The mirror that never lies

Specialist CBT therapy for anxiety, OCD, depression and more in West London

A mirror can become more than a mirror. Someone may approach it hoping for relief and leave feeling certain that a feature is unacceptable, obvious or impossible to live with. They may return repeatedly, change the lighting, compare photographs, avoid reflections altogether or search another person’s face for evidence. The distress is real, even when the person cannot settle on an answer about what they look like. It is important not to assume that appearance related distress means body dysmorphic disorder. Body image concerns can arise alongside low self esteem, social anxiety, eating related difficulties, trauma, a health change, an unwanted comment, a cosmetic procedure, grief or other experiences. A blog cannot diagnose BDD, decide whether a feature is objectively noticeable, or explain why a specific concern feels so compelling. In assessment, the question is not simply “is the person wrong about their appearance?” It can be useful to understand what they fear another person will notice, what they believe that would mean, how much time the concern takes and what they do to manage the distress. Checking, comparing, camouflaging, avoiding photographs, cancelling plans and seeking reassurance can each play different roles for different people. Other people’s reactions are not a reliable truth test. A glance can be ambiguous. Reassurance can soothe for a moment and then create another need for certainty. A compliment may be dismissed as politeness. This does not mean someone is being difficult or refusing support. It may mean that the problem has become organised around a question that cannot be permanently settled by looking harder or asking again. Any new, changing or worrying physical symptom should be discussed with an appropriate medical professional rather than assumed to be anxiety or BDD. If appearance related distress is accompanied by not eating, purging, severe restriction, self harm thoughts, a crisis or immediate safety concern, urgent appropriate help is needed. CBT may be considered when assessment indicates that it is appropriate. Behavioural or exposure based work is not a self directed instruction from an article to ask strangers for feedback, remove camouflage, stare in a mirror or enter a situation that feels unsafe. If it forms part of therapy, it is planned collaboratively with a qualified clinician, with informed consent, a clear rationale and attention to the person’s health and circumstances. The purpose is not to impose a verdict about someone’s appearance. It may be to understand the cycle between attention, fear, checking and the search for certainty, then develop a different relationship with that cycle. Progress is individual and may involve more than one form of support. For related information, see <a href="/therapy/body dysmorphic disorder/">CBT for body dysmorphic disorder</a>, <a href="/guides/body dysmorphic disorder cbt west london/">the BDD clinical guide</a> and <a href="/guides/mental health weight diet movement/">body image, weight and wellbeing</a>. The Lyceum Clinic offers assessment led CBT online and in West London.