Mirror mirror on the wall

I’m the ugliest of them all

I t is close to midnight but the young man is staring into the mirror, transfixed. A hideous beast, with tortured features and grossly exaggerated flaws, lines and pores stares back — but only he can see it. During the day he functions as a regular student, but as a young man suffering from body dysmorphic disorder, his nights are plagued by what he sees in the mirror night after night.

A growing number of South African men are affected by this illness. For some men, it manifests as bulking up obsessively beyond what is realistic. Others get eating disorders such as anorexia or bulimia. All are mental health issues.

“It is difficult to give an accurate figure owing to the lack of research in this area in South Africa, as well as the reluctance of males to seek treatment,” says Jasmin Kooverjee-Kathard, principal clinical psychologist at Chris Hani Baragwanath hospital.

“Figures on muscular dysmorphic disorder are distorted owing to the misperception that overly muscular body types are acceptable and deemed ‘healthy’ in nature, when actually they severely hinder the individual’s ability to function in everyday life.”

While most of us have issues with aspects of our appearance, some with this disorder are affected to such an extent that they stop functioning in society.

The situation is more acute for South African men because these conditions are not considered an African problem, but one that affects the Western world. It also means men often do not ask for help.

Estimates are that males account for up to 15% of patients with anorexia or bulimia globally and for an estimated 35% of those with binge-eating disorder.

Body dysmorphic disorder is based on a distorted sense of one’s body image, says the author of a local study, psychologist Matthew Mulholland.

In his 2016 study, based at the University of Pretoria, Mulholland found there was no race or gender distinction among sufferers.

“It is definitely prevalent, but the degree varies. There are those who are just unhappy with some physical feature, without it distressing them such that they’re preoccupied with it.

“Body obsession is relatively normal for people during adolescence. The warning signs are when it becomes more pervasive, affecting the individual’s daily functioning and causing distress.

“As in most psychological disorders, the level of intensity is determined by how sufferers function at work, socially, and in other domains. At the peak of body dysmorphic disorder symptoms, they may not be able to leave their homes.”

Mulholland delved into the concept after he developed body dysmorphia himself, stemming from remarks during his adolescence about how good-looking his twin brother was. “People would say I was the one with the personality. I began to look at my brother’s image as perfection.”

Flaws are real

Counselling and medical treatment helped him to become functional.

“For the sufferer, the flaws are real, unquestionably real. But to everyone else he looks normal. In severe cases, sufferers can’t make the connection that it is a distortion, even with the insight of seeing a psychologist. It is debilitating, no matter how much someone tells them there is nothing wrong.”

A young student who has body dysmorphia initially stopped going out when the sunlight was not flattering. He got to a stage where he could not look at himself in any reflective surface, and now he cannot look at his own shadow.

“I see a hideous face, unacceptable to society. It changes from day to day. The image is never consistent for me. Every new surface is a horror. Everything about my face is horrible, from the lines that I see, the size of my pores . . . specific features.”

One symptom of the disorder is to spend hours and hours stuck in front of a mirror, or looking into a mirror more often than usual.

“For me the line between eating disorders and this is a small one. There are similar core psychological dynamics,” says Mulholland.

Disguising the body and avoiding social settings are common traits.

Mulholland’s study found that homosexual men experienced the symptoms far more intensely.

Recently, 46-year-old international rugby union referee Nigel Owens revealed he had suffered from bulimia on and off for nearly three decades. He said it was linked to his sexuality and his own struggle to accept his homosexuality.

Known for his no-nonsense attitude on the field, Owens said he was now seeking professional help.

In the UK, eating disorders are reported to be up to 66% higher in 2010 than in the previous decade. These conditions have the highest death rate of any mental health illness. Social media only adds to the pressure.

Kooverjee-Kathard says: “Men are affected by what they believe are social norms influenced by the media. It is the false thinking that with muscles comes power. Non-acceptance of body image and low selfesteem then lead to the desire to attain a more ‘powerful’ and ‘muscular’ body type.”

Coming out of the closet

Johannesburg psychologist Bruce Laing agrees that “it is difficult for men to come out of the closet because these are culturally misunderstood to be female disorders”.

Registered dietician Kelly Schreuder said the issue of appearance was often one of control. “The way people use food when they have an eating disorder is a symptom of their need to exercise control over a certain aspect of their lives.

“Food is often restricted, or compensated for in some way — perhaps purging or overexercising — because the patient believes food reflects on their bodies in more extreme and immediate ways than it does in reality.

“Another side to eating disorders is that food is essentially nourishing and enjoyable. A healthy diet is the ultimate self-care ritual, and someone with poor self-esteem may feel undeserving of such care or pleasure.”

Schreuder said it was not easy to pick up when someone had an eating disorder.

“The disorders are often so well managed by the patient that they can go unnoticed for a long time.

“Some patients may seem perfectly healthy, but endure enormous struggles with food and self-esteem.

“It is not unusual for a family to be unaware of the extent of damaging behaviour until much time has passed.”