Being seen or being watched? A psychoanalytic perspective on body dysmorphia

Abstract

The focus of this paper is on individuals who present as excessively preoccupied with their body, perceiving some aspect(s) to be ‘ugly’ such that they feel compelled to alter and/or conceal this ‘ugly’ body part. These difficulties are understood as symptoms of an underlying narcissistic disturbance. The author suggests that the relative pervasiveness of an identification with a ‘super’‐ego accounts for the degree of severity of the disturbance (increasing the compulsion to alter and/or conceal the hated body part) and that it has implications for the patient’s accessibility in analytic treatment. Understanding the vicissitudes of the development of the body–self in the context of the earliest relationship with the ‘object of desire’ is core to helping these patients because of the quality of the identifications that ensue and that are then enacted the transference.

Key words:

• body image
• body–self
• dynamics of vision
• ego‐destructive superego
• narcissism

Acknowledgements

I am grateful to my colleagues in the Tavistock Clinic’s ‘Disturbances of Body Image Workshop’ for their support in developing the ideas presented here. I am especially indebted to Richard Graham with whom I co‐chaired the workshop. I would also like to thank Susan Levy, Priscilla Roth and Heather Wood for their very helpful observations on an earlier version of this paper and to all the reviewers for their comments and encouragement.

Notes

1. There is an excellent paper by Parker (2003) devoted to ‘body hatred’.

2. The majority of these patients had a diagnosis of Body Dysmorphic Disorder (BDD) and have been seen in public heath service settings. I have indicated where the patient was seen in the context of private practice.

3. The Wolf Man is a good example of this, with his imagined defects on his nose and his obsessive mirror checking (see Brunswick, 1971; Graham, personal communication).

4. As Schore (1994) highlights, neuromuscular systems, for example, encode patterns of early object relations.

5. I am referring here to the internal mother.

6. The latter is a sub‐group of the ‘distorting‐mirror‐mother’.

7. I am suggesting it is a contributing factor because I consider that the baby’s innate disposition also invariably interacts with the mother’s responses.

8. It is of note that in BDD the bodily preoccupation is commonly located above the neck, very frequently the skin surface (75%), but also shape of the head, hair, facial features (Phillips, 2005) – significantly the first physical sites of meeting between mother and baby. I understand this as suggestive of a deficit in the libidinal investment in the body by the ‘object of desire’ at the level of early skin‐to‐skin, face‐to‐face contact. Although concern with genitals is also encountered, this is far less common (approximately 7% of BDD patients). By contrast, in anorexia, the body dissatisfaction is typically located below the neck, in the lower body areas: the more sexual areas such as breasts, stomach and thighs (Cororve and Gleaves, 2001). In anorexia the anxiety thus appears to be linked more specifically to the sexual – as opposed to the sensual – body and its unconscious meaning.

9. This ‘observing’ other, as Steiner suggests, is frequently represented by “an observing part of the primary object, often the mother’s eyes” (2006, p. 942).

10. Unsurprisingly, actual attempts to alter the reviled body part have been shown to not lead to an improvement in how the patient feels: one study found that following cosmetic procedures 50% of patients diagnosed with BDD transferred their preoccupation to another body area (Veale, 2000). Mean satisfaction ratings with the outcome of cosmetic surgery also tend to drop after each procedure suggesting that, at some level, in his disgruntled relationship with the cosmetic surgeon, the patient enacts something of the experience with an internal object that can never be satisfied enough and with whom he is now identified. The surgeon now becomes the one who cannot produce the perfect body that will guarantee the patient’s approving look. This may account for the reportedly frequent threats of violence towards cosmetic surgeons and litigation by disgruntled patients.

11. I am grateful to one of the reviewers for drawing my attention this important point.

12. This is, of course, only a hypothesis that requires testing.

13. Perhaps unsurprisingly such patients are typically found to also have a co‐morbid avoidant personality disorder (Neziroglu et al., 1996).

14. Ms G is being seen in the context of NHS treatment where I have seen her in once weekly psychotherapy for two years. At the time of writing she has made some small, but encouraging, improvement whereby she has reconnected with several of her friends and is now working.

15. Although she was clearly in the grip of a psychotic state of mind, she was not psychotic in the psychiatric sense.