COVID-19 restrictions have upended the usually busy social lives of teenagers and for those who suffer from Body Dysmorphic Disorder (BDD), this isolation has led to heightened anxieties.
Teens with BDD obsess about a perceived flaw on the face or body that to others is either minimal or non-existent. The mental health disorder affects approximately 1.7 per cent to 2.9 per cent of the general population or about 1 in 50 people. BDD afflicts both boys and girls with an average onset at 12 to 13 years old. Little is known about why BDD occurs but some studies point to a lower level of the neurotransmitter serotonin in people with the disorder.
“We all have flaws,” says Dr. Debra Katzman, a Paediatrician and Eating Disorders specialist at Sick Kids hospital, “but we can still get on with our daily life. But for people with BDD, it really does affect their ability to function. To them the flaw is intolerable.”
For 16-year-old Joanne, that flaw was her forehead, or more precisely, the middle of her forehead. “I believed I had these massive imperfections growing out of my face. It was probably a pimple but anything that wasn’t completely smooth or flat was, in my mind, absolutely enormous and grotesque.”
Like most BDD sufferers, Joanne went to great lengths to cover up her perceived deformity, often waking at 4 a.m.
“I had to put on my makeup and then wash it off and put it on, wash it off 100 million times,” she says, “And look in the mirror in this light, and in that light and then this mirror and that mirror.”
She also kept a mirror on her desk at school, “I would just sit and stare at myself,” along with a mirror in every pocket. She regularly left class to inspect herself in different mirrors and different lights and sought constant reassurance from her friends, “It was all consuming.”
Repetitive behaviours are common hallmarks of the disorder, says Dr. Michele Foster, a Toronto clinical psychologist who works with teens, and can include grooming, picking or pulling at a defect along with constant checking in order to manage the perceived flaw.
Isolation due to COVID-19 has made it harder for some. “We often use things like getting out, going to see our friends, extra-curriculars, as ways to help keep us busy and distracted from our thoughts – and that’s all been limited,” says Foster, who cites virtual learning as another stressor. “A teen having to see themselves on Zoom all day versus sitting in a class can be quite distressing,” she says.
For Claire, the early days of lockdown were particularly hard. “I spent hours by myself. I wasn’t distracted by anything so I could, if I wanted to, sit and look in the mirror all day.”
While BDD often presents alongside eating disorders, it is different. “Eating disorders are about weight and shape and size and not perceiving your body accurately” says Dr. Katzman, “With BDD, you tend to focus on your appearance.” To be diagnosed with BDD, which falls on the OCD spectrum, the flaw has to cause distress to the point that it impairs a person’s functioning.
Claire started hating the way she looked in grade nine after a classmate told her that she’d be pretty if she got a nose job. “I started fixating on my features,” says the 18-year-old, “My nose, my hair, the shape of my face.”
Like Joanne, Claire’s flaws consumed her. She sought constant reassurance and spent hours a day checking herself in any reflective surface she could find: mirrors, windows, car doors – even spoons.
Social media can make it worse. It uses algorithms to detect what images a user is lingering on, “so if they look up, say, modeling or plastic surgery, they’ll get more of that in their feed,” says Foster.
She also cites the dangers of filters that let users craft ideal versions of themselves. “There’s anxiety because you look different in real life than on your feed,” she says, “It reinforces the belief that there’s something wrong with you.” There’s even a new term for this troubling trend: Snapchat dysmorphia.
Foster advises parents to be mindful of children who make constant complaints about their appearances. A child not wanting to go to school or extracurriculars and the desire to withdraw because of these perceived flaws is a red flag.
As to why most teens can weather imperfections, while a small group cannot, Foster cites both a biological predisposition and a genetic component. Environment also plays a role; a parent who is consumed by their own appearance, for example, or who criticizes their own body parts. “Kids pick up on that, and so those attitudes at home are really important,” she says. Bullying can also be a factor; “If you’re told ‘Your ears are too big,’ that teen might start looking at ways to pin their ears and manage it and hide it,” she says, “and that can escalate and intersect with the biological predisposition and snowball from there.”
For Joanne, whose impairment forced her to drop out of school halfway through Grade 10 – “I can’t go to school with this face,” she told her mother, a BDD diagnosis didn’t come until university. Treatment included cognitive behavioural training – “you learn to ask yourself ‘what is the function of this thought?’ ”– and medication, which helped turn down the noise in her brain so she could focus on recovery.
She also practiced exposure therapy, a technique in which patients confront their perceived flaw in a controlled setting. “If you’re worried about something on your body, the response might be to hide it or pick it,” says Foster, “With exposure therapy, you learn to sit with the distress in a gradual way.”
Recently Claire walked around completely make-up free for the first time in three years. “It was weird,” she says, “but no one actually seemed to notice.”
Mindfulness is also effective and helps patients gain awareness of why they’re practicing a behaviour.
“Do I pick at flaws on my face when I’m anxious about school or when I’ve had a tough day or when I’m hungry?” are some of the questions Dr. Foster has clients ask themselves. She also encourages teens to post photos of themselves as they actually are, as opposed to their edited selves.
Claire continues to struggle with BDD but says it has become less negative and more compulsive. She still looks in the mirror constantly. “I’m not even looking at anything at this point. It’s like a tic,” and thinks about her appearance “every second. It’s not like every second I’m thinking I look ugly but I’m always adjusting. I always have to be aware of how I’m looking.”
She’d like to get past it, she says. Therapy helps, as does writing affirmations into her phone and spending time with friends. Joanne, now in her 30s, healthy and happy, encourages parents to keep the lines of communication open with their teens and to not fear putting a label on an issue. “Sometimes labels can help you get the treatment you need,” she says, “and that’s not a bad thing.”