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“I thought I’d always be fat, ugly, and useless.”

When we’re hit from all sides by media images of perfect looking actors, models, and athletes (who are all subject to some fierce Photoshopping), it’s only human for insecurities about our appearance to blossom.

However, for the vast majority of people, these thoughts disappear with a distraction, reassurance from loved ones, and a healthy dose of rationality. Dwelling on the issue is immediately labelled ‘self-obsessed’ or ‘vain’, and so we leave well enough alone.

But in some cases, these feelings of negativity don’t go away. They permeate every waking hour, hanging like a dark cloud, warping the individual’s self perception so dramatically that they’re unable to see themselves as they are in the mirror, instead met with a kind of distorted, grotesque portrait. And in these cases, no amount of casual reassurance can dissapate the overwhelming sense of looking somehow disfigured and monstrous.

Welcome to the world of body dysmorphia, a crippling anxiety disorder that inflicts its sufferers with a severely distorted perception of how they look, resulting in excessive amounts of time spent fixated on appearance.

The term body dysmorphic disorder, or BDD, was first coined by Enrico Morselli, an Italian physician, in 1891, who described the intense distortion of perception felt by sufferers.

“The dysmorphophobic patient is really miserable; in the middle of his daily routines, conversations, while reading, during meals, in fact everywhere and at any time, is overcome by the fear of deformity…which may reach a very painful intensity, even to the point of weeping and desperation.”

However, while the term has been around for some time now, body dysmorphia has only been systematically researched for less than two decades. During this time, much has been uncovered, including a distinct set of clinical features, epidemiology, and treatment options; data is beginning to emerge on the neurocognitive deficits and underlying neurobiology of BDD sufferers.

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The most common obsession associated with body dysmorphia is the face. Whether it’s pimples, scar tissue, a large nose, thin lips, or lopsided eyelids, someone with a dysmorphic mindset will see this perceived flaw magnified to the point where it eclipses everything else.

Modern Family star Reid Ewing has admitted he had a pretty severe case of BDD when he came to Hollywood at the age of 19 in search of plastic surgery for what he saw as facial deficits.

“I told the doctor why I felt my face needed cosmetic surgery…He quickly determined large cheek implants would address the issues I had with my face,” said Reid.

“Of the four doctors who worked on me, not one had mental health screenings in place for their patients, except for asking whether I had a history of depression, which I did, and that was that.”

For a person to feel pressured into having invasive cosmetic surgery as a teenager, on a still-developing face, it’s no wonder the disorder is difficult to live with, and so often misunderstood.

Twenty-seven year-old Nicola Coad has suffered from both anorexia and body dysmorphia. Although she is now fully recovered with a supportive husband and a child, she still remembers those dark and seemingly endless days when the dysmorphia monsters infiltrated her life.

“Body dysmorphia I remember from around age of 19, when my eating disorder was at its worst. It came on very suddenly, from what I can recall,” says Coad.

At the age of 19, Coad was severely underweight, however, the nature of body dysmorphia wouldn’t allow her see it. When she looked in the mirror, she saw a grotesque, grossly overweight figure looking back at her.

“I was so lost in my eating disorder that I made it my reality. I couldn’t feel the bones, I felt fat. It’s amazing how the brain works, and can trick you. The fact I might actually be thin never registered.”

Of course, her family and friends constantly told her she wasn’t overweight. That she was the size of a bird, and desperately needed help. But try as she might, Coad couldn’t acknowledge it.

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“I tried to justify the differences between what others were saying compared to what I saw. I told myself they wanted me to be fat, that they were lying. I felt angry, frustrated and confused that everyone kept lying to me about me being fat. How could they not see the truth? I was scared I would forever feel that loneliness, and feel so targeted. I kept thinking I was fat and useless, that no one would ever love me, and no matter what I did I’d always be fat and ugly and useless.”

Unfortunately for sufferers of BDD, unlike other health conditions that can resolve quickly with appropriate rest and diet, the mind is the toughest prison to break free from. However, there is always hope.

“The ongoing support from my family showed me that I was worth them never giving up. The final thing that pushed me down the road to healing was meeting John, my husband,” says Coad.

“He showed me it wasn’t just family who could love me. He had no obligation to be there or love me, but he did. I saw I could have a future. Ever since my body dysmorphia left, I can honestly say I have never had a moment of it returning. I see myself as I am, and even when I’ve had a bad day or dark times I always see my reality.”

Body dysmorphia is an insidious illness that can affect anyone at any stage in life. And because it’s so deeply tied into self image, sufferers are often brushed off as ‘vain’ or ‘superficial’, however paradoxically the opposite is often the case – BDD’s physical fixations typically veil a much darker inner reality of personal demons.

“It’s possible that other life events contribute to BDD’s development. Perhaps people who later develop BDD experience a lot of rejection or lots of stress,” Dr Katarine A. Phillips explains in her groundbreaking book, The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder.

“People with BDD tend to be introverted and socially avoidant. They also tend to score very high on ‘neuroticism’, a measure of anxiety, depression, self-consciousness, anger and feelings of vulnerability…Another personality trait that appears associated with BDD is perfectionism, or unusually high standards for oneself. People with BDD say they want to look perfect and that they expect perfectionism in other areas of their life as well,” says Phillips.

It’s perhaps because of this perfectionism that sufferers are usually too ashamed to admit they have a problem, for fear of looking weak, or unable to cope.

“BDD is often a secret disorder. The BDD sufferer doesn’t reveal their appearance concerns and their health professional doesn’t ask,” explains Phillips, who says it’s important not to brush off the warning signs.

“BDD can be mistaken for vanity. But anyone who knows someone with it is only too aware of how serious – even life-threatening – the disorder can be.”

Comment: Have you suffered from, or do you know someone who has BDD?