Last summer, I couldn’t use the bathroom without asking permission. Except for half an hour every night, my phone was locked away. When I did use it, counselors monitored me closely, making sure that I wasn’t on Snapchat, using the reverse-facing camera or zooming in on photos of my face.
I was at McLean Hospital’s OCD Institute in Massachusetts. I’d had body dysmorphic disorder (BDD) for three years and obsessive-compulsive disorder (OCD) for 15. I was preoccupied with an indentation on my face caused by a cortisone shot intended to treat an acne cyst. I couldn’t go more than 15 minutes without checking my reflection — without, in BDD/OCD terms, ritualizing.
I was familiar with rituals. In seventh grade, I developed harm obsessions (I feared I would stab my mother) and sexual ones (I feared I would molest my classmates). I had no idea that OCD could have anything to do with these thoughts. I was terrified that I would be sent to prison, that I would be “found out” and locked up. I began kneeling in prayer throughout the day, asking God to banish the thoughts. Then the praying became just kneeling. Then the kneeling became a quick bend, a quick touch to the ground. I knelt so often that I have to wear a brace now when I exercise.
The harm obsessions disappeared, and another arrived. I was 17 and started noticing clear shapes and dark spots in my vision. I knew at once what they were: eye floaters. It occurred to me that I might go blind, that I might never be able to read again. I started spending all my time indoors. I read in my dim closet and ventured outside at dusk.
Eventually, I began exposure therapy. In exposure therapy, patients with OCD are exposed to a feared stimulus — a trigger — for a period. Once you understand that you will not die because you go on a plane/hold a knife/get a shot, you can perform the action again. Eventually, the anxiety surrounding the stimulus disappears.
I feared bright lighting, which made the floaters worse. So I stood outside and read “The Hunger Games” to my new therapist, who had confiscated my dark sunglasses. Eight years later, I can walk and read and drive in direct sunlight. So I had a lot of faith in exposure therapy.
My therapists at McLean told me over and over that I wasn’t at the hospital to change my thoughts. You can only change your actions, we were told.
By the beginning of 2018, I was in an MFA program for fiction writing and had been on one selective serotonin reuptake inhibitor or another for eight years. I also spent every second of my waking life thinking about my appearance. I simply could not stop obsessing.
Even when I was talking or reading or cooking, an uneasy feeling floated beneath my thoughts. Sometimes it took me a moment to remember what it concerned. Oh, right. The dent. But the feeling was always there. The anxiety never lifted.
I spent hours in front of different reflective surfaces each day. I sent my friends pictures of my face and asked for their feedback. I compared pre-dent photos with post-dent photos. I approached strangers and asked them to examine my cheek. Don’t you see it? Don’t you see it? If they didn’t, I felt angry and betrayed; I was certain they were lying. If they nodded and said yes, I plunged into a bad mood from which it took days to emerge.
That summer, I was going to work as a teaching assistant at my old beloved summer camp. And then I realized I couldn’t do it. I couldn’t spend one more day pretending to live a normal life. I had to recover from BDD first.
The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders classifies BDD as an OC-spectrum disorder. According to the International OCD Foundation, sufferers must meet several criteria to receive a diagnosis of BDD: an excessive preoccupation with appearance, repetitive behaviors (such as checking and camouflaging, like compulsively applying makeup), clinical significance (level of distress) and differentiation from an eating disorder.
Though BDD has a lot in common with eating-disordered thinking, the two should not be conflated. Katherine Phillips, M.D., who is considered somewhat of a god in the BDD world, wrote in her book The Broken Mirror, “Because of their differences it’s important to differentiate BDD from eating disorders and diagnose them separately.”
BDD concerns can be about weight and size, but they usually have to do with other aspects of the body. Phillips writes, “If a person’s concerns focus on the hips, stomach, or thighs but not on overall body weight, and the person doesn’t have notably abnormal eating behavior or otherwise meet criteria for an eating disorder, I diagnose BDD.”
I knew from my research that BDD is a stubborn, treatment-resistant disorder. It’s also, as far as psychologists know, not helped by plastic surgery. According to Phillips, “Ineffective treatments include surgery, dermatologic treatment and other nonpsychiatric treatment.” Her studies suggest that 6 to 20 percent of people who visit plastic surgeons’ offices have BDD. Getting surgery might help their anxiety temporarily, but it usually returns in another form. A woman who is obsessed with her large nose, for example, might get a nose job and then shift attention to her thinning hair.
On one level, I understood this. On another, I still wanted a dermal filler.
I researched my options. There was Juvederm and Voluma and Restylane, which a woman on an acne forum recommended to me. I visited my local plastic surgery office for a consultation, then panicked when offered an injection.
At the same time, I applied to several OCD treatment programs around the country. Two also treat BDD. In March, McLean Hospital’s OCD Institute sent me an acceptance letter. I finished my classes for the year and moved into Orchard House, a white Victorian three-story separated from the main hospital campus by a thin road. I engaged in four hours of exposure therapy every day. I was instructed to hold my phone at an angle that exaggerated my dimple. After examining it for 30 seconds, I shifted focus to anything else — reading, writing, cooking.
The first few weeks I did this, I didn’t see the point. I was used to looking at my face in bad angles. I’d been doing it for years. How could this make a difference? When I put the phone down after examining the dent, all I could think about was the image I’d just seen. It felt burned into my mind.
“I wonder if you can get PTSD from obsessive thoughts,” said a friend of mine at the OCD Institute. He struggled with intrusive thoughts of raping and murdering women. It was lunchtime; we were eating sticky white rice at a table that fit all eight of us. I thought of the harm-related thoughts I’d had in seventh grade, of dark shapes against a blue sky, of my reflection in a car window.
My therapists at McLean told me over and over that I wasn’t at the hospital to change my thoughts. You can only change your actions, we were told. But eventually, if you reduce your rituals, your thoughts might change too. We traced the cognitive behavioral triangle on a whiteboard every week. The vertices on the triangle stood for our thoughts, behaviors and feelings. Of these three, we were responsible for only one: our actions.
The only thing I could control was how frequently I looked in the mirror. And they were making it very hard for me to do that.
I argued with my therapist about getting a filler. She reminded me that BDD patients who have plastic surgery or change their appearance frequently regret the procedure or find a new body part on which to fixate. She was sure the same would happen to me.
I left McLean in the middle of August, after nine weeks. Though I didn’t feel entirely comfortable with my appearance (not the point, my therapist would be quick to say), I’d gone from 100 mirror checks a day to five. I focused on value-based living, a core tenet of ACT (acceptance and commitment therapy), which is central to OCD/BDD treatment. My reassurance-seeking also improved.
Before McLean, I asked all the people I met what they thought of my face. The small relief I felt from every compliment was short-lasting and only led to the need for more.
BDD patients who have plastic surgery or change their appearance frequently regret the procedure or find a new body part on which to fixate.
A month after I left McLean, in a fog of panic, I made an appointment with the nearest plastic surgeon who accepted CareCredit. I quieted the reminders my brain was sending about not making decisions when upset. I went into the office on a Friday. I had to shine my phone flashlight on my face for the physician assistant — the woman who would be doing the injection — to even see what I was talking about.
She poked at the area, which she remarked was the size of an eraser, with a purple pen. A constellation of dots appeared. She put a cool, clear numbing cream on it and left the room for 20 minutes. When she re-entered, she offered me a stress ball. I asked for a second one. They didn’t have another, but how about a breast implant? Sure. I held the stress ball in one hand and the lumpy, faintly glittery implant in the other.
“Just a pinch,” she said.
At the pinch, I inhaled sharply and jumped slightly in the chair, then worried that this had upset the whole process, that the filler was already migrating to another part of my cheek. But she said nothing. Finally, she stepped back. The nurses were smiling.
“Does it look different already?” I asked. They nodded. I took the mirror. Except for the purple dots, I didn’t see anything. I said this out loud, then added, “Maybe that’s the point.” I turned my face at a familiar angle, the skin on my right cheek bunching up to reveal any unevenness. I could still see the dent, but it was less visible. I celebrated by going to a restaurant and eating a cheeseburger with a knife and fork, not wanting to chew too vigorously and displace the filler.
But my mood — and my rituals — didn’t change. Over the next few days, I checked my face in all kinds of lighting. I made an unnecessary trip to my bank, a sign in the entryway invites customers to “meet the owners of your credit union.” Below those words is a mirror. I had always hated my reflection in this mirror, which spans the length of the wall. If I stood a certain way, two light sources — the light from outside and artificial lighting in the building — cast my dent in sharp relief. I approached the mirror tentatively. Post-filler, my cheek looked a little smoother, though if I turned my head to the left, I could see a slight divot where the filler had not spread. The indentation was not gone — a result that would have devastated me before McLean. But I felt surprisingly fine. I took a deep breath and resolved to review my notes from the summer. It was clear that psychiatric treatment, not cosmetic, had always been the answer, even though I had resisted it for so long.
I worried that some might be offended by this article, by the idea of a woman being so upset by a dent on her face that she spends thousands of dollars on psychiatric treatment. But that’s the crux of it: Body dysmorphic disorder may concern the body — it’s in the name — but it is a psychiatric illness. Just as we now know eating disorders have nothing to do with vanity, we need to extend the same understanding to BDD.
It is very likely that my obsession will shift to another part of my body. I’m almost certain I will develop a different OCD-related obsession in my lifetime. I’ve accepted that my life is going to be defined in large part by relapse and recovery. But my symptom-free years have been some of the happiest. I feel grateful to have some relief for now.