Body image and mental health - when is it a problem?
Body and mind

Body image and mental health - when is it a problem?

We all have body image issues, but when do we know that it's connected to something deeper than just changing something about our looks?

Sriranjitha Jeurkar

The way we look forms a large part of who we are and how we see ourselves. Focusing on our looks may seem crucial today with the social media pressurizing us to look ‘perfect’ and get validation from people who know us. And yet, most of us are not a hundred per cent satisfied with how we look. Given a choice, we would make some change to our appearance - but how far would we go?

You could compare this to our relationship with food. Some of us are conscious of what we eat while trying to balance between the healthy and the unhealthy while some of us don’t really care. Some of us stick to our diets to make sure we eat no junk food. And there are those of us who eat a cookie or a slice of cake, and spend hours at the gym or starve ourselves for the next two days – surely, that’s not healthy!  

Similarly, some of us dislike a thing or two about how we look, and feel conscious about it when we meet someone new. On the other hand, some of us actively try to change something about these features (think fairness creams/hair coloring/facials). But some of us would go to a different extent altogether (plastic surgery, rhinoplasty). 

Unlike with food, there’s no calorie count here or a way to measure how healthy you are with these thoughts, and when these thoughts become an obsession. When it comes to looks, there’s a huge gray space between what we consider healthy and unhealthy.

What makes us want to change our looks?

We may have different reasons for disliking how we look, or wanting to change something - health, fitness, social approval, belonging, greater visibility and power. We tend to create our initial impression of someone based on how they look, until we get to know them better. Because of our  social conditioning, we end up linking others' looks to certain qualities, particularly when we meet them for the first time. This creates a pressure to look good, and we often look for ways in which we can present ourselves better. 

A dermatologist from Bangalore says that most of her clients are women in their 20s and 30s looking out for a suitor - whether through dating or arranged marriage. The emphasis here is on fairness and losing weight (even if the girl is just slightly plump and not necessarily obese). As women grow older, she says, they come in for certain cosmetic procedures that will gain them acceptance among their friends. “Often, with middle-aged women, it’s not so much about what their husbands or family say, and more about what their friends say. They are often in circles where comments are passed about each others' appearance and this affects them. They then go in for botox or slimming procedures in a bid for acceptance,” she says. Men are more likely to go through procedures for acne and skin lightening; anti-aging is rarely opted for. 

Social acceptance is one of the needs that people look to meet when they opt for cosmetic procedures - whether it’s removal of acne scars, skin lightening or face tightening. Looking more presentable and attractive often helps most people feel more confident in their own skin; they feel relaxed and rejuvenated. This influences other spheres of their lives - whether they feel more assertive at work, or in their personal relationships - and the procedure helps them improve their self image and self esteem

Defining 'normal' and 'okay' 

But this is where things get hazy. How does one determine whether making cosmetic changes - haircuts, slimming, skin lightening or botox - is not about something deeper? How to separate the different factors - societal conditioning and pressures, how we see ourselves, what our aspirations are - to determine whether something is ‘just superficial’? 

Generally speaking, if one procedure can really change the way someone feels about his or her appearance, it probably isn’t a broader self-esteem issue. From a social welfare perspective, we can work towards changing some of these beliefs. But from an individual perspective, wanting to change one aspect of one’s own appearance does not necessarily indicate the existence of a mental illness

Shabari Bhattacharyya, counselor, Parivarthan Counselling, Training and Research Centre, Bangalore

That said, there are certain signs that point out that body image concerns are just a symptom for something else altogether. And there are few dermatologists and cosmetologists who are trained or empathetic to recognize it. 

Body Dysmorphic Disorder 

For people with Body Dysmorphic Disorder (BDD), there is a constant obsession on perceived defects in their appearance. The way they see themselves doesn’t always match up to how others see them, and their obsession over their flaws can be exaggerated in the mind.  

Psychiatrist Dr Sandip Deshpande recounts the story of a teenager, who had a small scar on his face. He would take several selfies every day to monitor the scar, because he was convinced that it was vitiligo. He would zoom into the pictures and compare the scar with pictures taken hours and days ago, to measure it at different angles. He would sometimes even wake his parents up in the middle of the night to confirm his suspicions that it had grown bigger. When they said no, he would be convinced that they were lying to offer him false reassurance. His obsession with his scar grew, and he would think about little else all day. He stopped going to college and would stay indoors all day. He went to several dermatologists unsatisfied with the treatment he received, until he was referred to a psychiatrist. 

This teenager’s case illustrates most of the symptoms of BDD - obsession with a perceived flaw; an exaggeration of the flaw; doctor-shopping or lab-hopping until they receive the treatment they think they need. 

BDD exists in India too 

“I think there is a perception that BDD is a western-centric disorder but this is just not true,” says Dr Deshpande. “I have had clients for whom obsession with their flaws take over their whole life. There was a young man who would routinely get his blood tested for rare minerals because he thought that’s why his hair was greying. And a young woman who would take more than an hour every morning to put on makeup that satisfactorily covered her scars. Some of them resort to pill-popping and self-medication, and that can be dangerous. When it becomes an obsession, it causes distress to the person and to others around them and keeps them from going about their routine. Then it’s important to seek help.” 

And since the nature of the disorder is an obsession with one’s appearance, a dermatologist or cosmetologist is the first person they would approach. And often, the problem is not picked up at this stage because there is no psychiatric or psychological screening before cosmetic surgery. They may go in for a procedure and then report unhappiness with the results. 

“We can promise about 50-60 per cent improvement with most of our procedures, but there are some people who insist that they get a 100 per cent improvement. Or they keep coming back for different procedures again and again. This is a bit of a red flag in my mind, because it tells me that there may be some other cause for the dissatisfaction. And at the end of the day, it comes down to your sense of ethics: you can just perform the procedure without any engagement, or you can talk to them over a couple of visits and gently broach the subject. Unfortunately, there is no framework of ethics for cosmetologists - so they are quite likely to find someone who will do the procedure, no questions asked,” says a cosmetologist.

But what is the solution? 

Mental health experts say that if a person is satisfied with their appearance after a single procedure, it is less likely to be linked to a broader self-esteem issue. However, if the person tries different procedures or methods to change their look, they may need psychological support to tackle the underlying cause. The only way to tackle this would be for the cosmetologist or plastic surgeon to recommend the person to a psychological screening before any procedure, to have a fair assessment. “If the person feels bad about themselves and is considering plastic surgery as a means to make themselves feel better, then that is something that needs to be explored. Will it really help the person feel better in the long run? Repeated procedures with the hope of feeling better is also a cause for concern, as self-esteem or a positive body image or self-worth can be obtained from the inside out and not the other way around,” says Bhattacharyya.

White Swan Foundation
www.whiteswanfoundation.org