Am I ugly? If that question makes you sick

Call in sick on the job because your hair doesn’t fit in the morning. Cancel an appointment because your nose looks too big. Risking a car accident because your own reflection is constantly distracting while driving. This may sound weird, but for people with a body dysmorphic disorder, such moments are part of everyday life.

Anyone suffering from dysmorphophobia is afraid of looking in the mirror every day. Those affected are firmly convinced that they are ugly or even disfigured, although their appearance gives no reason to be. An estimated 1.7 to 2 percent of the population in Germany suffer from dysmorphophobia or – to put it another way – from a physical dysmorphic disorder.

Prof. Dr. Ulrike Buhlmann is a psychological psychotherapist at the Institute of Psychology at the University of Münster. She has been researching and working on the topic for years and in a conversation she told us how to recognize an incipient dysmorphophobia, how the disease develops and what you can do about it.

Manche Frauen sind krankhaft unzufrieden mit ihrem Äußeren Dysmorphophobia can be behind permanent dissatisfaction with one’s own body. © Tatyana Dzemileva / How you can finally become more satisfied

What is dysmorphophobia?

The term is composed of the ancient Greek words dys = bad, morphé = figure and phobos = fear. It translates roughly as “the fear of being of bad shape”. Simply put, it is the permanent pathological idea of being ugly, often related to a very specific aspect of one’s appearance.

Wait, don’t panic: Of course, many women worry about their appearance or struggle with a supposedly too big nose or too short legs. This is no fun, but it does not mean that a dysmorphic disorder is present. The frequency and intensity with which you deal with these outward appearances, as well as the associated suffering and impairment of your life, are decisive.

How far this can go? “Affected people check their mirror image for up to ten hours a day or think about their appearance,” says Prof. Buhlmann. “We had a patient who caused a serious traffic accident because she had to constantly check her face in the rearview mirror of her car.”

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Does a Schönheits-OP for dysmorphophobia?

No, absolutely not. Quite the opposite, in fact. Although many of those affected see in a Schönheits-OP the only solution to your problem until they realize after the operation that they are still not satisfied and go under the knife again. Sooner or later, this drives some of them into financial ruin. The problem is not physical, it is a disturbance of self-perception.

People with a body dysmorphic disorder are not necessarily interested in looking like a top model, they just do not want to look disfigured, i.e. “normal” according to their own definition. “There have even been models among our patients”, reports Prof. Buhlmann, “Even if the affected people know that they earn their money with their attractiveness, they feel inferior as long as the perceived blemish is not corrected”.

Der Leidensdruck von Frauen, die unter Dysmorphophobie leiden, ist hoch. Women who suffer from a body perception disorder suffer a great deal of suffering. © fitzkes /

What are the typical symptoms of body dysmorphic disorder?

“In most cases, the supposed blemishes of those affected relate to a delimited area, usually in the face or on the head”, explains Prof. Buhlmann, “Others, on the other hand, have problems with another part of the body, the feet for example, or they feel altogether too big, too clumsy, not muscular enough”.

No matter what part of the body is involved, the suffering and pressure on people with dysmorphophobia is enormous. After all, at some point the tormenting thoughts about the outside world will determine one’s entire life. Those affected are increasingly avoiding social situations because they are simply afraid of showing themselves to other people or being laughed at for their appearance.

Many people constantly ask their surroundings whether everything about their appearance is okay – an immense burden on both sides. People’s friendships suffer, their jobs are often threatened because of the high number of days they are absent and partnerships often break down because of the illness; not least because people with dysmorphophobia can hardly allow intimacy or sexuality – the shame is too great.

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Interestingly, people with a body dysmorphic disorder are less severe in their judgments of their fellow human beings than they are of themselves. “Most of the time, those affected have a double standard, judge others very favourably in terms of attractiveness, and are only critical of themselves,” says Prof. Buhlmann.

Frauen, die unter Dismorphophobie leiden, schauen meist krankhaft oft in den Spiegel, auch beim Autofahren Women who suffer from dysmorphophobia usually look pathologically often in the mirror, even when driving a car. © Daxiao Productions /

How does a body dysmorphic disorder progress?

Dysmorphophobia belongs to the chronic disorders. This means that if the disease is not treated, it cannot be assumed to disappear on its own. “The more it becomes chronic and remains untreated, the more severe the suffering becomes,” says Buhlmann. “The earlier the affected persons can be treated, the higher the chances of success.”

The psychotherapist fights for the topic to become more public in society, which is still far too unknown in addition to diseases such as depression or anxiety disorders. “There are a lot of people affected, but they themselves often don’t even know that it is a disorder that can be treated,” says Prof. Buhlmann, who receives enquiries from people affected from all over Germany. “Many of those affected by this disorder think they are crazy or feel completely left alone with their thoughts.

What are the worst consequences of dysmorphophobia?

Early treatment is also important because it can be a matter of life and death. This does not only mean car accidents due to too many mirror glances. The suicide attempt rate is 25 percent: “There are estimates that one in four people affected try to take their own lives because of concerns about their appearance. This is alarming considering that only a small percentage are in adequate treatment”.

How does a disturbed self-perception develop?

At present, the scientists are still lacking the results of long-term studies in order to be able to make reliable statements about the exact triggers of the body dysmorphic disorder. “We have assumptions, but have to be very careful with causal statements,” says Prof. Buhlmann. However, several studies have already been carried out in which the scientists were able to identify potential co-triggering factors. Perfectionism is one of them, as is depression or low self-esteem.

In den Sozialen Medien wird man mit Fotos scheinbar perfekt aussehenden Menschen überflutet. The illusory world of social media can be deeply unsettling and discontent. © PKpix /

Inevitably, the question arises whether dysmorphophobia is Illness of our media age in which a supposed perfection is permanently suggested to us on advertising posters and at Instagram. However, according to Prof. Buhlmann, there are no meaningful studies on this yet. “It is certainly not a disorder that has only emerged in the last 30 years,” she says,

“The subject of beauty has always preoccupied people. It remains an open question whether it is stronger today than in the past. We are all bombarded with the media and edited photos, and yet not everyone develops a body dysmorphic disorder. However, it may well be that vulnerable people in particular are particularly affected by this.”

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Should dysmorphophobia be treated?

If possible yes, which unfortunately has still not reached all those concerned. Some years ago, the team around Prof. Buhlmann started an internet survey. The result: Only 20 percent of the affected persons were in treatment at that time. “There is a high barrier to treatment,” says the expert, who repeatedly encounters the same concerns and prejudices among patients: They don’t understand me anyway. My therapist does not take me seriously anyway.

Only cosmetic surgery can help me, because ugliness cannot be treated.

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Especially on the subject Schönheits-OP Prof. Buhlmann’s alarm bells are ringing: “I am not generally against cosmetic surgery, but please do not do so if a dysmorphic disorder is present,” said Buhlmann. “We therefore often ask patients to give psychotherapy a chance and advise them to wait at least six months before the therapy takes effect and thus to avoid the desire for OP can be revalued.”

Which therapies help with body dysmorphic disorder?

As already mentioned: A Schönheits-OP is not the key to happiness in people who suffer from dysmorphophobia. However, they are still not satisfied afterwards. “Or the satisfaction lasts only for a few months and the problem then moves on to the next area of the body”, the psychologist knows. “Affected people often have themselves operated on 2, 3, 4 or 5 times up to financial ruin, because the operation cannot do anything about the low self-esteem of the affected person”.

What can a therapeutic treatment look like? “I myself think that Internet-based therapies are very important, because many affected people hardly ever leave the house anymore, and therefore the Internet is the only way for them to get in touch with others”, says the expert. “Internet-based therapy does not replace face-to-face therapy, but it does make it possible to offer more people an offer more quickly and perhaps get them to the point where they can get proper treatment”.

Women who suffer from a body-dismopher disorder would prefer to have Schönheits-OP  one by one One Schönheits-OP people with body dysmorphic disorders are often considered a last resort, but it does not help. © Romariolen /

However, therapists achieve good results above all with cognitive behavioral therapy – often also in combination with a medicamentous therapy . If at the beginning of the therapy the affected person has no or only very little insight that it is not an optical flaw but a psychological disorder, the therapist first conducts intensive discussions in which the illness is explained in detail.

Often the so-called mirror confrontation helps: Since those affected usually only focus on one aspect of their appearance, they are asked to look at their entire body in the mirror. With every person’s perception would change over time if only one area was looked at for a very long time. “We practice with the affected persons to look at themselves holistically and without judgement. This is difficult at first, but over time it works very well,” says Prof. Buhlmann.

But what does the patient think about her former suffering after a successful therapy? “Differently”, knows Prof. Buhlmann, “For some people the alleged blemish has actually disappeared, others still see it, but they have learned to accept themselves and no longer attach too much importance to the optics”.

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Do I suffer from dysmorphophobia?

You can test that. Even if Prof. Buhlmann’s team is unable to make diagnoses via the Internet – a self-test, which is available on the KDS -outpatient clinic is provided.

Here, if you suspect that you are suffering from a body dysmorphic disorder, you can fill out a questionnaire and have it automatically evaluated by the experts. “We ask questions and make assumptions as to whether it would be advisable to consult professional colleagues. There is always feedback,” says Prof. Buhlmann.

First of all, very important: You are not “ugly”! If you have the feeling that you are suffering from a body dysmorphic disorder yourself, or if you know of a case in your circle of friends or family to which the symptoms apply – professional help for those affected is possible and not a miracle!