Trigger warning: This story contains sensitive content regarding body dysmorphic disorder (BDD).
There have been times in my life where body dysmorphia made even simple activities and interactions difficult to bear. Obsessive thoughts about my skin, my legs and the overall shape of my body were enough to make me want to retreat from the social activities and work commitments that, at other points, gave my life meaning and brought me immense joy.
Thankfully, and with the help of specialised trauma therapy that I am currently working through, my symptoms of body dysmorphia have started to fade. For more extreme sufferers – whose condition constitutes body dysmorphic disorder (BDD) – the journey to recovery can be long and extremely arduous.
BDD is an under-reported condition which is surrounded by several misconceptions. It can be debilitating, as the social anxiety connected to appearance prevents sufferers from going about their lives. We might assume, then, that the lack of social interaction brought about by the current lockdown would benefit sufferers and alleviate the pressure to go out. But BDD is also an anxiety disorder closely related to obsessive compulsive disorder (OCD), and the need for strict regimens would surely be challenged by a situation that prevents many of us from exercising as usual, shopping in the way that we are accustomed to or maintaining our regular appointments.
The anxiety experienced even by people who don’t suffer from BDD or related conditions as a consequence of the disruption to their usual eating and exercise regimes has been compounded by the government's fatphobic comments regarding the role of obesity in exacerbating the symptoms of coronavirus. It was reported that Boris Johnson wanted to lead a "war on fat" after his stint in intensive care with COVID-19 – language that would have had a detrimental effect on many people.
It is a common misconception that eating disorders like bulimia and anorexia are the same thing as BDD. For many sufferers of BDD, weight plays no part in their condition at all. Nevertheless it struck me that the government's implication that people who contract COVID-19 are personally responsible for the severity of their symptoms on account of their weight could be particularly harmful to those sufferers whose BDD focuses on size.
It is a common misconception that eating disorders like bulimia and anorexia are the same thing as BDD. For many sufferers of BDD, weight plays no part in their condition at all.
My worry led me to contact Kitty Wallace, head of operations at the Body Dysmorphic Disorder Foundation. She speaks with immense clarity and knowledge about the condition, which is still prone to social stigmas and taboos that lead to severe misunderstanding.
"I think myself and the other trustees were a little bit naïve going into lockdown," Kitty admits. "We thought that maybe it would temporarily ease some anxiety because people with BDD wouldn’t have to go out and socialise. But what we found instead is that it’s had a hugely detrimental effect on the community and we’ve been inundated with requests for extra support."
The main issue, Kitty explains, is that for people with BDD the struggle is always against ruminating and obsessing over parts of the body. Sufferers who are currently furloughed or working from home have more time now to do just that, and little chance of escaping the mirrors and at-home treatments that can facilitate unhelpful 'safety' behaviours. This can mean getting stuck in front of the mirror for hours on end, obsessively picking or harming your skin, and googling various treatments to eliminate perceived 'flaws'.
What’s more, treatment for BDD has in many cases been put on indefinite hold or administered in a limited capacity owing to coronavirus restrictions. Cognitive behavioural therapy (CBT) is judged by many to be the most effective approach for managing BDD but much of this has gone online or, for smaller practices with limited capacity or digital technology, been postponed altogether.
Likewise, specialised CBT for BDD often advocates an approach called exposure and response prevention (ERP), which involves confronting fears and engaging in a closely managed and cautious way with whatever activity triggers or exacerbates the condition. How to do this when you’re being told to stay indoors and avoid other people presents a distressing conundrum in itself.
Social distancing is another consequence of coronavirus which is having a detrimental effect on the lives of BDD sufferers. "One of the really interesting things that came up in our support group," Kitty tells me, "was one of our members saying that she did manage to go outside for a walk but because of the virus, when people would be moving dramatically out of the way to avoid her, she would assume it was on account of how she looked." For a sufferer of BDD, the part of the brain that says, Well, that’s because they’re trying to stay safe is overridden – it’s almost as if your brain is trying to trick you.
One of our members said that she did manage to go outside for a walk but because of the virus, when people would be moving dramatically out of the way to avoid her, she would assume it was on account of how she looked.
Kitty Wallace, Body Dysmorphic Disorder Foundation
The digital tools we rely on to connect us during lockdown – FaceTime, Zoom, Skype – have enforced a constant reflection which is harmful to BDD sufferers. Socialising in real life, although challenging, offers an opportunity for temporary respite from obsessive thoughts. Socialising through a screen, however, comes with the unhelpful feedback loop of a camera pointed directly at your face. It’s possible to turn the camera off but, given the option, this too can become a compulsion. For the BDD sufferer, there’s the gnawing temptation of switching the camera on so that you can check how you look. Not only that but having your face presented to you onscreen alongside other people's faces can encourage unhelpful and harmful comparisons.
After our chat, Kitty put my concern about the government’s messaging on weight to the community WhatsApp group that her organisation has set up as a way for members to keep in touch. Along with the weekly Zoom chat, it has offered a lifeline to members, particularly those feeling isolated and alone.
The group agreed that the messaging was harmful to the wider community of people with body image and eating disorders. However they felt that a much more pressing issue are the other food-related considerations that people now have to factor into their routine. It is no longer just a case of healthy versus unhealthy but scarcity versus abundance, stockpiling versus shopping day-to-day.
"All of this can be very triggering for someone who suffers from disordered eating," Kitty explains. "People have suffered from the added worry of whether or not they should be eating all of their food in case there was a shortage further down the line."
"For people with BDD, weight-related issues aren’t about the number that appears on the scales," she adds. "It’s about looking in the mirror and thinking, Does this body part look too big, or abnormal? Or, If I’m a clean eater, will it clear up my skin?"
Before COVID-19 swept across the world, changing the way we live, our society was already suffering from an irresponsible discourse that carelessly conflated health with weight. Sarah Miller covered this earlier in the year in her New York Times piece, "The Diet Industrial Complex Got Me, And It Will Never Let Me Go", which considered the corporate exploitation of female body anxiety for commercial gain.
Now, because of a global pandemic, we also have to consider food supply chains, sustainability and the ethics of shopping in certain establishments and under certain conditions. This is not to say that these factors aren’t important but that, for sufferers of body image and eating disorders, the added burden of responsibility can exacerbate anxious tendencies.
The digital tools we rely on to connect us during lockdown have enforced a constant reflection which is harmful to BDD sufferers. Socialising through a screen comes with the unhelpful feedback loop of a camera pointed directly at your face.
It’s impossible to ignore the fact that, in the midst of all this, a debate raged online about the singer Adele’s weight. Out in the real world, we were clapping for NHS heroes and praising frontline workers but online discussions were still reducing women’s worth to their weight, rather than their contribution or character. It was a constant stream of tweets and Instagram posts which, for the disordered eater or body dysmorphic, provided endless content to scroll through and pore over.
For all these reasons, the last 10 weeks have been particularly difficult for sufferers of this condition, to which I cautiously add myself, as a past and mild sufferer.
There is hope, however, in the work of organisations like the Body Dysmorphic Disorder Foundation, which rose to the challenge and provided services when others were shutting down. Thanks to the feedback provided by their brave and open-minded members, we are building a clearer and more accurate picture of this disorder than ever before.
We now know for sure that socialising, engaging with the outside world and participating in activities which allow us to escape thoughts about our appearance is crucial to tackling this complex and devastating condition.
In the weeks to come, as lockdown restrictions are lifted and we begin to take tentative steps into the outside world, we should reward ourselves for overcoming this immense challenge and try, where possible, to embrace the rare and delicious sensation of being able to see our friends.
It won’t be enough on its own, of course, but just that change, combined with the thought that more of us are learning about the struggles of body dysmorphic disorder, will I hope go some way towards lightening the load.
If you are struggling with BDD you can access more information about the BDD Foundation's support services here.
If you are struggling with an eating disorder, please call Beat on 0808 801 0677. Support and information is available 365 days a year.