Raising Awareness for Body Dysmorphic Disorder

September 2018, Dr Amita Jassi and Dr Bruce Clark delivered an eye-opening session on Body Dysmorphic Disorder (BDD) and the awareness that needs to be raised to recognise individuals suffering with undiagnosed symptoms.  BDD is not something that clinicians always think of, however the talk highlighted the symptoms that we should be looking out for and the evidence-based treatments that can help the symptoms that people experience.

BDD is a mental health condition whereby individuals worry about specific flaws or defects in themselves that may not be present to the rest of us. The DSM-V criteria states that like all diagnoses, an individual’s BDD must impair and cause distress to the individual. This impairment and distress could be in the form of social avoidance, not attending school or work, self-harm and worrying about who may see them. Additional symptoms that lead to a diagnosis with DSM-V criteria are the presence of physical repetitive behaviours such as constantly applying make-up and checking mirrors, or presence of mental thoughts such as comparing themselves to others and seeking assurance regarding their looks. The compulsivity that comes with individuals thoughts that they cannot shake, shares a similarity to Obsessive Compulsive Disorders (OCD). When we are on the lookout for individuals who may be dealing with BDD, we must ensure that the individuals behaviours cannot be accounted for by other mental health disorders, for example anorexia. However, we must not discount the diagnosis as there are already many people who are not diagnosed.

Unfortunately, BDD is a diagnosis that is linked to high risk behaviours such as self-harm and suicidality. Therefore, it is really important that we are aware of symptoms to help support individuals with what they are going through. The condition can be present in individuals at any age, however it is most common in adolescents and young adults. Dr Clark and Dr Jassi reported that on average, people have five to seven concerns with themselves. Around 70% surrounds skin as a main concern.  Though people may be worried about particular features of their body, some people with BDD may also be worried about their general physical appearance such as feeling “ugly”.  Is it any surprise that so many people are faced with these symptoms if social media such as Instagram and Facebook promote some unrealistic images and sense of self? We must promote positive and healthy behaviours to reduce the impact of BDD.

Shockingly, the risk does not only extend to self-harm and suicide. Other risks that individuals expose themselves to are chronic substance use, self-surgery and debt. Grant et al., (2005) reported that 48.9% of their sample had a lifetime substance use disorder and Phillips et al., (2006) indicated that this was more likely in adolescents compared to adults. The self-soothing that individuals with BDD choose, have greater impacts on their overall conditions. Veale (2000) also reported that 36%, of 25 adults, who wanted surgery, had previously attempted some self-surgery of their own. This self-surgery was due to access of cosmetic surgery being denied or being unable to afford it. In the talk delivered by the professionals, it was absolutely heart breaking to hear some of the experiences and lengths that people had gone to as a result of their BDD. So much so, some people’s actions had led to debts to deal with their personal image.

But, how can you help now?

Dr Jassi and Dr Clark have kindly provided us with pointers to help determine whether people in our clinics may be dealing with BDD. If it takes an extra minute to add on a few questions if you are concerned, you could be saving a life and you would be making all of the difference.

1. Are you very worried about your appearance in any way or are you unhappy about how you look?
2. Does this concern preoccupy you? That is, do you think about it a lot and wish you could think about it less? How much time would you estimate you think about your appearance each day?
3. How much distress does this concern cause you? Does it cause you any problems socially, in relationships, or with school/work?

If the above questions prompts individuals that you are working with to answer yes with regards to DSM-V criteria, as opposed to weight worries which are associated with eating disorders, it is worth considering that BDD may be a factor for the individual. If you’re worried about how to ask, one piece of advice the experts gave was to reassure the young person that they’re not alone – many people worry about multiple areas of their bodies and some reassurance to an individual that this is not vanity or self-conceited behaviour may give an individual a bridge to talk to you about their symptoms. Addressing this to the young people in our services will prompt the conversation of BDD and reduce the shame that people feel. Communication is vital and as many clinicians will know, it can come in many forms. If you feel that perhaps verbally speaking about symptoms and feelings towards an individual’s body are difficult, perhaps try externalising this by prompting the young person to either write or draw how they are feeling. For tools to assess BDD symptom severity in young people the Yale Brown Obsessive Compulsive Scale modified for BDD (BDD-YBOCS) is used. Additional methods such as the Appearance Anxiety Inventory (AAI), the Body Image Quality of Life Questionnaire (BIQ-LI) and the Body Image Questionnaire – Young Person Version (BIQ-YP) can also be used to measure appearance concerns, specific features and the degree that these impact the individual.

It is also worth noting that whilst we are raising awareness for BDD, we are also trying to show that BDD is present alongside other diagnoses. It is important that we do not discount the presence of BDD alongside other diagnoses or discount other diagnoses when BDD is present. There is a high comorbidity of eating disorders, depression, social phobias and OCD with BDD but individuals may also exhibit concerns with their looks in these conditions without BDD. By acknowledging the symptoms of BDD alongside other conditions, we will be able to ensure that we target and provide treatment for a condition that is rarely treated.

We as aspiring and qualified mental health professionals should not be afraid of the diagnosis; by being mindful of what we’ve learnt about BDD will really help us make informed decisions when cases are presented to us. When are then faced with these situations, we will then also be able to provide the best evidence-based therapy for individuals.

The NICE guidelines have reported that Serotonin Reuptake Inhibitors (SRI’s) and Cognitive Behavioural Therapy (CBT) are the two effective treatments for BDD from adult literature. Research indicates that serotonin medication is the most effective for people who are diagnosed with BDD. A journey with medication requires patience given that it can take around eight weeks to notice severity to decrease (Phillips et al., 2002). Despite the length of time is takes for severity to reduce, other symptoms can also reduce earlier in the medication journey such as mood and anxiety. Like serotonin medication, CBT is been reported as an effective treatment for BDD in young people. Krebs et al., (2012) conducted a case study using CBT on adolescents with BDD and reported that at 3-6 month follow ups of CBT, there was a 57% decrease in symptoms. Although research is limited with a younger population, research is beginning to indicate the effectiveness of these treatments. With CBT, it is most important to work on the individuals perception and reduce the distress that arises as a result of BDD, as opposed to whether an individuals perceptions of self are true.

When it does come to treatment and working with people with this condition, there are certain things that we as professionals can do to help. Working with people who come into our service at appropriate times will be most helpful. For the 2% of the population dealing with BDD, being out in society in rush hour may provoke further anxiety – changing times to others will help people who come into our services.

Providing psychoeducation is also essential. Explaining BDD with the individual and addressing what we all think about versus what people with BDD think about can help put thoughts into perspective – they are not alone in their thoughts and these thoughts are psychological compulsions. It is also very useful to explain how our physical factual appearance can differ from our body image that changes with our feelings and experiences. Dr Jassi also reported how exposure and response prevention can be a useful CBT technique. Working with a young person to construct a hierarchy of their fears can induce response prevention. For example, if we were to set a hierarchy with a young person who did not like exposing their face and decided to add make up continually, their prevention would be resist mirror checking.

The talk regarding the symptoms and evidence-based treatments was so insightful and I would like to thank both Dr Jassi and Dr Clark for sharing the knowledge and helping to spread awareness on this topic. It is so important that awareness is raised so that individuals can be supporting with the best treatments. We must support people to realise that their view of self is psychological and not physical and that this can be alleviated over time with the right treatment.

Key Points

• BDD is a diagnosis that can occur no matter what age. If you’re concerned, asking a question the moment you query BDD is what could lead to someone getting a diagnosis and treatment that they need.
• Remember that people may have co-morbid symptoms so it is important to work with individuals to determine the correct diagnosis and assess their best quality of care given their personal circumstances.
• Try to remember that when you are working with someone with a diagnosis, that body dysmorphia is a psychological condition and we are working towards reducing anxiety and distress for the individual.

References

Grant, J. E., Menard, W., Pagano, M. E., Fay, C., & Phillips, K. A. (2005). Substance use disorders in individuals with body dysmorphic disorder. The Journal of clinical psychiatry, 66(3), 309.

Phillips, K., Albertini, R. and Rasmussen, S. (2002). A Randomized Placebo-Controlled Trial of Fluoxetine in Body Dysmorphic Disorder. Archives of General Psychiatry, 59(4), p.381.

Phillips, K. A., Menard, W., & Fay, C. (2006). Gender similarities and differences in 200 individuals with body dysmorphic disorder. Comprehensive psychiatry, 47(2), 77-87.

Krebs, G., Turner, C., Heyman, I. and Mataix-Cols, D. (2012). Cognitive Behaviour Therapy for Adolescents with Body Dysmorphic Disorder: A Case Series. Behavioural and Cognitive Psychotherapy, 40(04), pp.452-461.

Veale, D. (2000). Outcome of cosmetic surgery and ‘DIY’surgery in patients with body dysmorphic disorder. Psychiatric Bulletin, 24(6), 218-221.

This is an independent article and the views are not necessarily those of ACAMH.