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.”

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