Organized Chaos - Volumes 1 & 2
Mirror Mirror On The Wall:
by Eda Gorbis, Ph.D., MFCC
An Interview with Dr. Eda Gorbis about Body Dysmorphic Disorder
What is BDD?
Body Dysmorphic Disorder (BDD) is explained by the Diagnostic and Statistical Manual of Mental Disorders as a preoccupation with an imagined defect in appearance. If indeed a slight defect is present the individual's preoccupation with that defect is markedly excessive. There is an ongoing debate among researchers regarding the exact categorization of BDD as a disorder. Many professionals consider it to be a form or subtype of Obsessive-Compulsive Disorder. Nevertheless, the symptoms of BDD manifest as excessive concern with one's appearance or a particular part of one's body. The concerns are propelled by self-focused obsessions that generate significant levels of distress that disrupt one's ability to function. BDD is marked by excessive preoccupation so intense it makes it extremely difficult to focus on anything other than that body part or perceived flaw. This provokes requests for reassurances from others as well as checking and seeking reassurance in any available mirror or reflection. A major symptom of BDD is a tormenting doubt; the underlying question related to uncertainty about ones body part, or appearance. It is important to mention that symptoms can shift from concern about one aspect of appearance to another at any time.
Is BDD a symptom of OCD, or is it an entirely different problem?
There is an ongoing debate among researchers regarding the exact categorization of BDD as a disorder. Many professionals consider it to be a form or subtype of Obsessive-Compulsive Disorder. BDD is related to a cluster of anxiety disorders including OCD. General anxiety disorder, panic disorder, as well as bulimia and anorexia nervosa. The BDD fear structure is similar to that of OCD, but the obsessions and compulsions are specifically related to ones body.
How does someone know that they have BDD and isn't just concerned with a problem with their appearance?
BDD is not analogous to the common feelings of insecurity or appearance. It is related to self-consciousness that most people have experienced at one time or another. Many people are somewhat critical of their appearance, and some people will go to great lengths in attempt to change what they consider to be flawed. Plastic surgery is increasing in popularity. There are more people willing to take the risk of "going under the knife." A specific aspect of appearance can be surgically altered or "corrected" through procedures such as rhinoplasty (a "nose-job"). Many people who have had this procedure are happy with the results and can move on with their life. When BDD is a factor, the nose will never be perfect or, if they are satisfied with the nose, another obsessive fixation on a different body part will take over.
A person suffering from BDD is subjected to high levels of distress that interfere with healthy functioning. These obsessions consume more than one hour daily. The symptoms often disrupt interpersonal relationships, and impair social and occupational performances. This physical fixation caused by the disorder distorts self-perception. It makes it difficult for the sufferer to objectively appraise perceptions of his appearance.
It is not uncommon for people suffering from BDD to have a completely distorted perception of their own image. They may be able to accurately appraise someone else's appearance, but cannot be objective about their own. What people with BDD perceive is actually similar to the reflection we have all seen in a distorted carnival fun-house mirror.
How much concern about "problems" with one's appearance signals that that person might have BDD?
It could be BDD if your concern with your appearance leads to excessive distress. This includes withdrawal from social appearances or relationships, or even avoidance of public appearances as simple as going for a ride in a car or going to a swimming pool. Excessive concern about perfect appearance in dress, makeup, jewelry, and hair is also a symptom. This may result in grooming between one to 12 hours per day.
The avoidances can progress to tragic proportions. In severe cases of BDD, we often observe repeated cosmetic surgical interventions that are uncalled for, inappropriate, and unnecessary. The problem is that cosmetic surgeons, often due to difficulty in understanding and diagnosing BDD, are not able to identify BDD as the problem. The most extreme case that I saw in my practice involved a patient who had undergone 17 plastic surgeries. These procedures most people would consider unnecessary and even dangerous.
It is not uncommon for people suffering from BDD to perceive their own image as distorted. They believe their appearance is offensive to others. This notion reinforces the feelings of shame associated with BDD. It makes it even more difficult to go out in public. They are often able to appraise appropriately the appearances of others while they fail to objectively appraise the appearance of the self.
What people with BDD perceive is actually similar to the reflection we have all seen in a distorted carnival fun-house mirror. This concept actually lead me to add a new approach to the method I use in treating BDD. It happened while working with a patient. I tried to put myself in this patient's shoes. I tried to examine his point of view. His description of how he saw himself reminded me of what I saw as a child walking through a "house of mirrors" at a carnival. This realization set the development of a new therapeutic exercise in motion. We now use actual distorted mirrors for certain exercises during BDD treatment at Westwood Institute for Anxiety Disorders Inc.
What are some of the symptoms of BDD?
Symptoms of BDD include excessive concern with a particular body part or aspect of appearance. The distress caused by this fixation can lead to compulsive behaviors, such as, repeated questioning and reassurance seeking, endless matching of clothing, social withdrawal, impairments or nonexistence of interpersonal intimate relationships, inability to tolerate social situations, constant checking for physical imperfections through touching, testing for bumps, feeling for symmetry, searching for flaws, skin picking, measuring the waste line, noses, counting hairs that fall out, etc.
Who gets BDD? More women then men? Younger people?
People with other anxiety disorders are more likely to be diagnosed with BDD due to the high co-morbidity of anxiety disorders. More men are treated for BDD than women. However, more research is needed to see the exact distribution. There is some speculation that female BDD symptoms are more likely to be interpreted as "normal" female behavior. These symptoms are likely to be overlooked and remain untreated. The onset of BDD is not exclusive to a particular age group, though symptoms often emerge during teen-age years.
What causes BDD?
There are theories, but the specific causes of BDD are not known. Many experts agree that sociological and biological factors play a role in the development of BDD.
What is the difference between concern about one's appearance and obsessing about supposed flaws?
When concern with one's appearance interferes with social/occupational performance, it may be a symptom of BDD. If a person's appearance becomes the center of his focus and he can no longer maintain a healthy perspective on life, it has become an unhealthy obsession.
How can BDD impact a person's life?
The degree to which BDD affects one's life depends on the severity of the symptoms/condition. The person's ability to use mindfulness is a necessary practice for treating the disorder. BDD symptoms can cause one to avoid public places and social situations, undergo multiple and unnecessary plastic surgeries, be house-bound, cause low self-esteem, depression, anger, anxiety, and eating disorders. In severe cases, it can even lead to suicide.
Do people with BDD actually see themselves differently or are they interpreting what they see differently? Do they imagine flaws and imperfections or do they misperceive what they actually see?
People with BDD misperceive what they see. There is misinterpretation and distortion about the actual situation or features.
Do people with BDD experience a kind of paranoia about their perceived flaws? Do they believe or feel that others are taking special notice of their "defects," or staring at it or laughing at it?
People with BDD do experience extreme self-consciousness. BDD leads people to believe that other people are criticizing their perceived imperfections. Around others, they get the feeling of being scrutinized under a magnifying glass. As these fixations intensify, the belief that people are looking at the perceived "defects" seems rational. Other's actions are interpreted in reference to the particular "flaw". It seems that people are staring, laughing, and discussing them behind their backs.
Is the person with BDD literally delusional about the existence of the flaws or imperfection he feels he has?
BDD, just like OCD, ranges in its severity. The level of insight may actually be evaluated as good to poor or extremely poor. People with extremely poor insight may be close to overvalued ideation about the imperfections that they think they have.
What kinds of compulsive behaviors do people with BDD perform?
Compulsive behaviors of people with BDD vary depending on their "area of concern." If someone is concerned with his nose, he might touch it, check it in the mirror or any reflecting surfaces, get plastic surgery, and try to endlessly perfect it. In general, symptoms include seeking reassurance, body checks, and checking ones image in any reflecting surfaces.
Does a person with BDD typically ask family and friends for reassurance about his appearance or try to convince them that he is ugly?
People with BDD typically ask for reassurance. However, responses to repeated questioning lead to other questions in different forms that are underlined by uncertainty. These compulsions result in no relief. Rather serve to reinforce the false belief system and unhealthy fixations leading to further compulsive questioning.
Does BDD interfere with an individual doing his job, managing a household or maintaining relationships with friends and family?
One problem of BDD is that it handicaps one's relationships and functioning. A sufferer may be so concerned with having her hair done perfectly, that she will not be able to even leave the house. She has no time to do anything else except her hair.
Do people with BDD have problems leaving their homes, shopping, engaging in work and play activities?
People with BDD believe that some aspect of their appearance is not perfect. They spend endless amounts of time and effort trying to perfect that particular aspect of their appearance. If their "area of concern" is not perfect [it never is], they are reluctant to leave the house or continue with daily activities. It is not only that they know that they are not perfect, but they believe that they will be highly scrutinized by others (watched under magnifying glass). All these factors make it difficult for people with BDD to do even routine daily activities.
Are there treatments for BDD? What are they?
There are treatments for BDD. One of them is Cognitive-Behavioral Therapy (CBT) that uses Exposure and Response Prevention (E&RP). It can be useful to add mindful awareness training, cognitive restructuring and socratic questioning to CBT. At our Westwood Institute for Anxiety Disorders, we have been using videotaping, and objective self-portrait description in writings. We have recently ordered numerous distorted mirrors that are used in exposure exercises to help patients intensify the distortions. This technique has been successful so far. At our Institute, we commonly use a combination of medications and CBT. We often employ an interdisciplinary team to work on each case and treatment is tailored to each case. We also have five psychiatrists that are OCD, and anxiety disorder specialists.
Are there medications that are effective?
Medications may or may not be effective. Each and every case is different. For people with high base anxiety, medications may be used to reduce the amount of experienced anxiety. In some cases, medications can also be used to alleviate other psychological disorders that are present and may interfere with the treatment of the BDD (e.g., depression, panic attacks). However, some kind of therapy is required in addition to the medication.
Is Cognitive-Behavioral Therapy an effective treatment for BDD?
Cognitive-Behavioral Therapy has been proven to be highly effective in treating BDD. We have had many cases of people who have been treated with CBT and have had great outcomes.
What can family members do to help a person with BDD?
A family's understanding, support, and love are required. Oftentimes, people misperceive BDD symptoms as evidence of the sufferer being shallow and self-absorbed. It is very important for families to understand that BDD is a disorder. It requires treatment. It is also extremely important to help one find appropriate help as soon as possible because symptoms might worsen.
If you would like to learn more about BDD, you can contact the Neysa Jane, BDD Fund at neysabdd@comcast.net
Eda Gorbis, Ph.D., MFCC
Assistant Clinical Professor, UCLA School of Medicine
Westwood Institute For Anxiety Disorders, Inc.
921 Westwood Blvd., Suite 224
Los Angeles, CA 90024
(323) 651-1199
Web Site: http://hope4ocd.com
