The self-criticism doesn't stem from vanity or normal insecurity. Rather, it's the result of a growing condition known as "body dysmorphic disorder," or BDD, a body-image illness that affects millions of Americans and can result in disfigurement, depression, suicide and even murder.
"I've heard of a man with BDD who went as far as to take a hammer to his nose," said Dr. David Sarwer, a psychologist at the University of Pennsylvania's Center for Human Appearance. "I've treated a young man so obsessed with his moles that he'd carve them from his face with a razor."
The real or imagined physical shortcomings these people endure aren't just minor inconveniences. While many of us aren't happy with some aspect of our appearance and occasionally express anxiety, those with BDD are clinically obsessed, to the point their lives are adversely affected.
"I had all these issues with my appearance to the degree that I stopped going to work, stopped socializing, stopped returning phone calls and made a million excuses to decline invitations," said Allison, a 45-year-old insurance investigator.
Allison admitted she could "fill a drugstore" with the hair products she's bought over the years. She spends hours in front of the mirror and is constantly searching for "the perfect cut," spending as much as $130 at a time.
But sometimes the illness, which strikes an equal number of women and men, causes more than loss of money and esteem.
The disorder apparently caused Theresa Ramirez, 48, of Santa Rosa, Calif., to kill Dr. Michael Tavis, her plastic surgeon, with a .38-caliber revolver on July 3, 1997. Ramirez also shot the surgeon's 60-year-old office manager, permanently disabling her.
The murderous rage was over Ramirez's continued dissatisfaction with the appearance of her breasts, despite 12 operations over a seven-year period. She was convicted of murder last year and is serving a life sentence with no chance of parole.
During the trial, psychiatrists who testified for both defense and prosecuting attorneys, said Ramirez's quest for perfect breasts was "caused by a mental illness known as 'body dysmorphic disorder.' "
And not only is this disorder a growing concern for doctors and families of its victims, it's a legal worry for the thousands of plastic surgeons who practice in this country. A New York judge recently ruled that patients can sue their plastic surgeons because the doctors should be able to diagnose BDD.
On June 27, an appellate court in Manhattan ruled that a patient had the right to sue her plastic surgeon for malpractice because the doctor didn't properly diagnose her body-image issues. The decision creates a chilling effect on plastic surgeons who now must also show some expertise at psychiatry as well as surgery, said one physician.
"To subject patients seeking cosmetic surgery to extensive psychological evaluation, I don't think that's productive," said Dr. Mark Jewell, a board-certified plastic surgeon from Eugene, Ore., and the author of The Patient Consultation Resource Book, a text that deals with the issue of informed consent.
Jewell, in practice for 21 years, said he's performed cosmetic procedures on patients who've requested surgery on different parts of their bodies, but won't put himself in a position to have to operate over and over on the same body part.
"The kindest thing you can say to patients beating on you for additional revisionary surgery is 'no.' " said Jewell. "They should know that there's a limit to what a plastic surgeon can do."
Another plastic surgeon said the New York decision is actually in keeping with the sound practice of cosmetic surgery.
"It is a fundamental part of every board certified plastic surgeon's training to learn patient selection," said Dr. Daniel Morello, a plastic surgeon who's had a private practice in White Plains, N.Y., for 25 years. "The patient's not only picking a doctor, but the doctor's also picking the patient."
Morello, who received his surgical training at Hahnemann University Hospital in Philadelphia, also is president of the American Society for Aesthetic Plastic Surgery.
BDD affects at least 12 percent of those seeking out-patient psychiatric treatment, 8 percent of those with depression and 7 percent of those seeking cosmetic surgery, according to statistics from the Diagnostic and Statistical Manual of Mental Disorders.
While only preliminary data is available, experts say the percentages represent millions of people in the United States alone.
And those percentages are probably higher because the illness is so difficult to diagnose and because so many who suspect they may have BDD don't seek help, experts said.
"All I thought I had was a bad habit," said "Mary," 28, a Center City secretary who's been picking at her skin obsessively since she was 4 years old.
For 24 years, Mary would scratch or squeeze any bump on her body, whether it was a pimple, goose bump or mosquito bite. When the bump would turn into a scab, she'd repeatedly pick at the scab until a scar developed.
"I've done a lot of damage. I have scars all over my body," she said.
But Mary's doctor, the psychologist Sarwer, said her scars are minimal, a notion that Mary freely admits.
"To your eye, you wouldn't think they were bad," Mary said during a telephone interview. "But for me, they stand out like a red-white-and-blue flashing light. It's definitely a perception issue."
Mary's perception led her to wear heavy makeup and long pants year-round. As a high school cheerleader, she'd apply makeup to her legs to hide what she thought were hideous scars. On days when she'd have gym class, Mary would wear multiple pairs of pantyhose so that she wouldn't have to expose her bare legs while changing in the locker room.
"I'd put on sweatpants over the pantyhose and go to class." she said.
The illness did much to harm Mary's social life, too.
"I turned down a lot of pool parties. I didn't go to any proms, because I didn't want to have to expose the skin on my chest or back," Mary said.
Even though Mary has improved dramatically over the past few months, it was during her worst years with the illness that she met her husband-to-be.
"We actually met when I was full-fledged into it," she said. "He doesn't see the superficial."
Mary and her husband have been married five years, but her treatment for BDD only began this summer.
"I've improved in things like cutting down the time in the bathroom," where there are mirrors that can be used for inspection and picking, "from 20 minutes down to 10 minutes," she said.
Mary has also been keeping a log of her activities - what she does to control her obsessions, and when she gives in to them.
"She used to pick her skin an hour-and-a-half to two hours a day," said Sarwer. "In just the past couple of weeks, she's gotten a lot better."
While a BDD sufferer can obsess over any part of the body, the most common areas seem to be the nose, skin and hair, Sarwer said.
For those who think BDD can be cured with attention and compliments, think again.
"That's what nobody understands, because it doesn't matter what other people say," said Allison, who first noticed a change in her behavior about 10 years ago.
The symptoms of BDD have been described in medical literature as far back as the 1900s, but the illness received a name only in 1987.
While no one's sure what causes BDD, experts say the illness almost certainly has something to do with society's ever-growing obsession with appearance.
"We've been bombarded by images of beauty on television, in magazines, on the Internet, which inevitably leads to some comparison of ourselves to those images," Sarwer said. "Often, we fall short."
Described by Brown University's Dr. Katherine Phillips, author of the landmark book "Broken Mirror," as the disease of "imagined ugliness," BDD counts depression and eating disorders as its diagnostic relatives.
"An eating disorder inevitably contains a piece of BDD because that person is focused on a distorted image of their body, afraid of being fat," said Dr. William Davis, vice president of the Renfrew Center in Philadelphia, a treatment center for eating disorders.
A common denominator between depression and BDD is that experts believe both are caused by a deficiency in serotonin, a chemical in the brain that aids in the transmission of information between brain cells.
Pharmaceutical treatment of BDD is similar to treatment of depression, using drugs like Prozac. For BDD, counseling and exercises that recondition the patients' behavior are also prescribed, Sarwer said.
"It started out with things like limiting the times I went to the bathroom," Allison said of the exercise that cut down her exposure to mirrors. "And I also do things like not carry a pocketbook, so I don't have anywhere to put a hairbrush."
But for Allison, just the realization that she wasn't alone provided enough comfort to allow her to seek treatment.
"It was such a relief to find out this was something real, that there was somebody you could talk to about this who understood it," Allison said. "Can you imagine going into a psychologist for help because you're depressed about your hair, and knowing the psychologist is thinking, 'There's nothing wrong with this woman's hair?' "
If you think you have BDD and would like to participate in a free study of cognitive behavior therapy as a treatment, call Penn's Center for Human Appearance at 215-898-7314.
To post a question on BDD for Dr. David Sarwer, go to Philly.com, the Daily News' site on the Internet: health.philly.com
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