Body dysmorphia disorder: People with BDD share torment of perceived defects in appearance.

Image: ABC

“You’re beautiful” is a phrase Melbourne woman Bessie has heard many times, but the 23-year-old has always struggled to believe it. Instead, a body image disorder has made her believe she was so ugly that she considered taking her own life.

Body dysmorphic disorder (BDD) is a mental illness that involves an obsession with perceived or imaginary defects in a person’s appearance.

For Bessie, it began 10 years ago with a fixation on her nose, then her skin.

“The mirror became my best friend and my worst enemy. I was disgusted by what I saw, but at the same time I sought reassurance and thought next time I looked I might get that reassurance,” she said.

By the age of 14, she was determined she wanted cosmetic surgery.

“I started saving for a nose job when I was 13 or 14 — it was my plan for as soon as I turned 18.”

Bessie’s desire for cosmetic surgery came long before she sought psychological treatment, and presentations at doctors failed to recognise her disorder or offer appropriate treatment.

Being unable to access the surgery as a minor, she sought temporary relief by covering all mirrors and reflective surfaces in her family home with newspaper — but the solution was short-lived.

Like many people with BDD, it took years for Bessie to recognise her battle was internal and could not be resolved by changing her appearance.

“As I got older I realised it wasn’t just something wrong with me physically, it was the way I was processing my feelings and the way I related to myself,” she said.

“A lot of the time I would become hysterical and I felt like there was nothing I could do to change it because it was who I am.”

Last year, her disorder took such a grip that Bessie feared for her safety and sought psychiatric help to protect her from hurting herself.

“I ended up in hospital for the fifth time — I felt like a failure and that I never could get it under control.”

Recovery sparked by solidarity with others experiencing BDD.

The one thing that kick-started Bessie's recovery was meeting other people who experienced body dysmorphia through a Melbourne-based support group.

"When I went to the group I cried the entire time — everything that was said resonated and I'd never heard those things said aloud before, only in my mind," she said.

At the group, 57-year-old Paul also sought relief, more than 40 years after his battle with BDD began.

For Paul, his skin colour was the focus of the disorder and he spent years going to great lengths to cover or darken his skin because he felt it made him abnormal to be fairer than average.

"I was aware of it when I was 15, not that I could put a label on it but something was definitely wrong because my body image I thought was unacceptable," he said.

"I spent many years, decades really, living a debilitated life. I've never married, and socially ... I put it down to BDD."

Paul spent nearly two years in almost complete isolation, too ashamed of his appearance to leave the house.

He said meeting others with BDD had been key to overcoming the disorder, along with a determination to investigate his identity.

"Am I just what I think about my body? Well that doesn't seem right," he said.

He and other members of the support group have started the website Seeing it Through Our Eyes where they share their stories and connect with others.

Cosmetic surgeons on frontline of serious mental illness.

One of the support group's facilitators, counsellor Roberta Honigman, began treating people with BDD after working as a counsellor for cosmetic surgery patients.

"I started to realise there was a theme, and that it was BDD," she said.

"It's not about weight or size, it's more about shape, how people perceive themselves ... people become fixated on an aspect of their appearance and it becomes the root of all things bad in their lives."

Ms Honigman developed a non-compulsory screening tool for cosmetic surgeons to help identify patients who may be at risk of BDD, because she said often they were the first medical points of contact for sufferers.

The Cosmetic Physicians College of Australasia (CPCA) said it supported teenagers having a three-month cooling-off period before undergoing cosmetic surgery but left this to the doctor's discretion.

In a statement, CPCA spokeswoman Dr Cath Porter said it was also "essential" that patients of any age have a medical assessment before surgery that deemed them psychologically suitable for treatment.

"If a cosmetic physician suspects that a patient is suffering from body dysmorphia they can then refer them to a psychiatrist or psychologist for specialist assessment," Dr Porter said.

Ms Honigman said the birth of social media had intensified the experiences of people with BDD — a pressure Bessie can relate closely with.

"It really enables you to be constantly comparing yourself," she said.

These days, though, Bessie feels she understands the disorder well enough to develop her own ways of coping with it and accepting her appearance.

When asked what she sees when she looks in the mirror today, Bessie said she still saw imperfections but glad she never went through with cosmetic surgery.

"I still have days I'm not happy with how I look, but I'm more able to let go and focus more on things I do like about myself."