How Face Masks Became a Coping Tool for People With Body Dysmorphia

April 4: That's the first day this year Dalia left her house in daylight. She remembers because it was the day her face mask arrived in the mail. Before that, she could only venture outside after sunset, disguised by darkness—her fear of facing the world blunted by the fact that the world can’t see her face. 

But when the COVID-19 pandemic made face masks mandatory in public settings, Dalia was able to walk in the sunlight without crippling anxiety. She paused when she first stepped outside, disoriented by the California sun. She had forgotten what sunshine feels like. 

“What you see in the mirror is not what others see when they look at you,” Dalia recalls her psychiatrist telling her at 16. She was diagnosed with body dysmorphic disorder (BDD), a psychiatric illness involving an intense, debilitating preoccupation with a perceived flaw, usually in the facial region. Dalia remembers staring at her hands—bruised and bandaged from breaking her bedroom mirror earlier that week—as her psychiatrist discussed treatment options.

For years, Dalia confined herself to her house, only taking on remote jobs, the world outside her door relayed to her through newspaper headlines and social media posts. She didn’t want people to see her skin, which she says is deformed in texture and marred by acne scars, her nose, which she says is three sizes too big for her face, and her mouth, which she says is so small and mouse-like that she is afraid to draw attention to it by speaking.

“I always felt like people were staring at me in disgust, and I just couldn’t do it anymore," she tells Verywell. "I couldn't handle the anxiety of being outside. I couldn't handle people seeing me as a monster."

Therapy didn't ease her symptoms, and antidepressants only made her sleep more and eat less. Somehow, though, she's found a makeshift remedy in the form of face masks. They’ve served as a situational blindfold that prevent people from seeing her perceived flaws. Dalia says that face masks have helped her carve out a quiet existence outside of her illness. And she's not the only one. Multiple people who experience face-related BDD are discovering a protective effect from face masks. 

“Face masks have made my life so much easier. It’s like I can breathe. I can go to the gym without feeling like people can see my face. I can do other activities without feeling like the whole world sees my flaws. Even if people stare, I feel okay because they can’t really see me,” Lauren, a brand manager in Florida, tells Verywell. “If there was an option to go around town without people actually seeing you, I would have taken that option a long time ago.”

Jaime Zuckerman, PsyD, a clinical psychologist based in Pennsylvania who treats anxiety disorders such as BDD, tells Verywell that there is a scientific backbone to this phenomenon. 

“On a surface level, wearing a mask will temporarily reduce the frequency of checking behaviors, the need for social referencing, and obsessive thought patterns," Zuckerman says. "Because everyone in their environment is wearing masks, the actual number of facial features that are publicly viewable is the same for everyone. So, in a sense, the differences in facial features have been removed. The aesthetics have been neutralized. Everyone is covering their face except for their eyes. Facial differences, as well as the opportunity for BDD preoccupation, is greatly minimized because of this now neutral playing field. No one stands out from the crowd.” 

Dismantling Coping Rituals 

Patients with BDD see themselves as extremely deformed and unattractive, even though any "flaw" in their appearance is usually minor or can't be seen by others. To cope with intrusive thoughts, they respond with compulsive behaviors: layering on makeup, repeatedly checking mirrors, seeking out cosmetic procedures, and avoiding social settings. These rituals temporarily reduce their psychological discomfort and therefore become hardwired into both their brains and their routines as coping strategies. 

However, Zuckerman says that these ritualistic behaviors are not sustainable, and instead make patients’ negative emotions and thoughts related to their BDD more pervasive. 

“One aspect of this vicious cycle is the associations that people make between neutral stimuli and the removal of internal discomfort. For example, checking a mirror a specific amount of times—let’s say five—temporarily reduces anxiety," she says. "What begins to occur, however, is the person starts to believe that it is the actual checking of the mirror five times that is responsible for the anxiety reduction. This leads people to create illogical associations which may lead to magical thinking, like, ‘If I step on an even-numbered step something bad will happen.'"

In many cases, face masks reduce the occurrence of these ritualistic behaviors by generating an environment that can’t create and contain these illogical associations. People with BDD stop searching for their reflection on every surface if they know their face is covered. In some ways, Zuckerman says, this is a step toward healing, because dismantling compulsive rituals helps reduce internal discomforts like sadness and shame. 

Such is the case for Emma, a retired high school librarian based in Canada, who has a severe form of BDD centered on her skin, nose, teeth, and body. For years, she's designed her life around very strict rules in order to shield herself from the trauma of self-exposure. She skips birthday parties, funerals, and family gatherings. She doesn’t let anyone see her stripped down or in swimsuits. She spends hours applying and reapplying makeup. In the end, she says her endeavors are fruitless, but she can’t stop herself from repeating them. She describes them as OCD-like compulsions. 

“I have wasted hours, days, weeks, months, and years obsessing, avoiding, hiding, ruminating, crying, canceling plans, buying useless products, and generally feeling miserable because of my BDD,” she tells Verywell. “But things are easier now. I never went out without makeup pre-COVID, but now with masks, I can. Masks are freeing. They make me feel less judged, anxious, and scrutinized for my appearance.”

Dissolving coping rituals like Emma’s is a key element of exposure therapy, which is one of the main forms of treatment used for BDD. Here, psychologists create a safe environment and then slowly expose patients to their fears. The goal is to eventually have the patient confront their fears without relying on their compulsive behaviors as a crutch.  

However, Zuckerman points out that there are limits to this. Even though BDD patients are being exposed to their fears—in this case, the anxiety associated with their faces being seen in social settings—they are only doing so because they are cloaked in masks, and therefore in a false sense of security.  

“While fears are being slowly faced during COVID with the help of wearing a mask, the fear that people with facial BDD are being exposed to is, in a way, a watered-down version of their actual fear,” she says. “I would compare this to a person doing exposure therapy for an elevator phobia, but while doing their exposure, they take a benzodiazepine to reduce their anxiety. Therefore, the fear that exposure therapy is targeting has been muted from the start and is not an accurate representation of the true fear the person feels when having to ride an elevator.”

She says that as a result of this, people with BDD may simply retreat into their ritualistic compulsions once the masks come off: with Emma, for example, hiding her face behind heavy layers of makeup, and Dalia avoiding the hours between sunrise and sunset.

Looking Beyond the Surface

The question that persists for these patients is if it's possible to retain any of the benefits derived from masks once they no longer have to wear them in a post-COVID-19 world.

Julian, a military sergeant based in Florida, desperately wants that to be the case; but isn't too optimistic after agonizing over his BDD for the past 14 years. He thinks his teeth are too big for his mouth and that his jawline looks garish and unstructured.

“There’s a lot of comfort in wearing a mask in public: I feel like I don't have to worry about what people see because they can’t see a whole lot," he tells Verywell. "Unfortunately, I’m pretty sure my obsession with people’s thoughts about my looks will come flooding back once the pandemic ends."

However, there may be some strands of hope. The same mechanisms that reinforce compulsory behaviors in people with BDD could be the same mechanisms that undo them.

“When those with BDD venture out wearing masks, their social behavior is subsequently reinforced by others," Zuckerman says. "Even though the comfort they feel is a temporary one facilitated by the intended function of a mask, this social reinforcement makes it more likely they will engage in social behavior in the future. It could be that the social reinforcement and new experiences people with BDD are now getting will be enough of a reinforcer to take their masks off socially post-pandemic.” 

While BDD can be an extraordinarily difficult disorder to treat, one therapy that Zuckerman finds beneficial is Acceptance and Commitment Therapy (ACT), which trains patients to tolerate their thoughts and fears as opposed to avoiding or masking them. One vital component of ACT is “value-based living,” which teaches patients to de-emphasize the role of their appearances by seeking out meaningful experiences and connections.

The idea is that if patients have enough exposure to positive events without their distorted thinking sullying their experiences, they might find a way to climb out of their illness.

Dalia has never tried ACT, but she says she can understand how it may help someone like her. Since April, she's found solace in small moments her BDD would have otherwise prohibited: riding her bike around the Newport Beach Pier, hiking up nearby hills with her sister, sitting in front of the ocean with her favorite book in-hand.

While they're not a miracle cure, Dalia says that these experiences are reminding her that she can still find beauty around her, even if she can’t find it within her. 

Dalia's BDD symptoms began after her high school boyfriend told her she should see a dermatologist and then broke up with her shortly after. She was convinced he left her because of her skin and stubbornly viewed herself through that lens of deformity in the years after.

But last month, while watching the sunset cascade over Catalina Island with her best friend by her side—skin freshly sunburnt, mouth sore from laughter—she remembered that there was life before her BDD.

"So maybe there can be life after," she says.

The information in this article is current as of the date listed, which means newer information may be available when you read this. For the most recent updates on COVID-19, visit our coronavirus news page.