Imagine being so obsessed with a part of your body that you were literally frozen in front of the mirror scrutinizing it. Or feeling so afraid of what you might see if you did look, that you avoid mirrors altogether.
For approximately five million people in the United States with body dysmorphic disorder or BDD, this reaction to their bodies is a reality that can have significant impact on their lives.
"BDD is an extreme preoccupation with a part of one's appearance," says Roberto Olivardia, co-author of the Adonis Complex. "Often times that preoccupation is with an imagined defect where the person is seeing something that other people clearly cannot see."
Slight anomalies like scars or minor hair loss that produce exaggerated responses such as social avoidance and camouflaging can also earn a diagnosis of BDD.
"It's about looking at yourself in the mirror and not even being able to say that you look OK," Erika Pikor, a longtime sufferer, told ABCNEWS medical correspondent Dr. Tim Johnson.
Pikor was diagnosed with BDD after spending years obsessing about her appearance, sometimes spending as many as three hours checking herself in the mirror and withdrawing from social contact.
"I feel like I've lost a lot just because of this," Pikor says. "A lot of time that I've just lost, gone. It's very disappointing because it's time I could have been very productive in doing things that I enjoy. But I came to a point where I didn't enjoy anything anymore."
Undetected and Misdiagnosed
Although the disorder was first described over a century ago, BDD did not make a name for itself in the diagnostic literature until the late 1980s. And while strides have been made in increasing awareness about it, BDD remains widely unrecognized and misdiagnosed.
"I would say the majority of people that come to me have been people who have been struggling with BDD for years," says Olivardia who runs a group for people with BDD at McLean Hospital in Belmont, Mass. "A lot of people go through years of being misdiagnosed with depression."
Others who aren't recognized as having the severe body image disorder are diagnosed with psychotic disorders or with eating disorders like anorexia. And often the first physicians to come across people suffering from BDD are not mental health professionals, but cosmetic surgeons.
"Ultimately they think that the solution lies in changing the body part [they dislike]," Olivardia says. "But I have yet to see someone with BDD who feels 100 percent better after it."
Another reason for the lag in diagnosis, say experts, is the fact that people who suffer with BDD do so privately.
"It's a very secretive disorder," says Dr. Katherine Phillips, director of the Body Image Program at Butler Hospital in Providence, R.I. "People tend to be very embarrassed and ashamed of their concerns. Most people don't get treatment, and that's really sad because it's generally a very treatable illness."
Because of the similarities between BDD and other psychiatric disorders like obsessive compulsive disorder, medications like Prozac and Zoloft are part of the treatment arsenal.
"Seventeen percent of people with BDD will attempt suicide in their life because of these preoccupations," says Olivardia. "The use of medications is very important."
Other types of treatment involve cognitive and behavioral approaches to counteract negative thoughts about appearance as well as to put an end to the behaviors that interfere with daily social functioning.
Experts also look at the underlying issues that may be at work, such as low self-esteem, anxiety or mood disorders, or troubled family backgrounds. Many people with BDD can learn to reach a point where they can function with the disorder, if not learn to positively view their perceived flaws.
"Some individuals may still feel that they look ugly, but they can still get out of the house, they can still go to work, they can still maintain social relationships. They just have to challenge those thoughts that interfere in their head all of the time," Olivardia says.
Increased awareness of the existence of this body image disorder is helping more people recognize the problems in themselves as well as raising the number of studies being conducted to find out more about BDD, says Phillips.
"Somehow the word is getting out, which is a very good thing. The first thing you have to do is recognize it and get the right kind of help and find a health care provider who knows something about it and how to treat it," she says.