Introduction

This piece explores how The Substance uses psychological horror to depict body dysmorphic disorder (BDD). Blending film critique with personal experience, it examines the film’s portrayal of self-perception and identity struggles.

The 2024 film The Substance takes a deeply personal approach to horror, intertwining identity and self-destruction in a way that feels disturbingly real. The film received overwhelmingly positive reviews, earning an 89% rating on Rotten Tomatoes and a 73% score on Metacritic. While many praised Demi Moore and Margaret Qualley’s performances, others criticized the film’s pacing.

Unlike traditional horror films that rely on external threats, The Substance shifts the terror inward, making the protagonist both victim and villain. Horror has long been a vehicle for exploring human psychology—films like Black Swan and The Babadook use horror to externalize mental illness. The Substance follows in this tradition but takes it further by making self-image the very thing that haunts its protagonist. Beneath its themes of societal pressure, the film presents a compelling reflection of body dysmorphic disorder (BDD), a mental illness affecting about 3% of the population.

BDD is a subtype of obsessive-compulsive disorder (OCD) in which individuals hyperfixate on perceived flaws. They may attempt to “correct” these flaws through excessive use of cosmetics, frequent exercise or avoidance behaviors.

For those who have never experienced body dysmorphia, The Substance may feel like pure fiction. But for someone like me, who struggles with both perfectionism OCD and BDD, the film felt unsettlingly real.

On the surface, my compulsions may manifest as wearing specific clothing or seeking reassurance about my appearance. Quiet struggles include avoiding mirrors and engaging in disordered eating, restricting certain foods or compensating for larger meals by not eating. The film captured what I believe is a universal reaction to self-worth being intrinsically tied to appearance. In the case of Elisabeth Sparkle and Sue, this internal punishment is projected onto another person.

The film strongly emphasizes Elisabeth and Sue as “one.” Elisabeth represents the individual who perceives their own flaws, while Sue embodies the disorder itself.

A key trait of OCD is the presence of intrusive thoughts—unwanted, distressing ideas that surface without warning. For someone with BDD, these thoughts might include:

I’m not pretty because of my size.

Other people are judging me

What if I lose opportunities because of my appearance?

For Elisabeth, whose career hinges on public perception, this fear isn’t just imagined—it’s reinforced by the world around her. Sue, however, continually amplifies these anxieties through her actions.

BDD fuels the pursuit of an unattainable “perfect self,” leading individuals to hide their perceived flaws, attempt to alter them or punish themselves for not meeting impossible standards. Instead of accepting their shared existence, Sue and Elisabeth see themselves as separate entities in conflict.

Sue tries to erase Elisabeth entirely—locking her away in darkness, disposing of her images and auditioning to replace her. But Elisabeth is not a flaw; she is a person obsessed with her own perceived imperfections. Their battle represents the internal struggle of self-acceptance—the inability to be authentic, the frustration of never reaching perfection, and the self-punishment that follows.

The film also fixates on certain sensory experiences, such as the unsettling scene where Dennis Quaid’s character eats. Though he is simply eating, the framing, sound, and atmosphere distort it into something grotesque.

This captures an overlooked aspect of OCD—the way fixation on certain sensory details can turn neutral experiences into sources of disgust or discomfort. What should be mundane becomes unbearable, mirroring how Elisabeth perceives herself in a way that others may not.

Despite being conventionally attractive, both Sue and Elisabeth tear each other apart. If they had followed the company’s advice and cared for each other rather than battling for control, their fates could have been different.

In the film’s finale, the monstrous form we see embodies this fractured sense of identity. While still hiding its flaws, it chooses to attend the New Year’s event, seeking acceptance despite inevitable judgment. Elisabeth’s final moments offer clarity—a moment of authenticity.

Following our passions, even in the face of criticism, is essential to self-acceptance. Perceived flaws may feel infinite, but our identity extends beyond appearance.

The Substance doesn’t offer easy answers, but it reveals a terrifying truth—when self-worth is tied to appearance, the real horror isn’t how others see us, but how we see ourselves.

What did you think of The Substance? How do you interpret its themes of self-perception and identity? Let’s continue the conversation in the comments!

Rotten Tomatoes & Metacritic Scores: Rotten Tomatoes - The Substance (2024) | Metacritic - The Substance

Body Dysmorphic Disorder Statistics & Information: Mayo Clinic - BDD Overview | American Psychiatric Association - BDD

Horror as Psychological Exploration: Psychology Today - Why We Love Horror Films