Together with his therapist, Jim creates a hierarchy of situations. On his list, Jim includes: taking out the trash during the day (rating of 10); walking his dog (20); going to the grocery store (30); paying the cashier (40); sitting next to someone on the bus (50); having lunch at a restaurant with a friend (60); shopping at the mall (70); attending a social gathering (80); going on a date (90); and joining a sports league (100). While in each situation, Jim collects his evidence. At lunch, he monitors people’s reactions to him. He might ask: Are they gawking? Do they seem disgusted? Are they laughing? He finds that no one is reacting negatively to him and his anxiety starts to decrease after facing these situations.
Samantha is deeply bothered by her acne. She checks her face in the mirror 12 times a day, constantly picks at her acne, compares her skin to celebrity photos and spends hours trying to camouflage her blemishes. To start reducing these behaviors, Samantha and her therapist create a ritual hierarchy, recording the least difficult habit to the most difficult to give up. Her hierarchy looks like this: photo comparing (20); skin picking (30); mirror checking (50); and camouflaging acne with makeup (80). Every time Samantha wants to check her acne in the mirror, she closes her eyes and counts to 10.
In her book, Understanding Body Dysmorphic Disorder: An Essential Guide, Katharine M. Phillips, M.D., a leading expert on BDD and director of The Body Dysmorphic Disorder and Body Image Program at Butler Hospital in Providence, R.I., lists additional strategies for reducing rituals:
- Decrease the number of times you do the behavior per day. Instead of checking the mirror 12 times a day, try reducing it to eight times.
- Spend less time on the behavior. If you typically look in the mirror for 20 minutes, reduce the time to 10 minutes.
- Delay the behavior. If you have the desire to check yourself in the mirror, consider postponing it. The more you delay a behavior, the less likely you are to rely on it in the future.
- Make it tougher to do the behavior. Some patients cut their hair throughout the day to get it just perfect. To avoid this, stop carrying scissors with you, have a loved one keep them or get rid of them altogether.
Mirror Retraining. Patients can spend the majority of their day scrutinizing themselves in the mirror. This might be partly because patients selectively focus on the details—such as a small mole or scar—instead of taking in the whole picture. In mirror retraining, “patients learn to pay attention to their appearance in a new, non-judgmental way, learning to give neutral and positive feedback,” Shepphird said.
When Jonathan looks in the mirror, he says, “All I can see is my hideous mole and my big nose.” Instead of focusing on his flaws, the therapist asks Jonathan to describe himself in neutral terms, such as “I have brown hair, I’m wearing a blue suit” and in positive terms, “I like the buttons on my suit myself, I think my hair looks good today.”
Eventually, patients learn that their rituals only further their anxiety and that this anxiety is fleeting. A woman who always wears hats to hide her small mole will find that after she takes off her hat, “the anxiety she has usually fades quite quickly, because other people don’t gawk, stare or point,” Corboy said. He notes that people are typically too busy worrying about their own thoughts and feelings to notice others. And even if some people do evaluate us negatively, this isn’t “nearly as catastrophic as one might initially fear. Ultimately, “does it really matter if some stranger at a grocery store thinks we are unattractive?”
Research has found that SSRIs are tremendously helpful for patients with BDD. These antidepressants—which include Prozac, Paxil, Celexa, Lexapro, Zoloft, Anafranil and Luvox—are also commonly prescribed for depression, OCD and social anxiety disorder, all of which share similarities with BDD.
Other antidepressants—with the exception of clomipramine (Anafranil), a tricyclic antidepressant—and neuroleptics haven’t shown the same effectiveness as SSRIs, though these medications can be prescribed as supplements to SSRIs, Greenberg said. SSRIs are particularly effective because they focus on reducing obsessional thinking (e.g., “I can’t stop thinking about my terrible acne!”), compulsive behaviors (e.g., mirror checking, camouflaging) and depression.
Patients often are concerned that taking medication will change their personality and turn them into zombies. However, as Dr. Phillips notes in her book, “patients who improve with an SSRI say that they feel like themselves again—the way they used to—or the way they’d like to feel.”
When taking medication, there are several recommended approaches. SSRIs “should be tried at their optimal dose for at least 12 weeks before switching or augmenting medication,” Greenberg said. On its Web site, Butler Hospital also suggests taking SSRIs for one to two years or longer and taking the highest recommended dose, unless a lower dose has been effective.