Do We Really Know What We Look Like? By Fugen Neziroglu, PhD on 10/4/18 - 12:36 PM

We all think we know how we look, but do we really ‘know’? How can we? Certainly, we can see ourselves in the mirror, but do we really have a sense or knowledge of how others see us? We only have an idea based on what the mirror tells us and ultimately how we regard ourselves, the value we place on appearance, what our mood is and the feedback we receive from others. Is that objective?

How we perceive things changes from person to person. Have you ever found someone you regarded as attractive, only to ask someone else who comments, “Yeah, he or she is alright looking”? Well, how can that be if it is the same person? Yes, we all have different concepts of beauty, and the value we place on attractiveness determines how much attention we pay to our looks or those of others. The value that I place on attractiveness or brilliance would influence how I, and I alone, perceived that person. The same goes for ourselves.

I specialize in the treatment of people with Body Dysmorphic Disorder (BDD), which is a preoccupation with one or more nonexistent or slight defects or flaws in physical appearance. This preoccupation gives rise to compulsive behaviors that are performed in response to the appearance concerns that range from picking to plastic surgery. To the outsider, BDD may seem like a trivial concern and a matter of vanity, but it is really quite the opposite. The person feels disgust and shame regarding some aspect of his or her appearance and is often highly anxious about being seen and evaluated by others. About 40 percent end up homebound, they are hospitalized more often than schizophrenics, and 80 percent have suicidal ideation with 29 percent attempting suicide. It is a significant and serious disorder.

I was drawn to these clients because they are challenging and often misunderstood. They are perpetually wounded and cannot escape from their symptoms because they are of their own making and, after all, how do we escape our own bodies? Unfortunately for them peace does not come at the end of a surgeon’s blade, and this is where I come in trying to convince these clients to change the way they think about their body rather than the body part itself. Our goals are very different, and our first challenge is to agree upon a common goal.

I remember the day Jimmy, 22 years old, came to my office after trying to convince his parents to pay for surgery, angry that he was wasting his time with me. He sported a baseball cap with a hint of bangs showing partly below. He said he did not like the way his hairline looked, and that he wanted a second hair transplant, which his parents would not allow. In his sophomore year of college it had become impossible for him to sit in class or socialize and he had to finally had to take a protracted leave of absence. Jimmy thought that his forehead was too big and that his hair was receding. Nothing would convince him otherwise, so to hold onto my own receding credibility, I did not dare argue my perception with him. I said that I understood and that there was little I could do except ask him to try to think a bit differently about his appearance over the next few months, since his parents would not pay for another surgery.

My road ahead was not going to be easy, nor was his. He came in a few times a week, trying to align his purported values with the time he spent catering to them. Although he claimed that he did not value attractiveness as highly as education, family and friends, he soon realized that he spent more time on his appearance than anything else. We tried to set that straight. I took him out of the office without his hat and had him expose his hairline at the beauty counter of a nearby store. He had to sit with his anxiety, hair and forehead exposed in all the places he had avoided including the university cafeteria, the local bar and with friends. His anxiety and disgust decreased over time in all of these situations. After almost 6 months Jimmy was able to return to school, socialize with friends and eventually date. He had regained his life and had no need for surgery. At that point, he was able to recognize that the problem was not his hairline, but instead his beliefs about it, and the ways in which his preoccupation interfered with his life. He was back on track with a better sense of control. I believe that my CBT-oriented approach with Jimmy was useful; although I believe that it was equally important helping him reconnect with those experiences in his life that were of greater value than his hairline and appearance.

File under: The Art of Psychotherapy