CBT for Body Dysmorphic Disorder

Most of us have some worries about how we look, but what if those worries get so bad they stop you being able to go out?

Body Dysmorphic Disorder (BDD) is a serious problem but it can be overcome, as Gareth explains.

Gareth and Prof David Veale talk to Dr Lucy Maddox.

This show includes mention of suicide.

Show Notes and Transcript

Podcast episode produced by Dr Lucy Maddox for BABCP For more information have a look at...

Websites

The website of the BABCP is at babcp.com.

To find an accredited CBT therapist go to http://www.cbtregisteruk.com.

The website of the BDD Foundation is at: https://bddfoundation.org/

You can find questionnaires, information, videos of people with BDD speaking about their experience and resources about where to seek help.

This Australian website has self-help booklets on BDD: https://www.cci.health.wa.gov.au/

Books

A really good book by David is this one: Overcoming Body Image Problems by David Veale and Rob Wilson.

Gareth recommends looking through when you're not too anxious, and persevering even if it doesn't reduce your anxiety straight away as it will help you hit the ground running with therapy.

Credits

Editing consultation: Eliza Lomas

Music: Gabe Stebbing

Picture: Vince Fleming from Unsplash

Transcript

Lucy: Hi, and welcome to Let's Talk About CBT, the podcast made by the British Association for Behavioural and Cognitive Psychotherapies, BABCP. This podcast is all about CBT, what it is, what it's not and how it can be useful.

In this episode we explore CBT for body dysmorphic disorder, or BDD. BDD involves being really preoccupied with perceived defects in your appearance.

Most of us will experience dissatisfaction about some aspect of how we look, but body dysmorphic disorder is much more severe. It's really distressing and it really gets in the way of people's lives.

I went to hear first-hand about what it's like to experience BDD.

Gareth: Yes, my name is Gareth, I'm an ex-sufferer of BDD and I've had CBT for BDD in the past.

When I had BDD I really believed that I was very ugly, that I had very deformed features and that other people would notice these and treat me differently because of them.

I used to worry about my nose, that it was too big and that it was just sort of unattractive. That my face was too thin, this may sound funny, but that my head was too small for my body, proportionately. I guess there were some other concerns that my eyes bulged out of my head and things like that and that I was just too skinny overall. But I think the main things were nose and jaw.

Lucy: Did it sort of creep up on you or did it happen quite suddenly?

Gareth: No, I think it definitely crept up on me. It was interesting, in therapy, looking back and thinking where it started from; I had some very clear memories from earlier in life. When I was eight years old and then a little bit later, but then it crept in during my teenage years and it was only when I got to 17 or so that it really sort of mushroomed and the anxiety just became very disabling.

I think because it becomes all encompassing, it starts to affect all areas of your life and a part of the condition is you develop a lot of behaviours in response to the preoccupation, I guess. So for me, I would often research surgical procedures online for hours on end or take photographs or videos of myself and analyse them for long periods of time. Or look in mirrors for long periods of time analysing my perceived defects and thinking about how I could change them or improve them.

But also, avoiding a lot of things because of my concerns about the way I looked. I guess the two things operated in tandem. As the behaviours around mirror checking and things started to increase, then the avoidance did as well and I became more and more withdrawn from the world. It was really a very distressing and unpleasant period of time.

Some of these activities, once you get hooked into it, once you look in the mirror and get the emotional reaction to how you look and start to check, or once you start to take photographs and get involved in that procedure, hours can just disappear and your mood just goes down and down as time goes on. So yeah, very time consuming.

Lucy: Did it get in the way of you making friends and going out to social things?

Gareth: For me I had a good group of friends up until age 19 or 20, but then it really did start to interfere with that and stopped me from seeing them and those relationships broke down, which made me feel more isolated and have more time to think about my appearance and sort of made the whole problem worse.

But ultimately the anxiety was so bad that I couldn't work for, I think seven years, which was probably a quarter of my life at that time. So it was a very long period of time.

Lucy: It's really hard for me to imagine you being so worried about that actually because I'm come to meet you now and you're clearly professional and going about your business. It's hard to fit those two together. So things seem to have changed a lot?

Gareth: Yeah, they definitely have. I think they changed so much that sometimes I don't… It can be hard to remember sometimes what it was like in the past, even though I only had the treatment, I think eight years ago now, no, nine years ago, sorry, I'm older than I thought. (Laughs)

It's hard to remember how things were sometimes because things feel very, very different now. I don't really have BDD thoughts, maybe once a year at most, I look in the mirror, a thought will pop into my head and then I just think, no, I don't do that anymore and that's it. So yeah, I'm in a very different place.

Lucy: I also spoke to an expert in the treatment of BDD.

David: My name is David Veale, I'm a consultant psychiatrist at the South London Maudsley NHS Foundation Trust and a visiting professor at the Department of Psychology in the Institute of Psychiatry and Psychology and Neurosciences.

Lucy: You've been quite a pioneer in the treatment of BDD, what got you interested in it?

David: Well, actually in this building I remember treating, trying to treat somebody with BDD and being pretty hopeless. That was when I was a trainee, so it was at least, blimey, 30-35 years ago (laughs).

I remember when I was first appointed as a consultant we did treat somebody with BDD who went on to commit suicide a few days after he was admitted. I think that did have a major effect on me. At that stage nobody really knew what BDD was or how best to treat it.

The awareness of these sorts of problems is increasing; it's a lot better than it was say 10-20 years ago, but there's always more to be done.

I think the problem is that it's not taken seriously enough. I think often people treat it as body dissatisfaction. We're all dissatisfied, but this is something quite different. What we're talking about here is something that's quite significantly distressing and interfering in their life and usually associated with many repetitive behaviours, particularly things like checking in the mirrors or checking their appearance in some way, or constantly comparing and ruminating all the time.

It's a different league to normal body dissatisfaction. I think if people recognised or understood how severe it was, or in terms of the suicide risk and so on, then I think it would be taken more seriously.

Lucy: Is it similar to what people experience when they have an eating disorder or is it different?

David: It's not quite the same as an eating disorder. I mean there are a few people, usually with less severe problems who get very preoccupied by weight and shape and so on. And don't necessarily have an eating disorder but then they have mild body dysmorphic disorder.

But usually with body dysmorphic disorder people are much more preoccupied with features around their face, particularly the nose or their skin and their chin, their hair and so on. Although any part of the body can be the main features that [people] get preoccupied by.

Lucy: It must be kind of hard to find out if you have it, if you feel like it's an objective reality, that you really are very ugly or something is very unusual about the way that you look. How do people tend to find that they've got this problem?

David: Well, by definition most people believe that this is a problem to do with their appearance and so they don't generally tend to seek help from mental health professionals. They're much more likely to seek help from cosmetic surgeons and dermatologists.

And it's only perhaps often that the pressure of family or friends to try to help them get the appropriate help.

Lucy: How can cognitive behavioural therapy, or CBT, help with body dysmorphic disorder?

David: Well, we've got a number of different studies now suggesting that cognitive behaviour therapy can help people to change their body image. In other words, prior to having CBT they may have very different body image in terms of what people see in their mind's eye. After therapy then that body image can change, can be altered as such.

But it is difficult. It is tough. It's certainly not a wonder treatment and compared to other interventions in CBT for different types of problems, it's not as powerful because it's still a very difficult problem to solve.

It may take 20-25 sessions to get a good treatment programme going. Very occasionally people who don't make