Inside Body-Image Disorders

Aron Cowen spent most of his 20s in front of the mirror, despairing over his appearance. He used so much chemical straightener on his curly hair that it turned orange and started falling out. Two nose jobs only left him feeling worse about what he described as a crooked, bumpy profile. By the time the Los Angeles resident was 30, he had started measuring the lengths of his ears with a small ruler, convinced that one was bigger than the other. Still, he had a hard time convincing people that anything was wrong with him.

Even after a psychiatrist diagnosed Cowen with body dysmorphic disorder (BDD)—a rare psychiatric condition the sufferers of which see themselves as ugly and disfigured no matter how normal they look to others—family and friends remained certain that it was just "all in his head." Cowen says, "People tend to dismiss it as 'not a real condition.' They don't see the difference between me and any normal person who doesn't like some part of their appearance, so they just kind of want me to get over it."

A decade ago plenty of people, including many health professionals, would have agreed. Cowen's condition might have been written off by some as a desperate plea for attention, the result of bad parenting, or perhaps a sign that Cowen himself was unable to cope with our appearance-obsessed society. In recent years, however, an increasing number of studies—including two published this week—have pointed the way to potential biological explanations for BDD and other behavioral disorders, such as anorexia nervosa. Doctors and patients can only hope that such tangible evidence of pathology will help remove the stigma attached to most mental illnesses.

BDD belongs to a family of disorders characterized by obsessive thoughts and repetitive behaviors that can render the worst of their victims housebound and suicidal. Known as Obsessive Compulsive Spectrum Disorders (OCSD), the group also includes anorexia, an eating disorder characterized by self-starvation, which has the highest mortality rate of any psychiatric illness. (The National Association of Anorexia Nervosa reports that 10 percent of anorexics die within a decade of developing the condition.) While BDD tends to affect men more often, and anorexia is more common among women, 30 percent of patients with one disorder also suffer from the other. Both conditions are rare: combined they affect less than 3 percent of the population.

In a paper published Monday in the Archives of General Psychiatry, researchers at UCLA show that people suffering from BDD process visual images differently than healthy people. Study participants underwent a brain scan while viewing three different pictures of the same face: an untouched photo, a blurred photo and a finely detailed line drawing. While healthy subjects used the left, or more analytic, half of their brains only when processing the finely detailed images, subjects with BDD used their left brain to process all the images—suggesting that their minds were trying to extract minute details even where none existed. "This is the first demonstration of a potential biological contributor to BDD," says the study's lead author, James Feusner, medical director of UCLA's Obsessive Compulsive Disorder treatment program. "It tells us that there is an abnormality in how their brains interpret what they see."

Using the same brain imaging technique, scientists at the University of Pittsburgh employed a guessing game to compare brain functioning in healthy women and in women who had once suffered from anorexia. In that study (also published Monday, in the American Journal of Psychiatry) participants were asked to guess whether the next number to pop up on a screen would be higher or lower than five. Correct guesses were rewarded with $2, while incorrect guesses were penalized $1. In women who had never had anorexia, the anterior ventral striatum (AVS)—a brain region responsible for instant emotional responses—lit up each time they won. In former anorexics, however, the AVS was relatively unfazed by a win, indicating that the anorexic mind does not distinguish between positive and negative feedback.

What did light up in the anorexic brains, and what stayed lit throughout the guessing game, was the caudate region—a section of the brain involved in linking actions to outcomes and planning. "Healthy women were able to make a guess, feel a moment of delight or disappointment, and move on," explains the study's lead author, Walter Kaye, director of the eating disorder research program at the University of Pittsburgh Medical Center. "But women who had suffered from anorexia felt no thrill at winning and were plagued by a need to strategize and avoid guessing wrong." The findings mesh with some well-known characteristics of the eating disorder, which is most prevalent in white, affluent females. "Anorexics have trouble experiencing immediate pleasures and are typically preoccupied with a fear of making mistakes," says Kaye. "Now we can see that this cause-and-effect brain circuit is overactive and that the reward center is muted."

Researchers have yet to determine whether faulty brain functioning causes OCSD or vice versa, and neither study manages to hint at new treatment strategies. Still, experts hope the findings may contribute something even more fundamental. "The thing that's been missing in psychiatry is the ability to relate behavioral disorders to some part of the brain that isn't working right," says Kaye. "We are learning more and more that conditions like anorexia are not willful acts meant to punish parents or get attention; they are serious medical conditions." With a little more hard evidence, he may just win over the skeptics.