Some dismiss body dysmorphic disorder (BDD) as vanity; others believe it’s a rare and extreme condition. Though many misconceptions continue to circulate, BDD is a real, fairly common body image disorder. It affects men and women equally and has shades of severity. Fortunately, BDD can be successfully treated with medication and psychotherapy. In fact, both cognitive-behavioral therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs or SRIs) are considered the first line of treatment for BDD, according to Jennifer L. Greenberg, Psy.D, Clinical and Research Fellow in Psychology (Psychiatry) at the Massachusetts General Hospital/Harvard Medical School.
Here’s a closer look at how this underdiagnosed, often misconstrued condition is treated in adults and adolescents.
CBT is a “present-focused, short-term, goal-directed therapy,” Greenberg said. The goal of this treatment is to reduce an individual’s negative thoughts about their appearance and their compulsive behaviors—the rituals they use to quell their anxiety. These rituals can include checking themselves in the mirror, seeking reassurance from others, camouflaging the area of concern with cosmetics, clothing or tanning and picking their skin.
When looking for a therapist, make sure he or she “has CBT training and experience treating a number of people with this condition,” Corboy said. “If your therapist doesn’t know what BDD is, does not specialize in CBT, and has not treated others with BDD, find another therapist.”
As part of CBT, the therapist will use a variety of techniques, including:
Cognitive Restructuring. Patients with BDD hold deeply negative thoughts about their appearance. They might have an all or nothing perspective (e.g., “I’m either beautiful, or I’m hideous”) and discount any positive aspects. The goal of cognitive restructuring is to “teach clients to challenge the validity and importance of their distorted thoughts about their bodies,” said Tom Corboy, M.F.T., director of the OCD Center of Los Angeles.
Patients learn to “restructure the negative thought patterns to be more realistic,” said Sari Fine Shepphird, Ph.D, a Los Angeles clinical psychologist who specializes in BDD and eating disorders.
Part of having a realistic perspective is evaluating the evidence for negative beliefs. So, a therapist asks “what evidence do you have for this thought?” Challenging distortions “shows a patient that this thinking isn’t just irrational and inaccurate, but it’s also not helpful,” Shepphird said.
Sandra regularly tells herself that she is hideous and no one will ever date her because she has a large—in reality a minute—mole on her face. Her therapist helps her challenge the “distortion that her small mole is a huge, hideous flaw, and the irrational belief that nobody would ever date her (or anyone) with such a mole,” Corboy said.
Mind Reading. In addition to holding negative thoughts about themselves, people with BDD assume that others view them negatively. With this technique, patients learn that these assumptions aren’t rational. Therapists also challenge these assumptions by giving patients a realistic set of reasons, Shepphird said.
Jane catches someone looking at her and automatically thinks, “Oh, they must be looking at my huge scar, and thinking I’m ugly.” Jane’s therapist talks to her about possible reasons the person looked her way. “The person could’ve been looking over your shoulder, admiring your clothing or thinking your hair is attractive,” Shepphird said.
Mindfulness/Meta-Cognitive Therapy. “From a meta-cognitive perspective, the important thing is to learn to accept the presence of distorted thoughts and uncomfortable feelings without over-responding to them with avoidant and compulsive behaviors, which actually reinforce and worsen the thoughts and feelings,” Corboy said. In other words, patients don’t let their thoughts drive their behavior.
Mike can’t stop thinking about how large his nose is. These thoughts are so pervasive that Mike frequently avoids class. By practicing mindfulness with his therapist, Mike learns to accept his beliefs and release them, working on attending his class.
Exposure and Response Prevention. BDD and obsessive-compulsive disorder (OCD) have distinct similarities. Patients who have BDD or OCD typically engage in ritualistic behaviors to avoid anxiety. This is where exposure comes in. To stop avoidance, patients create a hierarchy of situations that cause them anxiety, and give each situation a rating of 0—causes no anxiety or avoidance—to 100—causes intense anxiety and avoidance—working up to the situation that causes the most concern. While in the situation, patients also gather evidence about their beliefs.
In response prevention, the goal is to reduce—and eventually stop—the compulsive behaviors that patients use to decrease their anxiety. “Paradoxically, rituals and avoidant behaviors reinforce and maintain BDD symptoms,” said Greenberg. These time-consuming rituals interfere with daily life and increase anxiety and avoidance.
To reduce rituals, a therapist might assign what’s called a competing action, a behavior that the patient uses instead of the ritual. Ultimately, by facing anxiety-provoking situations and reducing rituals, “the patient is opened up to new and healthier behaviors that will actually help,” Shepphird said.