What is Body Dysmorphic Disorder?

– 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.

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