With Body Dysmorphic Disorder, Acne Can Go Beyond Skin Deep

Trigger warning: This story discusses mental health disorders and suicidal ideation.

At 19, near the end of my freshman year at college, the first boy I ever loved broke my heart. That May, I experienced the mystifying world of breakouts for the first time: A smattering of fresh, fat whiteheads popped up on my cheeks akin to the appearance of stucco. Acne is a personal journey and isn’t necessarily a concern for everyone. But in my individual journey, I was mortified—extremely so. (Though they didn’t look “that bad” to my friends and family.) By summer, I’d launched a war on all things pimple, determined to eradicate this personally esteem-crushing plague with whatever cleansers and creams I could get my hands on.

I had no concept then of what I know so intimately now: That this hyperfixation on acne (or rather, my warped perception of it) has a name, Body Dysmorphic Disorder. Commonly referred to as BDD, Body Dysmorphic Disorder is a mental health condition defined by the Anxiety and Depression Association of America as consisting of “a preoccupation with perceived flaws in one’s physical appearance.”

“BDD occurs when someone intensely focuses on their appearance because they believe they have a flaw or defect in the way they look,” explains Michelle Goldman, Psy.D, a clinical psychologist at Columbia Health and Hope for Depression Research Foundation media advisor. “The flaw, however, is either not observable to others or is minor. This causes great distress in the individual, however, and usually results in specific repetitive behaviors, such as checking their appearance in the mirror and seeking reassurance from others about their appearance.” (Been there, done that, I thought the first time I heard a version of this definition while sitting on a therapist’s paisley couch.) “The disease can easily get worse over time if not addressed,” adds Goldman.

When I returned to Philadelphia for school that fall, my BDD diagnosis, made by a matter-of-fact clinician my mother begged me to see, inhabited me like a ghost. It has continued to do so, to varying degrees, to this day. I don’t know if I’m supposed to say that. At 27, nearly a decade after that dark time, I am, after all, supposed to be healed. Dropping out of school, considering suicide, attending residential treatment in Wisconsin for five months, graduating college, and going on to live what most would call a fun and fulfilling life—all these things are supposed to heal a person. Right?

As it turns out, not exactly. While I am incredibly fortunate to have gotten through the worst of this illness with nothing less than my life, I’d be lying if I said BDD concerning my acne—specifically the occasional closed comedones on my forehead that have remained my main obsession for the past six years—was no longer a struggle. In treatment, you learn how to sit with the thoughts and let them hiss as you live the life you desire and value. But while my worldview has widened significantly, it wilts back to the size of my face the minute my forehead breaks out.

Make no mistake: I am rationally, if not painfully aware that no one cares about these minuscule bumps (or even notices them) nearly as much as I do. Unfortunately, BDD does not care about rationality. All other priorities fall by the wayside in my pursuit to regain clear skin; I become anxious, antsy, and selfish. I stare at the mirror from all angles, willing the acne to disappear so I can just be happy again. And a sad, tired girl stares back, begging me to accept her. Or, at the very least, for our world to expand once more.

I understand that some may find it silly or even ridiculous to feel this way, especially amidst the #skinpositivity movement that has made brave, joyful waves across social media in recent years. Influencers I deeply admire (shoutout to @laviniausanda!) bear their “imperfections” with pride, reframing skin texture and acne as something not just to be normalized, but celebrated. To these content creators, I tip my metaphorical hat. “Happiness” and “clear skin” should not be synonymous. But while it’s easy to remind friends with such insecurities (online and IRL) that acne in no way diminishes their beauty or self-worth, it can be far more difficult to extend that same sense of kindness to ourselves, BDD or not. Ask how I know. 

Still, maybe this is where true healing lies: in treating ourselves with grace and compassion. Or, when that’s too hard, embracing a sense of body neutrality. This concept, often attributed to certified intuitive-eating counselor Anne Poirier, involves seeing the physical form primarily as a vessel, focusing on its capabilities and functions when the thought of loving your appearance seems entirely too much.

There’s an exercise I first learned in treatment related to this practice, and I swear it helps: I look in the mirror and catalog each facial feature—forehead acne included—without emotion, as though I am listing out pieces of fruit. It doesn’t always work, of course; such is the nature of mental illness recovery tools. And in my own experience, the peace it provides doesn’t last all that long. But if there’s one cliché about healing I’ve heard in my eight years of living with Body Dysmorphic Disorder that holds up, it’s that the journey to better mental health is anything but linear. Which, I’m beginning to realize, is actually OK.