness and prevent it when aging, and so people with body dysmorphic disorder may turn to cosmetic surgery, which nevertheless fails to satisfy them.
Unlike other people seeking cosmetic procedures, the goal of someone who fears ugliness is not simply a result, but a result that will eliminate the fear. This is the fundamental misunderstanding: because the fear does not arise from an objective fact (being ugly or beautiful) but operates independently, no degree of beauty, however perfect, will resolve it.
Procedures are therefore often repeated, refined, or layered on top of one another, with increasing risks to anatomical integrity.
There is usually strong resistance and irritation when a physician explains that the distress does not arise from an actual aesthetic condition, but that—regardless of the person’s real physical features—body dysmorphic disorder makes them dissatisfied with their body, whether it can objectively be described as “beautiful” or “ugly”; it makes their nose seem crooked, whether it is actually crooked or straight; it makes them feel too fat, whether they are actually fat or thin.
In the most severe forms, there is an alteration of visual and proprioceptive perception—that is, of how a person represents their own body, movements, and proportions—progressing to the point of a genuine delusion.
For example, some people claim that certain parts of their body are disproportionate, too small, too large, too swollen, and so on, and maintain this belief despite all objective measurements and the judgments of others. At this stage, there is no longer any meaningful reference to what other people may say: they are ugly even when others say they cannot see the problem; their body is deformed even when its measurements are normal; and so on.