Since an estimated 1 in every 50 people of the general population suffers from BDD — making it more common than schizophrenia and anorexia — it’s possible that millions of others with BDD also saw their symptoms worsen during their countries' lockdowns.
We are all adjusting to what is known as the new normal: Faces in public spaces are often covered with masks, work meetings are done online, human interaction is socially distanced, and people are encouraged by their governments to stay home. But for people with body dysmorphic disorder, experts tell me the lasting effects of being in lockdown combined with adopting these preventive measures to stop the spread of COVID-19 could have worsened their symptoms and introduced new complications: Wearing a mask gives those with BDD an excuse to hide their appearance that is perceived by them to be flawed, frequent FaceTime and Zoom calls can become triggering when continuously forced to see a mirrored reflection, and limited human interaction can worsen BDD symptoms.
"Especially for people that are not getting adequate treatment, I think [being in lockdown] can make BDD worse,” said Dr. Katharine Phillips, a Professor of Psychiatry at NewYork-Presbyterian and Weill Cornell Medicine who has studied body dysmorphic disorder for over 25 years. “Lockdown is stressful and stress can increase psychiatric symptoms, whether it's BDD or depression or anxiety. Also, we really encourage people [with BDD] to be going out and doing things and being socially active if their BDD is not so severe that they can't do those things. So some people [with BDD] backslide when they're socially isolated.”
The practice of comparing how you look to how someone else looks is a natural and universal human tendency, but when it debilitates one's capacity to go about their daily life is when it crosses over from vanity to possibly being a result of a mental health disorder like BDD. “We've learned that there really are visual processing differences in people with BDD. This is a brain-based condition and cultural factors probably contributed as well. This is not vanity,” said Dr. Phillips. “[Someone with BDD] may just think what they are experiencing reflects a character flaw or that they're just a vain person. Sometimes they may not even realize there is treatment for what they are experiencing.”
Presently, social media presents itself as a conduit to amplify imagery and text that showcases life’s highs and rarely the devitalizing lows, resulting in a fragment of resemblance displayed on billions of digital profiles to the whole of one's lived experience. Based solely on the photos I have posted on the internet where I’m shirtless or prancing around in a red speedo on a European beach, someone lurking on my profile would probably assume I’m confident in my body and flaunting it to reflect that. But as Dr. Phillips explained to me, while some individuals with BDD hide away from the world, others may rely on approval from others through conspicuous acts such as posting photos of themselves on the internet. I now recognize that the intention of posting these photos was not entirely just a way for me to flaunt my appearance but a way for me to validate that the distorted appearance I saw most days in the mirror was not the one perceived by others.
Today, the majority of people with BDD are either undiagnosed or decide not to pursue professional treatment options like I did, which could be rooted in the fear of coming across as superficial or vain when someone with BDD is asked to describe symptoms to a professional. Especially if someone’s condition is so severe they don’t leave the house or avoid meeting people, Dr. Phillips said this is also a common reason why some people may avoid treatment. “They can think they look so ugly that they don't want anyone to see them. That makes it hard to seek care because usually therapists or doctors want to see the person,” she said.
If BDD is left untreated or unaddressed, the consequences can be pernicious. There is a spectrum of severity, Dr. Phillips explained, where a person with a severe case can become so preoccupied with the perceived defects on their face or body to the point of causing severe emotional distress. At this point, if the person does not seek the recommended treatment, BDD can begin to interfere with every aspect of one’s day-to-day life. “For some people with BDD, this is a life-threatening condition. Suicide rates are very high among people with BDD. They can be very very depressed over how they think they look.”
It’s still not known what causes BDD, but Dr. Phillips believes that environmental influences like trauma and overexposure to sociocultural messages projecting an ideal “perfect” could contribute. “This does not mean trauma is the cause of BDD. It’s never that simple,” she said. “It might be one of many factors that might increase the risk of getting BDD and it’s not the case that everyone with BDD has experienced significant life trauma.”
The memory is poignant in my mind of when at 7 years old, I compared my adult swimming instructor's chiseled body to my prepubescent one in the shallow end at a community swimming pool.
Chlorinated water droplets embellished his vascular torso like rhinestones, the veins on his toned arms sharply visible. I wanted to be him, not only for his body composition but also for the physical characteristics he shared with every North American teenage heartthrob relevant to me. I wanted his dirty blonde haircut the same way I saw it in the movies, not my straight black hair. I wanted his frost blue eyes, not my brown ones. I wanted his porcelain smooth skin, not my own. This was the first time I critically compared my body and my race to another and as I got older, this exigency for comparison ravaged my life.
Insecurities with my appearance inflamed when I entered elementary school. I was ashamed of my distinctive facial characteristics inherited from my Chinese ancestry, predominantly my facial moles that are positioned across my face like a constellation, and often asked others if I should save up the money to get the moles surgically removed. Though my family was aware of these deep-rooted insecurities, they did not know I was diagnosed with BDD until recently. Over a recent phone call with my stepsister, she recounted a memory from decades past of me drawing myself with blonde hair and blue eyes in self-portraits, possibly to satisfy the desire I had to look like the white teenage heartthrobs plastered on the covers of my cherished and well-loved teen magazines.
I never saw myself in these magazines I read, or the music I listened to, nor the movies I watched. The Asian actors I did see on television and movies growing up were often cast in demeaning roles based on racial stereotypes or their country’s culture. They spoke broken English, they were not the main character, they were complacent in the background, and they did not resonate with me. Still today, even after the well-reported watershed moment for Asian representation in Hollywood with the critical acclaim and commercial successes Minari, Crazy Rich Asians, The Farewell, and Parasite, Asian Americans remain largely underrepresented in film and television even though Asians make up a large percentage of the population in Canada and the United States. Consequently, there was an inherent expectation within me to achieve the American or Eurocentric beauty standards of my idols, and I would often fantasize about achieving these standards one day through cosmetics and aesthetic surgery.
All I ever wanted during adolescence was to belong to a community. I didn’t have any gay friends until I was an adult and my school’s sex ed did not provide specific resources or support for LGBTQ+ people or people of color. So as I navigated the gay community unescorted, with all but YouTube videos and my Twitter account, where I virtually bonded with others over collectively witnessing the genius of Lady Gaga unfold. I combed the internet for someone who looked like me, for some sort of representation. But once again, I was unsuccessful.
Instead, I was inundated with the categorizations of gay men labeled based on their body type and age, and experienced an overwhelming pressure to live up to the figureheads of the gay community represented in pornography and popular culture, mostly made up of muscular white men.
Issues with body image pervade the gay community, in part due to the social demands for gay men to uphold high standards of beauty. Research shows these high standards shape one’s emotional and physical health, and have been linked to higher rates of anxiety, depression, and mental health disorders like BDD in gay men compared to the rates among straight men. Gay men also have a higher risk for developing an eating disorder compared to straight men, something I have struggled with since age 10 and something that is already commonly comorbid with BDD. In 2017, researchers even established a direct link between porn consumption and body dysmorphic disorder, which is consumed by 96–99% of gay men, compared to 72–76% of straight men.
I long felt disconnected from the heteronormative bubble I was raised in, and I later encountered the undercurrents of racism in the gay community upon observing numerous profiles on dating and hookup apps stating "No Asians," which displaced me from both standards of beauty and acceptance within two of my own communities. How was I expected to like the way I look after being outcasted for being gay and then again for being Asian? I now recognize these impossible expectations put me in a constant battle with my own identity.
“People who have body dysmorphic disorder, are gay, and of color have two layers of influence of how they look, so all of that needs to be taken into account because some of that needs to be dealt with for the person to fully heal,” said Chris Trondsen, a psychotherapist and clinician that specializes in BDD.
Upon assessing his clients, Trondsen, who is a gay man with BDD himself, says it’s important to identify the beauty expectations of his clients’ culture to see if their race and sexuality have influenced how their BDD is represented. The intersectionality of being a gay man and a racial minority increases the desire for acceptance rooted in years of rejection from societal standards of masculinity and beauty, Trondsen explained, and obtaining a “perfect” appearance is one way to avoid rejection and superficially mask feelings of insufficiency.
Currently, there is not much research on how sexuality or race can affect BDD, leaving BDD not only unreported and underdiagnosed but also insufficiently researched in how it can disproportionately affect LGBT people and people of color. “As a clinician and someone who has gone through graduate school, I have access to different journal article databases. So when I looked up studies specifically looking at the way that BDD affects the LGBT community, there was no research,” said Trondsen. “Everything that I read when I was struggling [with my BDD] assumed that I was heterosexual. It never included anything about the LGBT community; it was never something that was discussed.”
To recover from BDD, both Trondsen and Dr. Phillips said sufferers should always seek personalized professional treatment, which can include medication, naturopathic support, or a psychological treatment called Cognitive Behavioral Therapy, which has helped people with BDD recognize that the thoughts and beliefs they have about their appearance are not true. ”People start to challenge these unhelpful thoughts that they have about themselves, reduce mirror checking and camouflaging, and reengage with life focusing more on connections with people and accepting how they look,” said Trondsen.
These treatments don’t come cheap, which creates an obstacle for some sufferers to effectively treat their BDD after being diagnosed due to income, racial, and ethnic disparities in access to healthcare that exist around the world. As someone diagnosed with BDD who has avoided treatment for years, I now realize how vital receiving proper treatment can be and that my extensive self-care routine, although beneficial to my physical health, is not a replacement for professional and specialized BDD treatment.
The time spent in isolation during the pandemic was a rare moment of reflection, in the midst of an event that left so many in the world uncertain and with so much taken away. Being in lockdown and adapting to life during a pandemic cornered me in a place with my body dysmorphic disorder that was debilitating, after months of restricted access to my distractions. Yet the other day, as I looked in the mirror at the distorted reflection of myself, comparing my face and my body to the ones I saw on an illuminated screen moments ago, a visceral realization surfaced within me. I ultimately realized that it was time to prioritize my mental health and go to any lengths in order to heal and that my BDD is something serious millions of people suffer from and don’t treat seriously — or don’t even know they have. As I work toward no longer being ashamed of my BDD and unlearn the perception of myself I have formed as a result of years of conditioning, hopefully some time soon I will see myself in my true light.