It's common to feel dissatisfied with your looks, particularly in a culture saturated with visual media that places a premium on appearances (case in point: the rise of face-altering apps). But for the one in 50 people in the UK with body dysmorphic disorder (BDD), the problem is altogether more serious.
The anxiety disorder distorts sufferers' body image, often involving obsessive worrying over perceived flaws and compulsive behaviours. Suicide among people with BDD is 30 times the national average and just 5% of people with BDD get treatment from mental health services. Which may be why BBC Three has made it the subject of a new documentary.
Ugly Me: My Life With Body Dysmorphia follows 29-year-old Liane as she struggles to confront and overcome the crippling condition. Liane has lived with symptoms since her early teens and it has destroyed her ability to lead a normal life, her closest relationships, including her sex life and relationship with her boyfriend, Mitch. In the opening scene we watch her straightening her hair and breaking down in tears, explaining her fear of bringing shame on her boyfriend, Mitch, when others see them together in public.
"I really hate my face, I really hate it. I'm just so ugly no matter what I do," she says, adding that her hair isn't right. "I always remember feeling ugly. All I can remember is that feeling, all the time. It's me telling myself that I'm ugly. My brain working overtime telling me all the things that are wrong."
Throughout the documentary, it is hard to watch as Liane describes herself as looking "like shit", rough, fat, ugly, disgusting and as having a big nose and an asymmetrical hairline and face.
Mitch recalls the time Liane set her hair alight in frustration that it wasn't looking as she'd hoped, and says that over the years he's learned to simply not react to her self-criticism. Their relationship and sex life has also suffered as a result of the disorder, with Liane avoiding intimacy and being naked around him. Mitch says he feels like he's "living with a housemate" rather than a girlfriend and Liane admits to feeling insecure being out with him in public for fear that he will eye up other women.
In an attempt to confront the disorder, Liane visits Maudsley hospital in south London, a leading treatment centre for BDD, where she gets a formal diagnosis for the first time and meets Professor David Veale, an expert in the field who refers her for cognitive behavioural therapy and tracks her progress over a year.
Many patients often undergo needless cosmetic treatments.
"Symptoms tend to include checking their appearance repeatedly and trying to camouflage or alter the defects they see," says Veale, who is a consultant psychiatrist at The Priory hospital in north London. "Many patients often undergo needless cosmetic treatments. Onlookers are frequently perplexed because they can see nothing out of the ordinary, but BDD causes devastating distress and interferes substantially with the individual’s ability to function socially."
Social media, particularly Instagram, doesn't help those with BDD, Veale adds. "It is difficult to draw the line where body dissatisfaction stops and BDD starts." The preponderance of "perfect bodies" only serves to make BDD patients "want to fit in with what they see". While many people with BDD undergo cosmetic surgery in an attempt to quell their anxieties, fewer than 10% will be content with the results and they will often transfer their anxieties onto other body parts, Veale says.
"At least a third of patients I see with BDD have had one or more procedures of cosmetic surgery... It is increasingly worrying that BDD patients are able to undergo cosmetic procedures and I'm concerned that some patients may have 'botched' surgery which will ultimately make the condition worse."
It was 24/7, even in my dreams I'd have nightmares where that voice would be playing in my head. I didn't get a relief from it.
The documentary also hears from people recovering from BDD who recall the debilitating impact it had on their lives, while providing comfort to those like Liane that it's not impossible to overcome. "The BDD made me believe I was a bad person, a bad friend, a bad daughter, a bad sister," explains another woman featured in the documentary. "It went deeper than just the appearance worries. It was 24/7, even in my dreams I'd have nightmares where that voice would be playing in my head. I didn't get a relief from it."
During her therapy Liane is asked to take her mind back to being 14, the age at which she first developed symptoms, and it's heartbreaking watching her speaking kindly to her younger self. "It doesn't matter, don't worry about it. Just go and start a conversation with somebody, no one cares what you look like. It's in your head. Just go and talk to people. If you just stand there looking upset, no one's going to want to talk to you. It's got nothing to do with your makeup, nothing to do with your face," she says.
The documentary ends with her rekindling a passion for painting, a hobby she had neglected for eight years, and acknowledging the life-changing impact of her disorder for the first time. "Every day I'm trying not to engage with negative thoughts," she says, but admits it's an ongoing struggle. "I just have to keep going and keep trying with the [CBT] homework."
If you are living with symptoms of body dysmorphic disorder, please get help. Call Mind on 0300 123 3393 or text 86463.