Vogue Singapore August 2021

What is body dysmorphia, the under-reported disorder affecting a rising number of Singaporeans—including me

BY DANA KOH - A guide to Body Dysmorphic Disorder and what to look out for, according to experts Oliver Sündermann and Rany Moran

Do you obsessively check yourself in a mirror more than 40 times a day? Are there features that you feel are “never right” and cause you distress? Do such perceived “flaws” interfere with your life or lead you to avoid social situations? I recently took a Body Dysmorphic Disorder test and my answers to all of these were yes. And based on the score system, it is highly likely that I do have BDD and need some form of treatment.

Body dysmorphia can come in countless shapes and forms—it can look like someone who is severely underweight or overweight, someone who yoyos through extreme diets or eating disorders, or someone who looks perfectly healthy and happy, oftentimes a confident facade to mask their insecurities. “Body dysmorphic disorder is becoming more common—many with mild symptoms that they either ignore or don’t want to admit to, and go on living their lives with a secret disorder. They obsess over what they perceive as flaws, suffer some level of emotional distress trying to deal with or deny it, and this in turn affects the quality of life, be it isolating themselves from social gatherings, being constantly distracted at work, or worse, taking out their frustrations and sensitivities on their loved ones”, explains resilience coach and psychological counsellor, Rany Moran.

Together with doctor Oliver Sündermann and Moran, we dissect the what, why’s and how’s of this rising and all-too-familiar disorder.

What is BDD and its effects on one’s daily life

“Body dysmorphic disorder (BDD) is a disabling condition that is characterised by a severe preoccupation with one or several perceived flaws in one’s normal physical appearance,” describes Oliver Sündermann, clinical psychologist and cognitive behavioural therapist. “All parts of the body can be the focus of the concern but most people with BDD worry about visible aspects such as their skin, hair, height, or facial features. BDD causes significant distress, impairment and shame, and therefore people with BDD cover or hide their disliked feature, constantly check it (e.g. in the mirror, with their phones, or by touch), seek reassurance from others, ruminate, or seek to correct it (e.g. with cosmetic surgery). Many people with BDD have their concerns minimised by friends, family and doctors, who might tell them that they look fine or that they should not be so vain. Thus, BDD is a very lonely place where sufferers feel stuck in their bodies and misunderstood by others. Often they have accumulated large debt because of expensive cosmetic procedures, being unable to function at work or hold down jobs, all of which leads many to feel extremely hopeless and depressed.

Body dysmorphia is an underreported condition in Singapore and Asia

According to Dr. Sündermann, “BDD is both under-reported by clients and under-recognised by professionals, and thus often remains undetected for many years”. Statistically, “about two in 100 people in the general population are estimated to suffer from BDD, but this data is largely based on Western studies”. Still considered a stigma to speak up about in Asia, let alone Singapore, disorders such as body dysmorphia have, unfortunately, been underreported and under addressed—”the latest survey by the Institute of Mental Health did not include questions about BDD” adds Dr. Sündermann. To get the information they needed, the deputy director of National University of Singapore’s clinical psychology programme and his team surveyed university students in Singapore and found that about three to five percent meet diagnostic criteria for BDD, which is in line with other international studies.

The rising popularity of aesthetic procedures may be fuelled by BDD

In clinic settings like cosmetic surgery or dermatology clinics, however, Dr. Sündermann states that “many more people are expected to suffer from BDD. One Singaporean study found that 29 percent of people in dermatology clinics met the criteria for BDD, which is a much higher rate than in similar clinics in Western countries”. Moran highlights: “People who have BDD can appear infatuated with their physical appearance and to others, this can be misconstrued as narcissism or excessively vain. But in reality, the individual suffering from this is engaging in obsessive behaviors to either check, hide or cure their imagined imperfections. Beyond constantly checking mirrors, touching up their make-up or hair, or spending too much time getting ready, these everyday gestures can lead to more serious desires to get aesthetic procedures to fix or enhance themselves. Unfortunately, people with BDD often suffer from constant feelings of inadequacies and may seek out such treatments over and over again”.

Individuals suffering from BDD hide their “flaws” well

“To receive a diagnosis of BDD, the following criteria must be met: the preoccupation about the disliked feature must be for at least one hour per day and cause significant distress or impairment; importantly, the perceived flaw is not noticeable by others, or only slightly at conversational distance. Therefore, if someone suffers from a visible skin condition, very obvious hair loss or from other clearly observable physical differences, BDD would not be diagnosed. Furthermore, the person must engage in repetitive compulsive behaviors in response to their appearance concern (e.g. mirror checking, excessive grooming, make-up routines) or mental acts (e.g. comparing with others, ruminating about appearance) and these concerns are not better explained by concerns with body fat or weight”, explains Dr. Sündermann.

Body dysmorphia is connected or can lead to other mental health problems

People who suffer from BDD often also experience other mental health problems or disorders. This can range from depression (the most common), Obsessive Compulsive Disorder or social anxiety, to eating disorders such as anorexia or bulimia. While research shows that females with BDD are more likely to form an eating disorder, there is a condition referred to as “reverse anorexia” or more commonly known as muscle dysmorphia or bigorexia that’s found almost exclusively in men where they become fixated with the size of their muscles. This subtype of BDD is prevalent amongst weightlifting and bodybuilding communities, and can push individuals to unhealthy extremes of exercise due to their obsession to get bigger and more defined muscles.

BDD can affect children as young as three years old

A positive parenting expert, psychological counsellor Rany Moran emphasises that even children can develop body image issues: According to the Professional Association for Childcare and Early Years (PACEY), 24 percent of childcare personnel witness signs of body-related unhappiness amongst kids as young as three years old. That number almost doubles as children get older, with 47 percent identifying similar body image anxieties in six to 10 year olds”. She adds: “How we talk to our children about beauty and bodies is crucial—just as important as how we talk to ourselves about it. As parents, we are the first and main role models in their lives, and if our children see us constantly obsessing over calories, fat-burning workouts, the weighing scale or ways to “conceal” our physical imperfections, they will too. The same goes for if you’re constantly bingeing on junk food and lounging on the couch. Children internalise our words and actions more than we think, and to raise and praise body positive children, we need to help them define what being strong and beautiful is by instilling healthy lifestyle habits, normalising conversations of all bodies, and changing the narrative of their negative thoughts or experiences”.

Counselling and cognitive behavioural therapy can help treat BDD

“Fortunately, BDD is treatable with cognitive behavioural therapy (CBT) specific for BDD, antidepressant medication, or a combination of both. In CBT the person first develops an understanding of how the BDD developed (e.g. as a result of bullying, appearance teasing or sexual trauma), an how it is maintained—usually be a host of behaviors that aim to camouflage, hide or fix the perceived appearance flaw but have the unintended consequences of making the person more preoccupied and worried about their looks, preventing them from finding out that they are safe without these unhelpful strategies, and thus perpetuating the distress,” says Dr. Sündermann.

“In therapy, the client learns to challenge their appearance-related beliefs by dropping these strategies. For example, a client who is worried about skin blemishes and can only leave the house with extensive make-up rituals would learn that they can go out without the make-up, without the predicted catastrophes (e.g. everyone laughing or making comments about my face) to occur. Mirror retraining helps to develop a healthier relationship with reflective surfaces. Clients also learn to shift their attention from an internal focus on how they feel they look to their external surroundings. Trauma processing is indicated if certain events are at the root of the problem, and continue to affect the person’s perception of herself”, he adds. “As a psychological counsellor, my role is in recognising the root of these negative or irrational thought patterns, providing a safe environment for the individual to express their feelings on self-worth and image, and presenting daily strategies to deal with these concerns. Such therapeutic interventions can come in the form of normalising conversations on all bodies; redefining the definition of “taboo” words like “fat” (by talking about how good fats have an essential role in both our diets and bodies as a source of energy and protection for our organs); and identifying negative thoughts then changing the narrative with a respectful, non-blaming and empowering approach”.

Body dysmorphia can lead to physical conditions like chronic pain and anxiety attacks

Dr. Sündermann says that many people who suffer from BDD experience various physical effects. “First, physical sensations in the disliked feature, e.g. their nose, or ear, are commonly experienced, especially after cosmetic surgeries, and these can strongly amplify the person’s preoccupation with that feature, thereby worsening the appearance-related distress. Panic attacks are also commonly experienced, and if a traumatic experience is at the root of the BDD, the person may also experience intrusive memories or flashbacks in the form of visual images or sensations. People with chronic pain are also experiencing body image problems; often chronic pain patients engage in ineffective pain-coping behaviours such as avoiding movements, which can adversely affect the person’s perception of their bodies (e.g. “my body is not working right”, or “I look old and frail”)”, he explains.

If you or a loved one is suffering from Body Dysmorphic Disorder, seeking treatment with a professional is the best course of action. The NUS Clinical and Health Psychology Centre is one such place for help, and can be learned about online, or by emailing or calling their team.