Through a mirror, darkly. Understanding Body Dysmorphic Disorder

What does it mean to be seen? How do we perceive our own appearance? How accurate is it? When I look at myself, am I really seeing what you see when you look at me? Is a photograph or a reflection in a mirror a real depiction of someone’s face? Is beauty or attractiveness objective? Is it subjective? A combination?

Misunderstood, under diagnosed and not properly recognized, Body Dysmorphic Disorder (BDD) is a difficult diagnosis. It involves an intense, repetitive focusing on a specific part of one’s body combined with the perception that that that body area is flawed or ugly. Skin, hair and the nose are the most common areas of focus, but a person with BDD can be preoccupied with almost any body part. Over long periods of time, a person with BDD can shift their preoccupations from 6-7 different body parts (see Wilhelm, Phillips & Steketee 2013). Typically, the body part in question is not typically viewed as ugly or flawed by others, yet what can be surprising is the strength of the conviction that people have about their perceived defects. Before CBT treatment, between 27-39% of people with BDD state that they are completely convinced about their perception of is accurate and not distorted at all (Phillips & colleagues, 2008). Along with these perceptions come a time consuming or life impacting set of behaviors centering around evaluating, covering up or fixing their appearance or avoiding situations in which they will be triggered because of their appearance.

Population studies suggest a 1-2% prevalence, meaning that 1 or 2 people out of 100 currently have BDD. If you don’t think that’s a lot of people, keep in mind there are 10 million people in Los Angeles County, so that means there are probably about 200,000 Angelenos with BDD right now. Older studies done in dermatology clinics and cosmetic surgery clinics found that rates of BDD range from 9-53% of patients (Wilhelm & colleagues, 2013, pg 11) and that people with BDD can get multiple procedures done and are consistently dissatisfied with the results of those procedures.

Do we know a lot about BDD? Yes. Could we learn much more? YES! To give you a flavor for how under studied BDD is, I did a quick PubMed search on scientific papers published with a keyword of BDD and compared it with OCD and major depressive disorder.

It’s clear from the graph above there aren’t many studies BDD. From 1950-1990 there were just 39! That’s about just one published paper per year. Compare that with over 3000 published papers on OCD during the time period. That’s 10x more. And forget about the number of papers on depression; there were about 530 papers published on depression for every one paper published on BDD.

Although understudied, there are some very good studies on BDD. Modern conceptualizations of BDD probably got their start in Genoa Italy around 1891, when Enrico Morselli coined the term of “dysmorphophobia” after doing case reviews of 78 patients. He described it as a “persistent idea of deformity combined with tremendous anxiety about that awareness” (Fava, 1992). Morselli wrote extensively about dysmorphophobia but only recently has BDD been a more commonly talked about disorder. In their excellent overview, Sabine Wilhelm, Katharine Phillips and Gail Steketee write that patients with BDD “are convinced that they are physically deformed and are reluctant to initiate or stay in psychiatric treatment” and “they need more intensive engagement and ongoing motivational interventions.” (Wilhelm, Philips and Steketee, 2013).

Details vs Holistic awareness

Exactly how one comes to get stuck on a flaw in their appearance is not exactly as you would expect. The strength of the belief that one’s skin is flawed is not hallucinatory delusion, but may actually stem from a razor focused ability to notice details combined with poorer holistic visual perception. Neuroimaging studies by Jamie Feusner and his colleagues have consistently shown that people with BDD are better able to recognize facial details than comparison control participants. Early studies showed that when it came to looking at human faces, patients with BDD had left hemisphere hyperactivity in higher-order, detail specific visual processing regions compared to non-BDD control subjects and less brain activity in front-striatal visual processing areas associated with holistic, contextual visual processing of facial features. So although patients with BDD were very good at noticing facial details, they were not good at noticing “gestalt” aspects of facial expressions. Later imaging studies found that BDD patients showed the same pattern even when not looking at people but at pictures of houses. Good at noticing details, not good at noticing the big picture.

CBT for BDD

Wilhelm and colleagues outline a treatment approach for BDD that has four core interconnected parts: awareness of maladaptive beliefs, exposure and response prevention, perception retraining, and reworking problematic deeper held beliefs about the self. In our approach at Spectrum CBT we promote and prioritize an essential additional piece which is a focused examination of the behaviors and habits involved in thinking. So not just what you believe, but what and how you think about things in your daily life.

Awareness of maladaptive beliefs

Each of our minds are so active, so talkative, that what we see, hear, touch and taste is an augmented reality. Our sensory experiences of people’s smiles, the shapes of their eyes and the sounds of their voices are augmented with memories, stereotypes, reminders, agendas. Our mind refashions sensory experience through our internalized anticipations, feelings and beliefs. “People often judge appearances”, “being attractive all the time is extremely important”. These beliefs color and shape our experience. So you and I could be talking and we could perceiving our conversation in very different ways.

In CBT, we like to use jargon like “maladaptive”. What this specifically means is a fusion or a pairing of two concepts: usefulness and a better approximation of realness or truth. TRUTH! It’s hard to figure out what’s really true and I’m not a philosopher, so I’m not going to spend too much time on truth. I don’t know if the X files are right. I don’t know if truth is out there. I don’t know if truth is knowable. But a foundational piece of being scientific and employing the scientific method is that there is an order to things, that through observation we can learn and improve our understanding of how things work. In CBT we apply this mindset to ourselves. There is an order to us, and we can learn and improve our understanding of we work and how others work. But more importantly, maladaptive relates to the concept of usefulness. Is this action useful? Is this thought useful? And then useful for what? Useful for keeping me miserable? Useful for helping me navigate life’s challenges? Maladaptive then are beliefs

Exposure and Response Prevention

I don’t like the term exposure and response prevention. It’s like saying “groovy”, “tubular” or “awesome”. There was a time and place for it and now it sounds old. I prefer “behavioral engagement”. How do you engage in tricky life situations? What beliefs wake up and become prominent? What habit urges kick in when you are challenged? And how can we work on shifting and improving these habit and approach styles? Through practice; intelligent, focused practice. Not haphazard, but thoughtful; not focused on flooding and overwhelming people so that their anxiety will go away, but focused on teaching people how to approach and handle situations differently so that they can work through them fluidly and much more effortlessly. Engagement is a form of learning by doing, like bike riding. You don’t read about riding a bike and you don’t talk about riding a bike. You practice riding a bike. Sometimes learning something is really hard so it helps to have someone to help you learn it. That is exposure and response prevention.

Perception Retraining

When you look in the mirror, what do you see? It should be an easy answer. I see myself. But, that answer hides a deeper more complex answer. The real answer is, it depends.

Sometimes I see my face, sometimes I see how I have aged, sometimes I see my nose hairs, sometimes I “don’t” see my nose hairs. The act of perceiving almost seems to toggle between between a “detail” mode and a “holistic” mode. Some people may perceive faces in a more detail-focused way and others may perceive faces in a more holistic-focused way that integrates visual information and emotional expression. People with BDD seem to perceive faces in a much more visual, detailed manner (Feusner et al, 2007, JAMA Psychiatry). People with BDD also tend to view these details and then habitually compare and evaluate details of faces. You could say that having BDD involves a tendency to automatically be in detail-mode and difficulty getting into holistic mode; plus, while in detail-mode, people with BDD also view certain details (their nose, their eyes) through an evaluative good/bad filter rather than an observant, descriptive, nonjudgmental filter. A goal of perception retraining would be to help individuals practice using that non evaluative filter instead of the default judgmental filter.

Beliefs about the self

In basically any form of therapy, we bore down into the deep of who are you? Or perhaps a better way to put it is, who do you THINK you are? Often we will find that we hold some dark, problematic views of our self and BDD is an outer manifestation of that and a perpetuating cause of those dark views. So in CBT we explore what those views are. What are those core beliefs about yourself? Chances are you hold competing views of yourself (capable vs incapable; lovable vs unlovable) and sometimes the negative, nastier views of self are more dominant, more active, and are fed more “juice” than the more positive views. So can we devise mechanisms for alternative core beliefs to get some energy? To get some sunlight?

Maladaptive habit-based thinking

Thinking is complex set of mental behaviors and just like any other set of complex behaviors like walking, running, dancing, cooking, eating etc, we have the capacity (really the necessity) of chaining simple behaviors together to form a whole-integrated pattern that then becomes fluid and feels “natural”. Then this behavior set can be linked to specific cues in our environment based on location and time. As an example, at night, I develop a routine of putting on pjs, brushing teeth and reading in bed. This becomes a habit. If I deviate from the habit, I become uneasy. Habits are behaviors that stimulus triggered and produce a feeling of resolution when I complete the habit. Thinking types - reviewing, planning, comparing, explaining, problem solving can become thinking habits. Thinking habits that I do too much, do at the wrong time, or habits that I do poorly. Habits can be helpful or problematic. If someone has BDD, they probably have thinking habits that are very problematic. So part of our job is to examine what these habits are and work with a person to start deconstructing these habits and see if we can replace them with better ones.

REFERENCES

Fava, G.A. 1992. Morselli’s Legacy: Dysmorphophobia. In Psychotherapy and Psychosomatics, Vol 58.

Feusner et al., 2007. Visual information processing of faces in body dysmorphic disorder. Arch Gen Psychiatry Vol 64.

Feusner et al 2011. Abnormalities of Object Visual Processing in Body Dysmorphic Disorder. In Psychological Medicine, Vol 41.

Wilhelm, Philips and Steketee, 2013. Cognitive-behavioral treatment of BDD. Guilford Press.

Phillips, Didie, Feusner & Wilhelm, 2008. Body Dysmorphic Disorder: Treating an Underrecognized Disorder