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Body Dysmorphic Disorder (BDD)
BDD usually starts in adolescence or early adulthood, and is a morbid intensification of the normal minor worries about the body, which are common at that age. Technically, BDD is a preoccupation with a nonexistent or minimal defect in appearance that generates significant distress or impairment in social, occupational and/or other important areas of life; and involves unrealistic beliefs in other people’s reactions to this ‘ugliness’.
People with BDD put a very large emphasis on their appearance and believe that other people evaluate them negatively solely on the basis of this appearance. Whether this is as shallow as in: ‘pretty people equals nice people’, or has a darker side where becoming the subject of attention raises social fears or the perception that the ‘deformity’ is a visual signal to prove internal badness, will be to do with the individual. Research suggests that 29% of people with BDD have other obsessions and compulsions completely separate from their BDD handicap and that BDD might even be classed as a more severe form of OCD. BDD should not be confused with vanity or ‘normal’ concern with one’s looks and appearance. It is also sometimes confused with Social Anxiety Disorder and research does suggest that BDD sufferers tend to be shy. Unlike people with Social Anxiety problems, the BDD sufferer does not tend to find the problem ‘silly’ and will be just as anxious when alone as when in company. He or she is also likely to become upset when the perceived ‘ugliness’ is mentioned.
‘Normal concern with one’s appearance’ is, of course, a subjective term. Over the past few decades’, the acceptability of concern about appearance has grown in Western cultures alongside the availability of clothing and cosmetics to achieve changes and improvements and the financial resources to purchase these.
At different times and at different ages we may all have an increase in our perceived need to ‘look perfect’ and many people have an ongoing dissatisfaction with their appearance that might stray into the regions of BDD on occasion. However, people with BDD will be spending at least an hour a day (and often very much more) checking in front of mirrors and other reflective surfaces (or avoiding these at all costs; or doing either at various times), camouflaging the perceived defect with excessive use of cosmetics, or inappropriate clothing such as scarves hats and sunglasses (inappropriate to the specific situation that is), avoiding social contact and suffering much internal torment and despair.
‘BDD preoccupations have been noted to structurally resemble
obsessions in that they are distressing and anxiety producing, persistent
recurrent thoughts that are difficult to resist or control.’
Looking at the literature, it is difficult to gauge where a preoccupation enters the world of obsession and then, sometimes, delusion. All levels of obsessional thinking have a tendency in that direction. Many people have come to Anxiety Care with ‘absolute’ beliefs in certain things: the requirement to be perfect with only total loss of personal value as an alternative; a belief that a certain activity has caused irreparable harm despite endless proof to the contrary; a belief that only evil people have negative thoughts. It goes on and on.
As delusions are fairly common in the general population, (one research project showed that nearly 10% of ‘healthy’ people had more delusional beliefs than the average score from someone with severe psychotic illness), it seems fair to conjecture that they are not an all-or-nothing concept; that they exist on a continuum of insight (how far we are able to judge their validity) that ranges from good through poor to absent altogether.
This might ease the minds of some people who visualise their disorder plunging them into psychosis that, to most, is synonymous with raving madness. A further comfort should be that BDD does not respond to anti-psychotic medication, but does to the SRI’s, which are the medications of choice for OC disorders.
The whole area of: ‘My BDD, is it or isn’t it delusional?’ is probably not worth too much attention unless a sufferer allows such feelings to take them into extreme remedies such as ‘self-surgery’ (picking or trying to cut out a perceived blemish), total withdrawal or acute depression. Research seems to suggest that higher doses of one or other SRI would be indicated in these situations.
Research further suggests that surgery is rarely useful. People with psychologically untreated BDD might then simply transfer to another bodily ‘abnormality’ or focus more on the surgically altered one, seeing it as still ugly and still in need of attention. There is anecdotal evidence that people who have surgery tend to gain little long term benefit because it is a symptom being treated, not the problem. In such cases, it would not be unusual to hear the person concerned, once the euphoria of having surgery has worn off saying that his/her life will be perfect once the nose/mouth/eyes etc have been really put right. Without adequate treatment of the BDD this ‘really’ might only stop when the money runs out or when surgeons refused to operate any more.
Like OC problems in general, reassurance or practical alterations to the situation; in the case of BDD, activity that colludes with the perceived need to hide the ‘deformity’, are very unlikely to work. The combination of cognitive behavioural therapy involving exposure and response prevention, plus medication is the treatment of choice.
There are differences between OC thinking and BDD thinking. The BDD thinker may view the thoughts as relevant to his or her personality and beliefs; and, although severe and debilitating, a ‘normalish’ part of life. The OC thinker on the other hand will invariably view the thoughts as intrusive and alien, nothing to do with his or her perceived once ‘true’ personality.
The OC thinker will also use ‘curing’ thoughts such as counting, thinking ‘good things’ etc. that are relevant to him or her but probably have little connection with the intrusive thought or thoughts that they are used to counter. The BDD thinker will invariably be focused on the perceived abnormality and all thoughts will surround this area and be totally relevant (to the sufferer at least) to the cause of preventing the abnormality being seen.
Then, although the BDD sufferer might indeed have ‘classic’ OC symptoms as well, the situation once encountered in a group can be understood. This was during a discussion about thought processes. Two people presenting with OC problems around thinking had both been asked to write down their thoughts by a therapist. The one whose thought processes were perceived as alien to his true character, had been horrified at the way one thought led to another. That is, when writing the thoughts down and the inevitable happened: ‘The therapist is going to read this, I’d better not think anything worse, like…oops!’ This person was appalled at his ‘evil’ and completely missed the fact that a worsening of thoughts and images was unavoidable once a process aimed at not-thinking worse things had been slotted into place.
The BDD sufferer, on the other hand, quickly understood the situation and stopped writing the thoughts down when it became obvious to her that it was the fact that these thoughts were going to be read that was making them more and more alien and embarrassing, not the content of her character. A discussion then began about how this situation could have occurred, so different between two people with the perceived same problem. The answer was, of course, that they did not have the same thinking problem. The OC thinker was locked into ‘bad’ thoughts as a sign of personal evil and so was super sensitive too, and invariably subject too, a series of such thoughts that, in reality, had no end.
The BDD thinker was only sensitive to thoughts that revolved around her ‘deformity’. She was capable of processing some ‘evil’ thoughts as a sign of low personal value and inadequacy as a wife and mother, but beyond a certain point had rational beliefs in her character. In short, she saw herself as worthless in many ways, but not evil or potentially out of control, while the OC thinker saw himself as basically worthy but becoming progressively more evil and coming closer to the point where he would lose control.
‘Non-psychological therapy in people with BDD may do more harm than good.’
Another difference between OC and BDD thinking is that the OC thinkers ‘curing’ thoughts and rituals are used to reduce anxiety, while the BDD thinker’s thoughts are not used in that way at all. The BDD thinker will be hyper vigilant with thoughts focused entirely on concerns about the abnormality. These thoughts will, like the OC, be maintaining the disorder but in a different way. The OC’s relief by ‘curing’ a bad thought with another keeps the disorder active, while the BDD thinker does not cure the thoughts internally, but uses physical camouflage to hide the manifestation of the fear, which only maintains focus on the abnormality, the thoughts about it, and the anxiety that goes with the whole process.
One researcher presents a series of ‘clues’ to the presence of BDD that, while not required as part of a diagnosis, might be useful for anyone concerned that he or she or a family member has this disorder. Below is a slightly abridged version:
‘BDD usually begins during early adolescence, although it can
occur in children and can also begin in adulthood. It appears to be
a waxing and waning disorder this is generally chronic. Other disorders
can co-exist with BDD and may be more obvious to…a casual observer
than BDD itself, which may be hidden. These disorders include depression,
social phobia, and obsessive/compulsive disorder, which may be closely related
A questionnaire that originated from worldcollegehealth.org suggested that BDD is a possibility if ‘yes’
is the answer to the following questions:
Research indicates that it can take as long as three months (or occasionally longer) for the SRI medication to work, as is true with all SRI medications, and that relatively high doses may be needed for BDD; and that improvement of symptoms may be gradual so patience is essential.
From Anxiety Care’s experience it is vital to talk to the prescribing physician, when taking medication, if any side effects problems occur (and they will happen, if they are going to, before the benefit is felt) as many people, not totally convinced that medication is the answer, use temporarily unpleasant side effects as an excuse to abandon medication.
Cognitive behavioural treatment is sometimes useful but will only be truly effective if the sufferer understands that his or her perception of the defect is exaggerated.
‘Supportive psychotherapy serves to create a positive environment
in which to apply other therapeutic techniques, but doesn’t seem to
work by itself. Other psychotherapeutic approaches (for example, insight-oriented
psychotherapy, diet and natural remedies) have not been shown to be effective
Another problem may fit in among the OC Spectrum disorders, possibly close to BDD: olfactory obsessions. This involves the sufferer believing that some part of his or her body is producing an unpleasant and noticeable odour. Anxiety Care has encountered this problem in a number of younger people and adolescents.
There is research that suggests that, for the olfactory obsessive, the level of anxiety generated by social situations and the tendency to assume judgments of ones value as a person will be made by outsiders around the ‘fact’ of this smell, make it very close to BDD. Intense anxiety, hyper vigilance, shame and the need for reassurance are all similar to BDD with more similarities to this disorder than to classical OCD.
The treatment approach is much the same as for BDD. Sufferers must be helped to understand that their bodies will, occasionally, produce odours, just like everyone else’s, but that this is not a sign that the belief was true and that eternal vigilance should be maintained. Sufferers have to be helped to accept the disorder as a disorder, and to live with the possibility that the problem exists – nobody will guarantee them permanently freedom from bodily odour.
As mentioned earlier, our current culture puts much emphasis on looking good and this includes smelling good, so a minor level of olfactory worry may not be unusual. A recent episode of a popular television series featured a character, after being prevented from bathing for a modest period, stating that she smelt and that she hadn’t been aware that her body was capable of producing such an odour. This was obviously played for humour but was the more funny for portraying an almost-believable attitude in a certain type of person.
So olfactory obsession is, again, something that most of us might mistakenly believe we can relate too – we don’t like to smell. However this will be to an olfactory obsession as the proverbial tension headache is to a skull splitting migraine. People at the tension headache end of the continuum do not ruminate endlessly about the problem or spend much time trying avoiding social contact or watching surrounding activity (wrinkled noses, opening windows, ‘odd’ looks) for proof that the obsession is a reality.
Olfactory obsessives will probably need to be helped to take practical steps such as reducing bathing, reducing excessive use of deodorants and gradually getting used to the idea that they can tolerate the possibility that they have an odour and that this is not the end of life as they know it. And, as always, the mark of recovery is not the extinguishing of the belief, but the perception that it doesn’t matter one way or another.
Like all obsessional thinking problems, the need for a 100% guarantee
of immunity from fear is not the target, relief comes from accepting the
response at whatever level it settles down to (maybe, with olfactory problems,
you will always be a bit more concerned than most about your body odour)
and understanding that this is just life and doesn’t stop it being
liveable unless you choose to make it so.
SOME TREATMENT SUGGESTIONS
As mentioned, BDD sufferers may respond to one or other of the SRI (Serotonin Re-uptake Inhibitor) anti-depressant medications, which often work well on mixed anxiety, obsession and depression. Exposure treatment can work too, especially in overcoming social aspects of the problem (see the leaflet on social phobia).
A standard exposure programme of the type used in behavioural therapy cannot be offered here for all BDD problems of course; but, for example, someone who wears excessive makeup might be gently persuaded or helped to gradually reduce the amount used over a period of weeks by a small further reduction every day. Starting with what she can just about tolerate and working up in gentle steps; cutting some steps done into mini-steps if they present a problem. As said in other literature, there are no prizes for getting better the most difficult or painful way
A person who spends many hours a day looking in mirrors (see Rachel’s story below) could be helped to reduce these periods by a small amount every day using, for example, a kitchen timer to take, for example, two or three minutes off every subsequent visit to the mirror. This technique might also be used where the person spends long periods of time putting on makeup in front of a mirror every day. If, as mentioned, the BDD sufferer alternates between excessive mirror gazing and avoiding them at all costs, the presence of a small mirror in a room could be negotiated and the sufferer could them be helped to pass close to it and then tolerate looking into it for gradually lengthening periods. Suddenly producing a mirror in front of a BDD sufferer with this aspect to the problem is not a good idea. It is likely to make him or her lose trust in the person doing it and anyone helping a sufferer with an exposure programme has to be totally trustworthy.
Where odd or excessive clothing is concerned, the person might be encouraged to wear less – indoors at first, then on short outings in very familiar surroundings; working up to longer and longer journeys and more and more practical clothing. It should be borne in mind however, that where excessive and odd clothing is used, reducing one might not automatically make it easier to reduce the other. So the person might be at different recovery points with the different problems. For example, able to go out in clothing more suitable for the season, but still wearing too much of it. This might seem odd to outsiders, but nobody observing or helping a BDD sufferer should try to apply his or her own personal logic to the problem. The family and the helper, if there is one, are working with the sufferer’s reality, not the other way around.
Journeys out might also require the support of a trusted friend at first. Here, the friend would accompany the sufferer on each journey, ready to chat or distract the person if problems are foreseen (but not too much). The friend might then walk a little apart from the BDD sufferer as confidence grows; then further and further apart.
The friend must treat these tasks very seriously if they are undertaken. He or she must concentrate on the subject, no wandering off or looking in shop windows. A balance has to be attained where the friend does not show over concern that might trigger anxiety in the subject, but is attentive enough to note possible problems ahead such as shop windows (reflections), or large numbers of people (particularly children who might make fun of somebody wearing excessive makeup or odd clothing). If the sufferer is in the habit of seeking a great deal of reassurance from the friend or family before and during exposure tasks such as this, or during normal activity, families and friends can be helped to learn to refuse this. Reassurance does not relieve the condition but, in the long term, strengthens the anxiety as it works against the sufferer using his or her own strength and determination to endure the physical and/or mental feelings engendered by the anxiety.
To deal with excessive reassurance seeking, families (or friends) might practise with the sufferer (on a good day) saying something like: “We agreed that I would not give you reassurance”; or they might negotiate with the sufferer over very serious difficulties by agreeing to reassure once only. It is important that this scenario is an agreed one and that the sufferer is not bullied into accepting less reassurance. Trust is an important part of recovery when families are involved with it. The person with BDD will almost certainly already have low self-esteem and be concerned over upsetting family members. He or she might well reduce reassurance seeking for a while if bullied or shouted at, but this will be for personal reasons and have nothing to do with recovery.
Exposure work should be undertaken for an hour or so every day. It should also be noted that large amounts of anxiety are no better than small amounts when trying exposure work. In fact, large amounts might actually work against the sufferer trying again; for who wants to spend a great deal of their time very frightened?
It is also useful for the sufferer to keep a journal, noting down every exposure activity and the level of anxiety experienced each time, where 10 is as high as can be imagined and 0 is none at all. So, for example, minor anxiety might be noted as 2 or 3 and medium, 4 or 5 etc. Most people quickly become expert at recording their anxiety levels accurately. This helps because a person undertaking an exposure programme sometimes misinterprets improvements or manages to persuade him- or herself that something attained is not an improvement at all. Looking back over a journal that details feelings and fears and how they were perceived at the time, counters this.
However, it must be borne in mind that (in general) people with BDD tend not to believe that their fears are unfounded, and thus they may not be willing to undertake exposure work – at this point anyway. When they do agree to do so, it can be a slow business.
If there is a very minor blemish that has grown in the person’s mind to dysmorphic proportions and this is the only area in which the sufferer has problems (that is, he or she does not have a range of body parts that cause anxiety), referral to a plastic surgeon might, just might, be the answer; but a more appropriate referral in most cases would be to a clinical psychologist or psychiatrist who understands this condition. As said earlier, someone who has totally unrealistic concerns about a body part, or many areas of the body which cause anxiety, would almost certainly not be aided by one surgical response; and once started it might be difficult to stop.
Rachel, a married woman with two teenage children, has had BDD problems with her eyes since her teens. She recalls once being teased badly over the shape of her eyes at school and remembers the problem growing from there.
She began to worry about their shape and how red they seemed to look at times (she had a tendency to skin irritation in that area which added to the problem), feeling that people would notice this and find her strange and unattractive. This was not vanity or a desire to be extremely sexually attractive, but a belief that people might be able to detect how bad she felt about herself.
She would spend great lengths of time looking in mirrors, scrutinising her eyes. This occurred at home, at her place of work and in any outside environment where mirrors were available.
At one point, she had noted the existence of every mirror and mirrored surface available on her normal daily travels and looked at them all, taking very long periods of time to complete the simplest of outdoor activities.
In desperation, her family locked away all the mirrors in the house. However, she then began to look at her eyes in other surfaces such as knife blades, spoons, even the washing up water; and she would seek out mirrors when the anxiety was very high, finding where her husband had hidden his shaving mirror and using this.
She was in the habit of seeking reassurance from her husband that her eyes didn’t look strange or red. When he became upset by this and refused to continue, she then sought the same help from her young children; This made her feel as if she was abusing them and added to her anxiety and feelings of low self worth.
Even when she was aware that the ‘reassurance’ the family was giving was annoying them and that they were giving it without really looking at her, she still continued until shame and humiliation made her stop each time.
She determined to make it up to her family by becoming the best mother she possibly could in other areas. This lead to a great deal of extra work, then extreme tiredness and more anxiety.
Rachel had to give up her job because of the anxiety and depression generated by the problem, but this did not ease the BDD. Every day was a nightmare. She felt compelled to look in mirrors for long periods, but also tried to avoid them, knowing how long and how anxiety generating the process would be if she ‘succumbed’ when away from the house, regularly having to convince herself that a chance reflection in some surface did not require her to linger for long periods looking at herself. Sometimes she felt that she was humiliating herself in front of people by doing this, but often the anxiety was so high that she did not care.
In this way, Rachel spent many years of her life. She undertook several types of psychotherapy both as an inpatient and as an outpatient, but nothing really worked. Eventually she joined an Anxiety Care support group. Over a period of two years, she began to rebuild her confidence through group discussion and one-to-one counselling.
Eventually she took on small responsibilities and began to work at helping other people, many of them with obsessive/compulsive disorder (OCD). Though none of them had a BDD condition, many of the obsessive and compulsive activities described by these people were very similar to her own problems.
Rachel is showing steady improvement. She has had a number of quite severe ‘normal’ problems in her life over the past year or two but has dealt with them well: they did not push her back into BDD habits, which is a good sign that major changes in perception and improvements in self-value have been attained.
OCD & OC Spectrum
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