By Scott M. Granet, LCSW

	Introduction
	Case Example
	Prevalence
	Indications of Body Dysmorphic Disorder
	Considerations for Treatment
	Conclusion

 

Introduction

Putting on make-up. Looking in the mirror. Brushing teeth. Combing hair. Billions of people worldwide perform such mundane tasks everyday without experiencing any significant distress. Suppose, however, you see your reflection in the mirror and feel a sense of disgust about your appearance. You feel you look so awful that to go out in public seems too overwhelming, too frightening. Having a relationship feels nearly impossible, and being able to concentrate well enough to perform on the job or at school is a daily challenge. As a result you become nearly housebound, depressed, and have thoughts of suicide. It is at that point that you may feel like millions of others who have body dysmorphic disorder, also called BDD.

Case Example

Sarah is a 23-year-old woman who believes she has had BDD for the past eight years. When she was 15-years old she began obsessing over the shape of her nose. She had plastic surgery at 18. Two other reconstructive nose surgeries followed because she was unhappy with the results. Although many men her age feel she is attractive and often express interest in her, Sarah has stopped dating, and now rarely even goes out with her girlfriends. Obsessions over her skin and her cheekbones have also surfaced, and she has also sought consultation to have those perceived “flaws” corrected with surgery. She continues to use multiple skin care products to cover minor acne scaring, and is exploring the possibility of a cheek implant to correct what she believes to be an asymmetric appearance of her cheekbones. She has had several bouts of major depression, and has admitted herself on two occasions to a psychiatric hospital because she was seriously considering committing suicide, and she suffered one overdose of her anti-depressant medications.

Prevalence

As many as three to five million people in this country are believed to have BDD. It is known to affect men and women equally, and the most likely age of onset is during the early teen years. If BDD is believed to be so common then why aren’t more people familiar with it?

First, since many BDD sufferers experience tremendous shame over their appearance, they may choose not to reveal their concerns to anyone, including their therapist. Second, they may first pursue dermatologic treatment or plastic surgery, not recognizing that what may be wrong is more psychological than physical. And even when they do seek psychiatric care, they may pursue treatment for the depression, anxiety, and functional impairments which have resulted from the disorder, rather than treatment for the disorder itself. Lastly, many psychotherapists and physicians remain unskilled in assessing for the presence  of BDD.

Indications of Body Dysmorphic Disorder

While the focus of a person’s BDD can be any part of the body, the most common areas of focus are the head and facial features. Skin, hair, and the nose are the body parts most often of concern. Other areas, however, can also be the focus, such as weight, stomach, breasts, eyes, thighs, and teeth. If the concern is skin, the fear may pertain to skin tone and wrinkles, with hair it may pertain to thinning, and with the nose the concern may pertain to it being misshapen.

BDD involves much obsessional thinking over the body part, to the point where someone may obsess over it for hours each day. There are also numerous behaviors which may suggest the presence of BDD, such as mirror checking or mirror avoidance. Checking of one’s reflection, however, doesn’t have to stop with mirrors, as many other objects have reflective surfaces. These may include glass picture frames, store windows, and even watch faces.

In addition, people with BDD often engage in “camouflaging,” which refers to attempts to try and mask the body part, such as with the excessive use of make-up if the concern pertains to the skin, or wearing a hat if the fear is associated with hair.

Many people with BDD also will compare their body part(s) to those of others, such as friends, family members, or people in the public eye.

Excessive grooming can be another problematic behavior, whether it pertains to combing hair, shaving, or putting on make-up. Touching the body part, and skin picking are also fairly common as well. In an attempt to correct the supposed “flaw” someone may pick at their skin to try and remove a blemish, for example. Unfortunately, this often may result in exacerbating the situation instead of improving it. Reassurance seeking is also a frequent behavior, though typically this results in only temporary relief at best.

As indicated above, seeking unnecessary medical appointments and procedures can be another troubling behavior. Dermabrasions, breast surgery, and rhinoplasties are among the most frequently sought procedures.

Muscle dysmorphia is a form of BDD believed to affect mostly men who believe that their body build is too small. As a result, they may engage in excessive exercise, and in the use of supplements and steroids at potentially dangerous levels.

It is critically important to recognize that BDD rarely exists without the existence of other psychiatric disorders. Major depression and social phobia are quite common, as are suicidal thoughts. In fact, it is believed that as many as 25 percent of those with BDD have made suicide attempts. Given this figure, the risk of suicide may be greater in BDD than in any other psychiatric patient population.

Considerations for Treatment

A combination of medication and cognitive-behavioral therapy (CBT) is widely regarded as the best treatment approach for the vast majority of patients with BDD. When medications are prescribed, the first line approach is usually with the anti-depressants in the class known as serotonin reuptake inhibitors, such as Celexa, Lexapro, Luvox, Paxil, Prozac and Zoloft. (The drug Anafranil,  a tricyclic antidepressant,  also acts on serotonin and is  effective in treating BDD.)   The use of cognitive-behavioral therapy to confront maladaptive thought patterns, and the many problematic behaviors is equally as important.

Cognitive Behavioral Therapy is used to encourage clients to recognize the irrational nature of the thoughts about their appearance, and to engage in a behavioral modification technique known as exposure and response prevention. Highly trained clinical social workers can provide this therapy.

Cognitive Behavior Therapy involves having the person confront the behaviors, such as mirror checking and camouflaging, and then having the person resist the urge to engage in them. This may include, for example, going out in public wearing less make-up or perhaps none at all. The essence of this treatment is for the patient to learn that their concerns about appearance are excessive and beyond what is normal. Also, learning that life can be meaningful without having to alter one’s appearance is a necessary goal of treatment.

Conclusion

While BDD patients may appear to be overly vain, most are in fact desperate to appear to look normal. They want nothing more than just to fit in, and not to look grotesque, as many will refer to themselves as appearing. Given this, it is perhaps understandable that they may go to great lengths to improve upon their appearance, especially if they believe that their well-being depends on it. Although there is a shortage of mental health clinicians skilled in the treatment of BDD, considerable relief can be found with proper medication and CBT, as well as from the compassion and support of the medical professionals and therapists involved in their care.

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The opinions expressed in this article are those of the writer, and do not necessarily reflect those of the National Association of Social Workers or its members.