At 11 years old and weighing only 87 pounds, Ann would look in the mirror and see herself as 140 pounds. She was restricting her food intake, eating only cereal at breakfast and one small plate of plain pasta every day, which most times she then threw up.
Now 25 and still struggling but better managing her eating disorder, Ann says that what she sees in the mirror is still not what other people see. "I see every imperfection that my body has, every way that my stomach folds, every inch of fat that comes out of my pants or pierces through my shirt, every imperfection."
According to the Anxiety and Depression Association of America, Ann is part of the roughly 2 percent of Americans who suffer from body dysmorphic disorder, or BDD, a mental health disorder around body image that can cause serious and life-threatening eating disorders.
"My BDD comes from what I learned to believe my body should look like, whether from my family, movies -- the main character always being a size zero -- or watching fashion week where the models' thighs are the size of my toothbrush," Ann reflects. "Everywhere around me sends messages saying if I don't look like that, then I'm imperfect." With an associate degree in psychology, Ann (who preferred her full name not be used) says she fully knows that her eating disorder growing up was serious and that continuing to restrict her food intake is extremely unhealthy and can be dangerous. "But," she says, "my brain can't intellectualize my body dysmorphia. It's like my kryptonite. I understand that it can't be healthy, but my brain can't accept that. My brain thinks, 'You can fix this.'"
Amy Ornelas, a dietitian who is a certified eating disorders specialist, describes BDD as a psychological issue in which one's brain distorts what one sees, so those who suffer see themselves as dramatically larger or smaller than they actually are. "BDD is a translation of the way your body looks in the brain -- partially what we've been taught to believe and what we believe we see in relation to others."
Though BDD skews more to younger women, it impacts all types of people and is not solely about weight. Ornelas also works with people with fixations on certain body parts and people who feel everyone is judging a minute part of their appearance.
For her clients managing eating disorder-related BDD, Ornelas says malnutrition from eating disorders can cause it -- for example, when people with anorexia see themselves in the mirror as a healthy weight -- but typically it has more to do with a person's psychological makeup, things such as social anxiety and not feeling confident or wanted or loved.
"In high school, I didn't know who I was," Ann recalls. "I was confused, angry, trying to get boys' attention. I was the skinny girl. I didn't break 100 pounds until I was 20. Everyone was getting boobs, and with the body of a 10-year-old girl and no periods, I was stuffing tissue in my bra. I had great parents, but they didn't understand me or what I was trying to express. I really didn't feel like I was being heard by anybody. My two best friends were large girls, reflecting that people would think I'm the prettiest of my friends. Looking back, it was truly twisted and horrible."
Being overly skinny is an obvious sign of BDD and eating disorders for which parents of young teenagers in particular need to watch. Others include avoiding or constantly checking mirrors, adjusting or changing clothing multiple times a day, camouflaging (such as wearing baggy clothes to hide one's body), restricting eating, and excessive exercising.
The key to managing or coping with BDD is getting psychological and nutritional help.
"Treatment is about reality testing and talking through the distortion to make the person with BDD see and understand that part of the story they're seeing doesn't play out," Ornelas says. "But it's also about healing body distortion. BDD is really symbolic of self-worth and self-esteem -- coming from internal unworthiness -- so doing therapeutic work is important for the inside, to feel good about yourself and confident and take emphasis away from how you feel your body looks and your body being your only conduit for expression. It's so important to remind the person they're loved exactly the way they are and the rest of the world doesn't see them the way they do -- as well as getting their body fed back to normal weight."
Ann sees Ornelas several times a week for nutritional guidance and has been renewing her relationship with what she eats through what Ornelas calls "intuitive eating for healing the body with food -- helping turn off the brain and letting go of the good/bad, right/wrong and letting the body guide what food to eat. It's about getting back in touch with the rhythm of hunger and fullness. For example, wanting a piece of cheesecake might be emotional, but it could just be our body saying, 'I'm behind in carbs and fats, and I need it.' It's learning to trust if you need it or feel hungry and already ate lunch."
Ornelas confesses that treatment is complicated and requires lots of coaching. Ann agrees but feels hope for her future. "Seeing Amy, I've had a significant shift in my self-image, even in the last eight months," she says. "If this is the sign, I'm confident today that one day I will be able to love my body no matter what shape it is, no matter what time of my life. Just the other day, for the very first time, I looked in the mirror and thought I looked cute. I'm at a point where I don't hate my body. And that's a huge shift when I can look in the mirror and say, 'I don't hate this.'"