Body Dysmorphic Disorder - Even the pros struggle
I was listening to a great episode of The OCD Stories where Dr. Amita Jassi talks about the intersection of OCD and being Autistic and OCD and Body Dysmorphia Disorder (BDD). I listened to the podcast because I like to find out how other clinicians are treating Autistic folks with OCD in neurodiversity-affirming ways but I was captivated more so by the BDD segment.
As I’ve mentioned in previous articles, BDD is part of a cluster of disorders that are all related: OCD, BDD, illness anxiety disorder (IAD), tic disorders, and body-focused repetitive behaviors like skin picking or hair pulling. What these share is a similar cycle of maintenance that includes intrusive experiences, safety behaviors, and intensification with engagement. The definition of each of these components and how to intervene differs slightly between the related disorders, but are on the whole, quite similar.
In BDD, sufferers have intrusive sensations, thoughts, or environmental experiences that trigger a deep feeling that something is wrong with how part of their body appears. In response to these intrusions, sufferers may closely monitor the body part with visual or tactile examination, and spend hours ruminating over the perceived defect or go to extremes to “fix” the defect. The emotional darkness, despair, and hopelessness most BDD sufferers experience is hard to describe in ways that folks without the disorder can understand.
BDD shares so many similarities with IAD in that folks who have this disorder have low-insight, get a ton of cultural messaging that they’re “right” about their defects, and that they’re at high risk of self-harm. I very much enjoy treating both conditions but I have to admit, these are the OCD-related disorders that get me nervous-sweaty because the stakes feel so high.
Medical professionals often make it worse…
With intense IAD and BDD, collusion from healthcare professionals is a major problem. In IAD, I see clients spend tens of thousands of dollars pursuing treatments for which evidence is mixed, at best. In BDD, I’ve seen clients hire expensive personal trainers, nutritionists, plastic surgeons, midlevel cosmetic injections professionals, and other LICENSED health professionals to fix the problems their mind tells them exist with how they look.
In both disorders, because of how the underlying anxiety disorder works, the most extensive treatments will never be enough because they don’t target the anxiety and inherent uncertainty in our health and appearances. Medical professionals keep throwing new tricks at the perceived problem, only to make it even worse due to engagement in the OCD cycle. Plus, these clients also feel quite validated by medical professionals and take this engagement in their cases as affirming their worst fears.
As a therapist, I sometimes feel like I’m fighting colleagues when I treat folks with BDD and IAD and it’s really hard - plus you live in fear of someone reporting you for discouraging “medical treatment.”
Therapy is long, hard, and slow
When folks show up in my office with BDD, they often have an expectation that I have a special “trick” to get their anxiety to go away. They expect that I can stop this cycle but that they can continue to engage in “fixing” behaviors. Even the most motivated client may have trouble seeing their expectations for body change to be perpetuating a cycle of anxiety. They often still believe that their “problem” is in the physical world, in the form of how they appear.
I’m also often “swimming up stream” against the tide of trainers, diet-culture folks, and even cosmetic practitioners who are still engaged in the client’s care. They’re often not keen to hear that I need the client to be willing to drop their cosmetic goals for a bit, in order to begin their recovery process. I also may be asking a client to disengage in much social media use and cleanse their digital diet of appearance-related material, which could be EVERYTHING the client pays attention to these days.
The hard truth is that in order to treat BDD effectively, we will eventually have to stop doing the safety behaviors that have been maintaining the disorder or at least we have to substantially right-size them. As in IAD where we can’t expect people to never go to the doctor again, we also can’t expect that a BDD client will let all appearance-related routines go. But we will have to set a goal, founded in the client’s values, towards which to work. It may NEVER be safe for someone with BDD to get much exposure to appearance-related themes.
Medication can really help
The client distress in BDD is so high that it’s one disorder in which we almost always need OCD-appropriate medications to get the space we need to do psychotherapy work. Of course, I’m not a prescriber and can’t make any specific recommendations, but I’ll tell you that it’s best if we have a seasoned prescriber with significant experience prescribing for OCD and related disorders.
More than one of my clients with BDD has needed less common medication(s) to give them the space to do this work. While I can’t say whether this is typical, my messaging to everyone is that while BDD is NOT at all a psychotic disorder, the distress is so incredibly high that sometimes heavier prescribing is sometimes needed to break the cycle. This is why having a qualified psychiatrist or advance practice nurse is so, so important to having the right team.
We’re going to be learning together
I was also so comforted to hear from Dr. Jassi that BDD treatment is emerging and no one (save a couple of hyper-focused researchers) is the absolute expert in care. While we clinicians are eagerly reading the latest research to make sure our practices are in alignment, there is so much we don’t know about BDD. Therapists and clients should work together to stay abreast of the latest developments on how to do treatment better over time. But starting with an OCD framework is the best course of action, based on what we know today. And that’s all we can do: The best we know to do today.