woman in black long sleeve shirt and black panty sitting on white wooden stool

Children see things they don’t like about their appearance. This condition can lead to depression and anxiety, self-surgery, and even suicide.

A man used a razor to carefully slice his nose. He wanted to remove the cartilage, and replace it with one from a chicken. He thought he would feel much better. A man in America would use a hammer on his face. Someone cut off their fingers. People are silently hating themselves in public bathrooms all over the globe. Body dysmorphic disorder (BDD) is characterized by self-surgery, where the person has a distorted perception of their appearance. A nose, a hand. It is a place to look at, and to loathe.

We care about how we look. When we walk to work, reflective surfaces can distract us. We make minor adjustments, cover up, and straighten. We love to be seen from certain angles and hate our arms. It is when these worries become obsessive that they become a problem. When they interfere with a person’s life, when they can’t leave the house due to the constant need to look in the mirror, and when relationships, work, and personal relationships, fail, it becomes a disorder. The Maudsley hospital intervenes.

The Maudsley in London is the oldest psychiatric hospital. This red-brick tower on a hill is now surrounded by smaller units. They take up an entire city block along with a railway line. I wait in one of the squat buildings behind for Bruce Clark and Laura Bowyer. The walls of Michael Rutter Centre For Children and Adolescents, named after the “father in child psychology”, are lime green and heavy on leaflets. They cover family therapy, bulimia and missing persons. Parents sit with their children and their phones.

The only clinic that treats BDD in children is this one. They recently published the first ever randomised controlled trial of cognitive behavioral therapy (CBT), or body dysmorphic disorder, in children and teens. Although studies on adults are still rare, they are becoming more common. As they were carrying out their trial to treat adolescents, researchers in Sweden conducted the largest ever study of body dysmorphic patients and found that they could benefit online from CBT sessions. Both studies confirm that CBT works and all of them agree there is a cure. Finding the right patients is now the problem.

BDD is quite common. It’s believed that one in fifty people suffer from it. Clark says that BDD can be thought of in another way. If you look at a double-decker bus, there is a good chance someone with BDD is traveling in the same direction.

The Body Dysmorphic Disorder Foundation lists many famous people who have suffered from BDD. These include Andy Warhol and Franz Kafka as well as Sylvia Plath, and Michael Jackson. His face after multiple surgeries is a Edvard Munch-ish scream. Up to 20% of cosmetic surgery patients have it. A survey of US plastic surgeons found that 84% had performed on patients who had BDD. Of those, most said the outcome was poor and the patient wasn’t satisfied. BDD patients have led to the death of several surgeons.

There is very little information available about the disorder and especially about young people. Few people with the disorder are willing to disclose their symptoms and not all doctors (or GPs) have been trained to recognize them. Cosmetic surgeons are often the first to see patients with BDD. Patients don’t believe they are mentally ill, they believe they are ugly.

Zoe, 19 years old, has the cheeky beauty and charm of a Disney princess. Laura Bowyer introduces us. As her mother and I sit down on NHS sofas, she starts to describe her life. I start to notice my eyes wandering across her face, searching for the flaw she hates. I am at a loss. She is beautiful, she has symmetry, and she has a clear skin. Zoe was 13 years old when her classmate called her ugly. She says she started “scrutinizing herself, trying to improve myself, in order to avoid being ridiculed at schools”. She could only improve so much. “The verbal abuse was only for black women. They spoke of my “disgusting hair” and other things. These are things that I cannot change.” She was diagnosed with anorexia at 14 and began treatment. Then, it got worse. While they are related, BDD and anorexia are very different. BDD isn’t about their weight. Instead, they are more focused on their skin and hair (in that order). Anorexia is more common in women than men, but the demographics of BDD are equally distributed across all genders and across the globe. Every language has a word that means ‘ugly’, I am reminded.

Zoe presented her mother with a list of all the procedures she needed when she moved to school for her A levels. Fat transfers, liposuction, ear pinning and knee surgery. Her mother quietly said that she was quite assertive. She would throw things. It was dark. She glances down at her hands. Her knuckles have turned white from gripping. Zoe was 17 when doctor referred her to Bowyer for BDD. She hadn’t been outside the house in three months. Zoe covered her face with a headscarf and bleached her skin using acid solutions she had purchased online. Zoe describes feeling trapped in her body. “I felt my skin crawling. Itched. I never felt clean. I spent hours looking in the mirror and my face would shift after a while.” She broke the mirrors at home. “I would type in Google: “Are my friends lying?” She would then find support on the anorexia forums. “People would agree with me – they’d tell me I was right, I was ugly, I was fat.” She said that she didn’t want life after spending three hours online and four in front the mirror. “Because I knew that nobody would ever love and cherish me.”

woman in black long sleeve shirt and black panty sitting on white wooden stool

Bruce Clark is a child psychiatrist and clinical director of Child and Adolescent Mental Health Services in the UK. A young woman runs down the corridor and screams as I climb the stairs to his office. As her carer guides her through the door, I stop. Clark is calm and cheerful despite the chaos he has to deal with every day. His office upstairs is warm, even if it is galley-like. There is no room for the door to be opened with three people seated.

Before we met, he suggested that I read Dr Katharine Phillips’ work. Professor of psychiatry at Brown Medical School and the author of The Broken Mirror (a book that draws from her evaluations of over 900 people with BDD), she is the most well-known authority on BDD. In 2005, she revised the book. I reached out to her by email to inquire if she had learned anything new since then.

She said that the latest information was on visual processing in BDD. This amazing work shows that people with BDD may have abnormalities in their visual processing. They tend to focus on the small details of a stimulus and are less able see the whole picture than people without it. When they look in the mirror they see something else. She describes people who pick up unnoticeable marks on the skin and then run through traffic thinking someone is staring at their face. Clark and Bowyer acknowledge that they don’t know the exact cause of BDD, but they agree that Phillips can trace the roots to genetic, emotional, and neurobiological factors. They also note that approximately 20% of BDD cases are caused by family members.

Clark was attracted to BDD partly because he realized how hidden it was. The morbidity is high. He says that half of those with the disorder will be admitted to hospital, and around 25% will take their own lives. It’s a dark picture.

They were treating troubled young people. They threatened their parents, truant school and stole money to pay for the treatments they believed would fix their faces. Clark says that today there is an ease to access the idea of having surgery. The advertisements for cosmetic surgery look the same as spas. It is easy to see the entire path from the spa to Botox to a nose job. It’s not a shop.

Clark was shocked at the impact of the internet on these young people’s illnesses. Patients had also posted photos online asking for assurance that their disfigured appearances were real. The comments below showed that cosmetic surgeons responded. Clark discovered the website that a patient had written about. “American clinics were advertising procedures they would suggest to a child. She took it as evidence she didn’t have BDD.

Reddit has a page called “Am i ugly?” It seems like the place where tact has gone to pieces. A 21-year-old man writes, “So there’s this bothersome thing …”” and includes a few selfies. “It’s shadows. Lighting and shadows. In a world with constantly changing shadows and lighting, how can I tell if I am ugly? I suddenly find myself a monster with saggy skin when I reverse.”

There were no advertisements for cosmetic surgeons on this page. Usually, commenters suggested users make their appearance better by smiling more and cutting their hair. However, I did see one young person posting that they had BDD. Vice spoke with Joonas Broodin who, having suffered from BDD since the age of 12, and said that he uses the page to get support. A user commented on his photo and said that his nose and brow looked “heavy”. Broodin appreciated the comment. He said, “I’m grateful that people pointed out some of my obsessive details over the past nearly 18 years.” “In the past, if I pointed out things that I obsess over and people said: ‘No, it’s not important, you’re fine.’ It made me feel more insane and lied too.” He realized that he only saw details, while others saw a person.

The Maudsley focuses on two things. The first is to identify and treat BDD in children. They are adapting traditional CBT techniques and helping GPs to understand what to watch out for.

Clark and Bowyer are frustrated, which I can sense when I talk to them. There is finally a successful treatment for this often fatal disease. It can be treated in childhood, which could prevent thousands of deaths and years of pain. Yet, the patients are not being diagnosed. This is amazing, even though it doesn’t require brain scans or blood tests. Clark says that the screening process is based on four questions. Number one: “Are there parts of your body you are particularly concerned about?” Is it your primary concern about your appearance that your body isn’t slim enough? Or that your body might be too fat? What effect has your obsession with your appearance had upon your life?

Clark’s clinic trained a doctor to interview a patient who attempted suicide. It was at this point that the doctor discovered that she was upset about her labia. She hadn’t discussed the matter with anyone before. Bowyer successfully treated her. Four. Four.

It’s difficult to be in a room together with a young woman who calmly lists all the things she hates about herself. Zoe was raised by her mother, a librarian who radiates strength. “When I couldn’t reach her anymore”, she gave Zoe Margaret Atwood books that she thought Zoe might relate to. She describes the guilt, anger, and times she felt like giving up.

Today, Zoe is able to see a bright future as long as she sticks to her medication, uses the “tools I’ve been given”, such as “feminism which gave me confidence”, CBT, and adheres to her medication. She dreams of becoming a designer. “But selling only items that won’t make people feel secure.” She giggles. Zoe’s mum places her hand on Zoe’s knee and waits just a second before she says yes.