- Hi, I'm Dr. Tracey Marks, a psychiatrist,
and I make mental health education videos.
Today, I'm talking about body dysmorphic disorder.
And this is a video that's based on a few viewer questions.
This is not to be confused, though, with gender dysphoria.
That's a completely different issue.
I'll have a separate video, talking about that.
But body dysmorphic disorder, or BDD for short,
is a brain disorder that creates
faulty and inaccurate perceptions about your appearance.
For some people, you can even have delusional beliefs
that make you think that the flaws that you see
are an accurate perception.
Let's look at an example of what this can look like.
And this is adapted from the DSM-5 casebook.
Amy works in an office as an accountant.
And since she was 13, she's been excessively preoccupied
with scarred skin, her thinning hair, small chest
and a mole on her face that she thinks
makes her nose look gigantic.
Other people would tell her that she looked fine.
But she was convinced that she was ugly and hideous.
She also believed (tone pops repeatedly)
that everyone in her office talked about her
and made fun of her because of her appearance.
She spent five to six hours a day compulsively checking
all of these areas of her body.
And every time she passed a mirror or a window,
she'd need to adjust her hair to make it look fuller.
To deal with the scarred skin, she'd use a razor blade
to pick her skin, to clear up the scars.
She saw several dermatologists for face creams and peels,
but nothing seemed to help.
She also had two nose reduction surgeries,
but she felt like the doctors botched the jobs
and didn't know what they were doing.
Amy missed several weeks (tone pops repeatedly)
of work because she felt that her co-workers
created a hostile environment by making fun of her.
She was given an ultimatum to report to work or be let go.
She filed a complaint against her boss
for promoting harassment in the workplace.
Amy didn't date because she believed
that men didn't find her attractive
and only wanted to use her for sex.
She often thought that life was not worth living
because she had nobody
who could accept her freak appearance.
Family members tried (lively band music)
to get her to see a psychiatrist,
but that only made her angry
because they considered her ugliness a mental disorder.
Amy had been having some trouble sleeping for months
and had some sleeping medications from her doctor.
After she was told that she couldn't come to work
because of the complaint that she filed,
she took all of her sleeping pills.
She sent her sister a text message, saying that
no one needed to worry about her anymore.
Her sister, knowing Amy had been looking
really depressed and withdrawn,
called the police, (sirens wail)
and Amy was admitted to the hospital
and treated for depression.
So this is a sad story about Amy.
But this is pretty typical as to how this can look.
It doesn't always result in a suicide attempt,
but approximately 80% of people with BDD
have lifetime suicidal thoughts.
25% of those people make an attempt.
Let's look at the criteria,
according to the "Diagnostic and Statistical Manual
"of Mental Disorders, Fifth Edition."
A preoccupation with one or more perceived deficits or flaws
in physical appearance that are not observable
or even appear slight to others.
The key here is that you're preoccupied with the flaw.
And so, in Amy's case, she really did have a mole
on her face, but she saw the mole as being so huge
that it made her nose look huge.
So an observer would see the mole,
but they don't necessarily draw the same conclusions
that the mole is so noticeable that it's worth talking about
and ostracizing her about.
You perform repetitive behaviors in response
to the appearance concerns.
Some examples of this would be mirror-checking,
excessive grooming, skin-picking or reassurance-seeking.
Or you could a lot of time comparing
your appearance to others.
And if you do this, you can stare at people
in a strange way without realizing it.
This can create social problems for you.
Because if someone feels like they're being scanned
every time they're in your presence, they may avoid you.
The preoccupation causes distress or impairment
in social, occupational or other aspects of functioning.
In Amy's example, she was so sure
that everyone was ostracizing her that she blamed her boss
for creating a hostile work environment.
And then, she took it to the next level
of filing a complaint.
That kind of stuff causes a lotta trouble.
The company has to get their legal department involved.
And then, you get a reputation for being a troublemaker.
Also, Amy had no relationships because she felt unlovable.
She either avoided people and didn't given 'em a chance,
or she assumed that any interest that someone showed in her
was only to use her for sex.
And then, just to be complete, the last criteria is that
the preoccupation is not better explained
by concerns with body fat or weight
in an individual whose symptoms meet diagnostic criteria
for an eating disorder.
This is just to separate this from an eating disorder
or issues related to body weight only.
The majority of people, about two-thirds,
start the having the problem in childhood or adolescence.
The most common body area to be focused on
is the face or the head.
And the head would be things like
insisting that your ears are too large or misaligned.
Now to clarify, what if you have large ears,
or you had to have procedure as a child
to have them pinned back?
If you're bothered by this,
does this mean that you have BDD?
No, this is a perception problem.
So it depends on how you respond to the need to have
a part of your body altered.
So yes, you had a procedure to have your ears pinned back.
BDD develops when you continue to believe
that your ears are so abnormal that everyone notices you.
You spend hours, preoccupied with it.
Maybe you ask people repeatedly, "Do I look okay?"
Do you see the difference?
On average, your preoccupations occur
for three to eight hours a day.
That's a lotta time.
Think about it.
If you sleep eight hours a day,
that leaves you with 16 hours left.
And then, let's say it takes you an hour
to prepare for work or school,
and then, you spend eight hours there.
Now you're down to about seven hours.
And part of that is eating, driving, studying.
So when are you gonna have dedicated time to obsess?
That's the problem.
It's not dedicated time.
It bleeds into the time that you're supposed
to be focused on other things.
And it interferes with your life activities.
For example, excessive grooming is one
of the things that people do.
So you may need an extra one to two hours in the morning
to get ready because you're always fixing things
with your appearance.
BDD doesn't always occur in a vacuum.
It commonly occurs with major depression.
The depression can develop in response
to the distress and impairment that the BDD causes.
And this is the case with Amy.
Basically, her life was crashing down around her.
Everything was messed up, her work, her personal life,
her relationships with her family.
So she became so despondent and hopeless
that she made a suicide attempt
and ended up in the hospital.
Another thing that commonly comes along with BDD
is social anxiety.
Amy avoided people and was very anxious around people.
But it was only because of her body image issues.
But some people will start off with social anxiety,
unrelated to the body dysmorphia
but then later develop the preoccupation with their body.
To understand social anxiety, watch this video.
I'll have a link in the corner and in the description.
What causes this problem, you may ask?
We don't know, exactly.
But body dysmorphic disorder has been associated
with visual processing abnormalities
and executive dysfunction.
The person with BDD shows a bias for analyzing fine details
rather than seeing a more wholistic view of things.
Another way of saying this is that a person with BDD
has a preoccupation with negative details.
So instead of seeing how your face looks on the whole,
you zone in on the mole.
And then, the mole becomes the only thing that's important.
And you assume everyone else thinks the same way that you do
about how awful that one aspect of your face is.
Body dysmorphic disorder is grouped
with the obsessive-compulsive disorders
because of the obsessions with having a physical flaw
with your body and the rituals and behaviors
that you engage in.
Likewise, the way we treat this disorder is similar to OCD,
a combination of medication and cognitive-behavior therapy.
The goal of the therapy is to correct the false beliefs
about the defects and minimize the compulsive behavior.
You can't just get someone to stop believing
that something is wrong with the way that they look.
The therapy uses a process called cognitive restructuring
to challenge how rational your thoughts are
and help you find thoughts that make more sense
and are actually more rational.
For example, let's say I ask Amy,
"What's the evidence that your face and nose
"is keeping you from having a relationship?"
Amy says, "I haven't had a date.
"I think that's pretty clear evidence.
"If guys didn't think I was ugly, they'd be asking me out."
I say, "Maybe there's other reasons
"that you haven't had a date.
"You don't leave your house except to go to work.
"You can't date people at your work.
"So how can men even find you to ask you out?"
I want Amy to disprove her own conclusions
by seeing other possibilities.
Another thing that your therapist may do is
de-catastrophize the situation.
With BDD, you have this irrational thought.
But then, you worry about the things that will happen
if you don't perform the rituals,
like checking or styling your hair for an hour
or picking the scars on your skin to fix it.
So part of the therapy is that
you think through the worst-case scenario.
Chances are, what you fear will happen,
like everyone laughing out loud,
isn't a realistic possibility.
And even if it is, you can handle it
better than you think you can.
Another thing your therapist can do
is help you to devise coping mechanisms
to help you deal with these situations
if they happen the way that you think that they will.
Then the other aspect of the therapy would be
decreasing or eliminating the rituals
or avoidance behaviors.
In my video on social anxiety,
I talk about building a fear ladder
that you gradually expose yourself to.
And this is a similar concept.
You and your therapist would create a hierarchy
of situations from least distressing to most distressing
and then, gradually work your way down the list.
Goals of the behavior therapy would be things like:
decreasing the reassurance-seeking,
re-engaging in social situations,
stop studying other people's physical features,
avoid looking on the internet for cosmetic options,
stop looking for opportunities to look in the mirror.
In fact, if you use a hand-held mirror,
hold it at an arm's length when you're grooming yourself.
And don't get that special magnifying mirror.
You don't wanna focus on part of your face.
You wanna look at your entire face as a whole.
As for medication,
there isn't an FDA approved medication for BDD.
But we will use anti-depressant medications
like fluoxetine and escitalopram.
We'll also use some of the anti-psychotic medications
like aripiprazole,
especially if you have delusional beliefs.
The treatment period is long, like a year
for the therapy and the medication.
And there's a high relapse rate,
meaning that after your symptoms resolve,
your concerns can come back at a later time.
It doesn't always have to be the same concern.
It could be a different body part the next time around.
I have some resources for you in the description,
so take a look there.
And stay tuned for my video on gender dysphoria.
See ya next time.