At 19, Aron Cowen suddenly became distraught over his hair, considering its curliness a “bad condition.” He chemically straightened it every week for a year, giving up only after it became severely damaged and developed an orange tint. While on a trip to Israel when he was 25, Cowen glanced at his reflection in a store mirror and saw his nose as huge and grossly malformed, like a beak. After that, he spent up to two hours each day reshaping his nose in front of a mirror and obsessing over its ugliness.

Unable to shake his fixation, Cowen opted for plastic surgery, but the effect was short-lived. A week after the operation the young man from Sherman Oaks, Calif., was back at the mirror, intensely scrutinizing his nose and noticing new flaws. And this time he felt responsible. “Now I felt butchered and disfigured,” he recalls. “I felt I had destroyed my nose.”

After a second surgery—this one requiring the removal of cartilage from his ear—Cowen began to question whether his nose was really the problem. The operation left him no happier about his face; in fact, he became so depressed that for a month, he did not want to leave his apartment and only did so on his girlfriend’s insistence. Two months later Cowen recognized his symptoms in a book about body dysmorphic disorder (BDD), in which a person becomes pathologically preoccupied with an imagined or barely noticeable defect in his or her appearance.

The disorder is suprisingly common. A large 2006 survey conducted in Germany indicates that 1 to 2 percent of the population suffers from BDD; a 2001 study of Boston-area women suggests a lower prevalence rate of 0.7 percent. Individuals with BDD are most commonly dejected over facial features, such as excess hair, acne, scars, or the shape of their nose or lips. They may also dislike a characteristic or part of their body such as their breasts, hips, height or genitals. As a result of the imagined defect, a person with BDD feels that he or she looks repulsive, even though BDD patients as a group are about as attractive as the general population and include some people who are considered to be quite beautiful.

Such a deranged conviction can be debilitating. People with BDD may spend hours every day examining their reflection in a mirror, picking their skin, grooming, or engaging in other compulsions that take time away from work, family and other important pursuits. One man lost his job because his compulsive mirror gazing made him repeatedly late for work. Sufferers may become depressed, anxious, ashamed and afraid of social interaction. In one study, nearly one third of BDD patients had been housebound for at least one week. Thirty percent have eating disorders; many abuse alcohol or drugs, and up to a quarter attempt suicide.

Psychologists and psychiatrists are searching for the cause of this affliction in hopes of bringing relief to patients. Psychological factors such as low self-esteem, coupled with society’s restrictive definition of physical beauty, are likely to play a role in the disorder. Recently, however, researchers have discovered that BDD patients also exhibit distorted visual perception, suggesting that future treatments may focus on retraining the visual system.

Off the Radar
Body dysmorphic disorder was first known as dysmorphophobia (fear of ugliness), a term coined in 1891 by Italian psychiatrist Enrico Morselli. Morselli had treated nearly 80 patients whose preoccupations with imagined deformities ruled their lives. Years after completing his therapy, Sigmund Freud’s famous patient “the Wolf Man” became obsessed with his supposedly malformed nose. Nobody considered a diagnosis of dysmorphophobia, however; instead a colleague of Freud’s diagnosed a penis complex.

In 1980 dysmorphophobia appeared in the third edition of psychiatry’s official diagnostic book, the Diagnostic and Statistical Manual (DSM). The term “body dysmorphic disorder” replaced dysmorphophobia in the volume’s 1987 edition, after psychiatrists realized that the condi­tion was less a phobia than an irrational convic­tion. BDD is also known as Thersites complex, after the warrior who was described in the Iliad as the “ugliest man in the Greek army.”

Despite its official status as a psychiatric disorder, BDD is relatively unknown, even among those who would treat it. “It’s off the radar for most psychiatrists,” says psychiatrist and BDD researcher Jamie D. Feusner of the University of California, Los Angeles. BDD patients are often diagnosed with depression, anxiety or an eating disorder, or even all three at once, without the doctor realizing that BDD may be the cause of all the trouble, Feusner says.

For their part, patients often say very little about the problem because they do not recognize it as a mental illness, instead believing that they are simply ugly—and what would a psychiatrist do about that? Many are also ashamed to talk about their odd obsession.

As a result, BDD sufferers typically wait three to 13 years for a diagnosis. In that time, many of them seek help from plastic surgeons. Some reports suggest that BDD patients make up nearly 15 percent of plastic surgeons’ clientele. As in Cowen’s case, surgery seldom solves the problem because it fails to address its causes.

What those causes are, however, is still a matter of some speculation. In the past, most researchers attributed BDD to personality traits such as low self-esteem and perfectionism, which may lead some individuals to be overly critical of how they look. Often such severe self-consciousness emerges at puberty, when dramatic changes to the body can produce feelings of inadequacy about appearance and when many people with BDD recall the first signs of the disorder.

Biological factors, including genes and brain chemistry, are likely to predispose a person toward such insecurities. For example, researchers have linked BDD to a disturbance in the balance of the neurotransmitter serotonin in the brain similar to that found in depression, which afflicts about 70 percent of BDD patients. In 2001 and 2002 psychiatrist Katharine A. Phillips of Brown Alpert Medical School and her colleagues reported in two separate studies that most BDD patients improve after treatment with drugs such as Prozac that inhibit serotonin uptake by nerve cells in the brain. These so-called selective serotonin reuptake inhibitors are also used as antidepressants, often at a lower dose than is required to treat BDD.

Environmental variables probably contribute to BDD, too. These variables may include being raised in a family that places excessive emphasis on physical beauty or having been teased or repeatedly criticized about a physical feature such as weight or facial blemishes. In one 2007 study, for example, clinical psychologist Ulrike Buhlmann and her colleagues at Harvard Medical School and Massachusetts General Hospital found that 16 individuals with BDD reported having been teased about their appearance more often than 17 mentally healthy controls did.

Seeing Too Much
In recent years, however, some researchers have begun to question whether a vulnerable personality, combined with an unfavorable environment, can fully explain BDD. Instead they have been advancing a radically different hypothesis: that BDD arises, at least in part, from a perceptual abnormality. A 2002 study by psychiatrist Jose A. Yaryura-Tobias of the Bio-Behavioral Institute in Great Neck, N.Y., and his colleagues lends some support to this theory. The researchers asked three groups of 10 individuals—one of BDD patients, another of patients with obsessive-compulsive disorder (OCD), and a third of mentally healthy people—to make changes to a computerized image of their face, if needed, to match what they believed their face looked like.  (The computer-rendered image was accurate to an ordinary person’s eye, but the study participants were not told that.) About half of the patients with BDD and OCD altered these depictions, whereas nobody in the control group did, suggesting that at least some BDD patients perceive their own face differently than others do.

Some evidence suggests that BDD patients may be more visually attuned than most of us are. In a study to appear in the journal Abnormal Psychology, Ulrich Stangier, a psychotherapist at the University of Jena in Germany, and his colleagues briefly flashed an image of a female face, along with one of five digitally distorted renditions of that face, in front of 21 female BDD patients, 20 patients with disfiguring skin conditions, and 19 individuals without any disorder and asked them to judge the extent of the distortion. The manipulated images had more widely spaced eyes, bigger noses, lighter hair, or additional pimples and scars. The participants chose among five levels of distortion that ranged from “hardly” to “extremely.” The researchers found that the BDD patients were better at judging the degree of image manipulation than the others were, suggesting that people with BDD may have unusually acute perceptual abilities.

What is more, such acute perception might sometimes produce perversions. In 2000 Harvard psychologist Thilo Deckersbach and his colleagues reported asking BDD patients to copy a complex figure and then to duplicate it from memory. The BDD patients performed poorly as compared with mentally healthy subjects, because they drew lots of details without capturing the figure’s overall shape. Although the BDD patients could have been exhibiting poor strategic thinking in the figure task, their main problem might be an overemphasis on visual details, helping explain why they worry so much about minuscule deviations in their features.

Feusner, along with cognitive neuroscientist Susan Bookheimer and their U.C.L.A. colleagues, has since found support for the latter idea. His  group used functional magnetic resonance imaging to scan the brains of 12 patients with BDD and 12 healthy subjects while the participants viewed three versions of various photographs of faces: a normal image, a blurred image and a flat but highly detailed image.

The healthy people processed both the normal and blurred faces with parts of their brain’s right hemisphere that ordinarily decode larger-scale visual features; their left hemisphere lit up only when they viewed the detailed pictures. In contrast, the BDD patients used their left hemisphere to interpret all the photographs. “They are processing all photos like highly detailed photos,” Feusner explains. “It’s ­almost as if their brains are trying to extract details from an image even when there are none.” The results, reported in December 2007, suggest that BDD may stem partly from an abnormality in visual-information processing.

The ability to appreciate beauty may, after all, have evolutionary value. Physical attractiveness could, in some cases, be related to health status; that is, “ugly” can be a proxy for less fit. Thus, being more adept at sorting the beautiful from the less handsome might have given a person a better chance of selecting a fit mate and passing good genes to his or her offspring. BDD may represent an extreme version of this talent.

Of course, nobody can say for sure that the visual problem is a cause rather than a consequence of the disorder. “We still don’t know whether people who develop BDD are born with [the visual-processing abnormality] or whether BDD came first and caused the problems with visual processing,” Feusner admits.

Image Correction
If aberrant visual processing is a cause of BDD, future therapies might focus on training patients to see things more globally using the right half of their brain. Repeated exposure to a blurred image or to a picture viewed from a distance or for only a fraction of a second, for example, might force the brain to adopt a more holistic way of seeing, Feusner speculates.
Medications also may be able to change the side of the brain a person is using for visual processing, Feusner says. Benzodiazepines such as Valium (diazepam) or Xanax (alprazolam) can shift brain activity to the right during a visual-processing task, some preliminary studies suggest. Eventual­ly, alternative drugs may accomplish this shift with fewer side effects.

Still, doctors agree that the problem cannot be entirely visual. Whereas more than 88 percent of BDD patients say they also scrutinize the appearance of others, focusing on the feature that they dislike most about themselves, a May 2007 study by Buhlmann and her colleagues shows they do not see the same perversions in other faces that they do in their own. BDD patients rated photographs of other people categorized as “attractive” (by the researchers) as being significantly better looking than did two other groups without BDD, suggesting that the patients’ perception of detail in others does not evoke the same negative emotional response that it does when applied to their own physique, Feusner says.

Indeed, many therapists treat BDD by tackling its emotional aspects, including patients’ perfectionism and fear of being rejected because of how they look. In cognitive-behavior therapy, psychotherapists attack patients’ distorted perceptions head-on and assign actions to help them give up their destructive habits. For instance, in some cases, they may instruct patients to ask other people—friends, family or even strangers—for feedback on their appearance. The others’ invariably positive, or at least neutral, comments can open the door to a patient developing a more realistic and better self-image. The act of confronting others might also help a patient overcome the social anxiety that often accompanies BDD.

Cognitive-behavior techniques can prompt significant recovery from the disorder, according to a 1999 study by psychologist Sabine Wilhelm and her colleagues at Harvard Medical School. But other psychologists believe in a more psychodynamic approach, in which they and the patient also work on uncovering past experiences that may have led to a BDD patient’s poor self-image.

In some cases, patients were neglected as children, says Uwe Gieler, a BDD therapist at the University of Giessen in Germany. According to one theory of attachment, if a mother or father rejects a child during the first 15 months of life, that child may question affection from others as well as his or her own self-worth. As a result, the person can be saddled with both relationship problems and low self-esteem.

Understanding the origins of the problem, Gieler opines, empowers a patient to recognize and “correct” a distorted self-image and put concerns about appearance in perspective. That is, patients may come to understand that imperfections in their face do not equal being an unattractive person or prevent them from having good relationships.

A New Perspective
When Cowen suspected that he had BDD, he went to see Feusner at the Los Angeles Body Dysmorphic Disorder and Body Image Clinic. Feusner diagnosed him with a moderately severe form of the disorder and put him on Prozac, which is now a standard treatment for BDD. He also put Cowen in touch with clinic director and therapist Arie Winograd, who told Cowen to stop touching or looking at his nose, a strategy aimed at curtailing Cowen’s obsessive behaviors.

In particular, the therapist instructed Cowen to avoid all mirrors, which perpetuate the illness because they put a person’s appearance in the forefront of consciousness. Or, as Cowen put it: “You need to forget how you look to reclaim how you are inside.” At close range, mirrors also enable patients to focus too much on facial details, Feusner says, and so may exacerbate the perceptual problem that accompanies the illness.

Cowen was an obedient patient. He stopped the mirror cold turkey, he says, and then gradually relearned to use it—in the normal way—with help from Winograd. For example, Winograd would turn the lights out so Cowen’s face looked less distinct and would coach Cowen to see his visage as a whole rather than focusing on the contours of his nose.

A year after beginning treatment Cowen was able to let go of his obsession with his appearance. “My looks and features and body parts don’t define me now,” Cowen says. “Sometimes I even think I look good.”