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HOW IS BDD DEFINED: PREOCCUPATION – ‘REAL’ AND ‘IMAGINED’
It isn’t known why people with BDD see themselves differently than other people do. Do they see what other people see but interpret it differently, considering the body part unattractive when others don’t? Or do they actually see the body part differently? The question isn’t so much whether the defect is “real” versus “imagined,” but rather why it is that people with BDD perceive their appearance differently than other people do.
Yet another knotty issue is how to determine whether a defect, if present, is “slight,” which the definition requires. If the defect is very obvious to others—if it’s immediately noticeable—then by definition the person doesn’t have BDD. But what if the defect is more subtle? Who’s to judge whether it’s slight or not? These questions take us into a subjective realm where reality and distortion can’t always be clearly differentiated. To some extent, just as beauty is in the eye of the beholder, so is ugliness. If someone with BDD thinks her legs are huge, but I think they’re only “slightly” big, who is right? Should a woman who’s 5′ 11″ and preoccupied with her height be considered “slightly” or obviously tall? In some cases, I don’t notice the defect when I meet someone, but when it’s pointed out I can see that it’s actually there. Is such a defect “slight” or “nonslight”?
It’s helpful to consider what most people observe. I often have corroboration from others—clinicians, family members, or friends—who agree that the defect is nonexistent or slight. The most common reason people with BDD are turned down for surgery or other medical treatment is that the physician can’t perceive the defect or considers it too minimal to treat. One patient was referred to me by a dermatologist who described her as “a woman with beautiful skin.” Many patients have been brought to me by family members who recognize that their loved one has an inaccurate view of how bad the defect is. I and several dermatologists did a study in which we independendy rated the severity of skin defects and found that in general we closely agreed about which defects were slight and which were clearly noticeable. This suggests that such judgments can be made with reasonably good agreement and objectivity.
*24/204/8*