Why does this woman think she is ugly?

Alanah has occasionally taken 200 selfies a day, and deleted all of them

Alanah thinks she is ugly, which could not be further from the truth. She suffers from Body Dysmorphic Disorder (BDD), a condition that causes people to become obsessed with perceived defects in their appearance. It's thought about one in 50 people suffer from BDD, but many of us - and even some doctors - are unaware of its existence.

"I thought it was cruel for other people to have to see my face, that it really is disgusting," says 20-year-old Alanah.

"I see marks all over my face, which my mum has told me that she does not see. I see my skin is just bumpy and blemished. I see my nose is way too big and crooked and sticks out too much. My eyes are too small."

Alanah is a beautiful young woman, but when she looks in the mirror she does not see what others see.

She suffers from Body Dysmorphic Disorder (BDD), and when her condition was at its worst she repeatedly checked her appearance in the mirror, taking pains to disguise any flaws she thought she saw. Her make-up routine could take up to four hours, and even after this she often felt too anxious to leave the house.

"My routine at the time was four or five layers of foundation and concealer. Eye make-up always had to be done as well, very heavy eye make-up, and it would just be constant," says Alanah. "So every little imperfection I'd have to keep touching up and keep going over and doing the same thing again and again."

She would also pick her skin - picking at any blemish until the skin was broken and raw.

As a curly haired little girl she was happy to be photographed and to appear in the family photo album, but at the age of 14, things began to change, for reasons she has never quite understood.

"I didn't notice [the signs] at the time but looking back now I know that they're symptoms of BDD. For example, I'd be in school and I'd be very aware of my surroundings. I'd be looking around to see who was looking at me, to see who was laughing, to see who was talking," she says.

"There were big windows in my school. I'd be looking in the windows to check the way I look. I'd go to the bathroom a lot more often, to mirror check."

At the age of 15, she stopped going to school. Her mother, Scarlett, would drive her in, but Alanah - despite her eagerness to study - would not get out of the car. They would drive home and then get back in the car to have another try, but once again Alanah would be unable to get out. The exercise could be repeated as many as eight times per day, Scarlett says.

This led to Alanah becoming very isolated, and it was devastating for her mother to observe the change in her character.

Find out more

No Body's Perfect with Rankin and Alison Lapper will be broadcast on Thursday 17 November at 00:00 GMT on BBC Four. You can also view it now on the BBC iPlayer (in the UK only).

"For the first two or three years we just didn't know what it was," says Scarlett.

"From being a high-achiever, very confident, she just imploded really, couldn't get out. I had to bath her, I had to get her drinks. She was just in bed all day long.

"It's heartbreaking because I know every mum thinks their children are beautiful, but there is literally nothing wrong with Alanah and I think everyone can see it," says Scarlett.

"It's so frustrating, and actually now I know not to fight if she says she's ugly, I just have to not keep going on about it. It's what she sees and that's it, and I have to leave it and try to focus on other things.

"The worse thing is that, as a mum, you're meant to protect your children and help them and I just felt totally helpless not being able to do anything for her."

Scarlett says her daughter would get upset if she ever displayed a photograph of her in the living room, so when friends she had not seen for a long time asked what her children looked like now, she had no images of her daughter to show them.

It took a long time for Alanah and her mother to get a diagnosis of BDD. Alanah was misdiagnosed many times as having teenage angst or social anxiety until finally her condition was correctly identified at the Maudsley Clinic in south London. Her recovery began during a five-month stay at the North London Priory and she now has regular cognitive behavioural therapy sessions.

Despite having not wanted anyone to take her photo since her early teens, Alanah courageously decided to confront her condition for a new series, No Body's Perfect, on BBC Four. She agreed to a photo shoot with the portrait and fashion photographer, Rankin, in order to raise awareness of BDD, and to help others recognise similar symptoms in themselves.

She says getting a diagnosis of BDD is difficult because there is such little awareness of the disorder - but also because sufferers are so ashamed of their appearance that they won't talk openly.

"So my main appearance concern is my nose, but it took me three years of therapy to even tell my family or my therapist that that's what it was. I didn't want to point it out," she says.

The photo shoot was never going to be easy for Alanah as she habitually rejects all photographs of herself. On some days she used to take more than 200 selfies of herself and then delete them all.

It is not unusual for someone with BDD to assess their appearance by taking pictures of themselves, says Rob Willson, a cognitive behavioural therapist and chair of the Body Dysmorphic Disorder Foundation. But having a photograph taken by someone else can be quite threatening because it is out of the person's control.

According to Willson, BDD often begins in adolescence and can sometimes be a response to bullying and teasing. It can also be related to something that makes a person feel different. So, for instance, developing acne could make someone feel like they stand out and trigger it.

"We all end up worrying quite a lot more about how we look in our teens, but specifically BDD separates itself out from everyday concerns [in that] the person would have to be preoccupied with their appearance for at least an hour a day," he says.

"It has to cause significant levels of distress - such as high levels of anxiety, high levels of shame or depression - and it also has to be bad enough to interfere with the person's functioning."

Social media made Alanah's disorder much worse because she would constantly be comparing herself to others her own age. But Willson says although today's image-obsessed culture has changed our behaviour and we now act like mini-celebrities, taking selfies instead of looking in a pocket mirror, we cannot pin the blame on social media.

"There are so many other factors - genetic factors, social factors, early-life experiences, personality variables - that go up to make a problem that is as severe as BDD," says Willson.

The nature of the disorder means a person thinks they have a physical problem rather than a psychological problem and so they may spend lots of money on makeup or cosmetic surgery. But without proper treatment, it can have far more devastating consequences, he says.

"It's one of the highest-risk problems of all psychiatric disorders," says Willson. "With one of the most extreme high risks of suicide, functional impairment and distress."

On the day of the photo shoot with Rankin, Alanah's mother said she had doubts whether her daughter would go through with it.

"I knew that she was going to tell Rankin that she doesn't like photos," says Scarlett, "but it wasn't the photos, it was herself in the photos she didn't like."

Although it was a struggle, Alanah came face to face with her disorder, by allowing someone other than herself to do her make-up and hair for the first time and allowing Rankin to photograph her.

The photograph of Alanah taken by Rankin is now hanging in her family home

"Towards the end of it I did feel a bit more comfortable and I'm really glad I did it. Now looking back I'd probably love to do it again all over but this time slightly more confident and less anxious," she says.

Remarkably, the picture is now hanging in Alanah's family home.

"I think it's very beautiful," says her mother Scarlett, "I think it's also captured her vulnerability a bit."

Alanah's recovery is going well, she is now at university studying psychology and hopes to go on to research BDD for a PhD. She also aims to become a cognitive behavioural therapist helping others with the disorder.

And what does she think of the photograph Rankin took of her?

In No Body's Perfect, in footage filmed soon after the photo shoot, she says: "My eyes are crossed, my hands and my arms look really big and chunky. My nose looks crooked, my face is out of proportion. I don't necessarily know if I can see myself very positively yet."

A few months later, she is more upbeat.

"It does change from day to day," she says. "I've let them keep it up in the living room, which they didn't think they'd be able to do. And I'm OK with it, so that's a good step."

No Body's Perfect with Rankin and Alison Lapper will be broadcast on Thursday 17 November at 00:00 GMT on BBC Four. You can also view it now on the BBC iPlayer (in the UK only).

For more information and support:

Body Dysmorphic Disorder Foundation

Mind

Help for BDD

OCD UK

OCD Action

The second International Conference on Body Dysmorphic Disorder will take place in London on the 26 November.

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