BODY DYSMORPHIC DISORDER: Most of us have a feature or two about ourselves we don't like. Our nose is too big, hair too flat, smile too wide. But for between 1 percent and 2 percent of the population, this dislike is actually an obsession over an imagined or minor physical defect. People diagnosed with body dysmorphic disorder (BDD) see their features as grotesque and disfigured, and their life is consumed with an obsession over it. Sabine Wilhelm, Ph.D., the director of the Body Dysmorphic Program at Massachusetts General Hospital, explains the severity of BDD by saying: "[Patients often] cannot to go school, they cannot go to work, they have difficulty maintaining friendships, and they don't date, and they don't get married. It's much more severe than the average appearance concerns that most people actually struggle with."

BDD SIGNS: BDD typically surfaces in adolescence or in the late teens, but cases have been reported in children as young as 4. Some patients find it too painful to look at themselves in a regular mirror and can only look in cloudy mirrors. Other patients spend hours each day looking at their reflection, obsessing about their "flaws." Dr. Wilhelm says: "It can be really any reflecting surface. It could be the back of a spoon. Or it could be the rearview mirror in the car, and we have had several patients who got into car accidents because they were driving over a busy intersection, and they were checking their appearance in the rearview mirror."

Examples of BDD behavior includes:

» Constantly seeking reassurance from family members by asking, 'Do I look OK?' or 'Do you notice anything unusual about my skin/hair/nose?

» Refusing to sit under bright light or go out in daylight

» Wearing long sleeves to cover up skin on arms

» Re-applying makeup every hour

CAUSES: Dr. Wilhelm says: "There are a number of different theories in terms of what might be causing BDD. There are biological theories -- we often find that BDD runs in the family, where a patient's mother or father has BDD. There are also psychological theories; many patients with BDD report that they have been teased as a child. Patients with BDD will often report that appearance was very important in their family so it became important to them, and of course, there are also cultural theories." In a study out of UCLA, researchers compared MRI scans of BDD patients' brains to healthy people's brains as they had participants study pictures of people's faces. Researchers found the healthy people used a part of their brain that processes information in a general sense, while the BDD patients used a part of the brain that processes details and failed to get the bigger picture, suggesting functional differences in the brain.

TREATMENT: Patients often seek help from dermatologists or plastic surgeons. But this usually doesn't help because the patients' problems are really on the inside. In some extreme cases, Dr. Wilhelm says: "We have had several patients who attempted to fix their appearance flaw themselves by cutting their nose, for example. We have had patients who, on purpose, got into an accident and tried to break their own nose just because they have not been able to afford a nose job so therefore, they thought, "If I break my own nose maybe I will need surgery for it and it can be fixed.'" What does work are and the antidepressants SSRIs and cognitive behavioral therapy -- done in about 20 sessions where patients have "homework." This homework is exposure and response prevention exercises. Exposure exercises refer to facing situations that patients previously avoided. For example, the therapist may have the patient sit under bright light, leave the house during the day, or wear short sleeves. With response prevention, patients try to gradually decrease the repetitive behaviors they engage in. They must spend less and less time looking in the mirror or using less makeup, for example.

However, most patients don't seek treatment from a therapist. Because they believe they are genuinely disfigured, they don't think they have a mental problem. Dr. Wilhelm says this severe and debilitating disorder is both under-recognized and under- treated. And suicide rates for patients with BDD are 45-times higher than rates in the general population.