Mar 14, 2019
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
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/
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.
Editing consultation: Eliza Lomas
Music: Gabe Stebbing
Picture: Vince Fleming from Unsplash
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 progress may be stepped up to a more intensive level of care. Very often it needs constant strengthening of more helpful ways of responding and dealing with the world.
Lucy: What sorts of things would happen in the therapy room, if somebody was having CBT?
David: The most important thing in CBT for BDD is first of all having an engagement, in other words, both having a mutual understanding of what the problem is.
In this particular case the problem of course is the person with BDD believes that they have an appearance problem. Whereas the therapist and everybody else believes that they have a problem with being preoccupied and extremely concerned and worried about their appearance and having a different… in other words, a body image problem.
And so individuals are invited to test out this alternative theory or understanding of the problem. And so that requires a lot of commitment in terms of trying to act and test out an alternative understanding of what the problem is.
But we’re not going to directly challenge the content of those beliefs about the evidence for someone being so ugly or whether this person looks a particular way. What we’re going to mainly focus on is the processes that keep the problem going.
And so in BDD we’ve identified a number of different thinking processes, particularly ruminating and the way you might analyse and go round and round and round, trying to ask yourself, why was I born so ugly or if only I hadn’t seen that surgeon and so on.
In addition, people are constantly comparing themselves and socially ranking themselves compared to others. Of course they’re always at the bottom.
They may be excessively self-focused on how they see themselves in that picture in their mind’s eye. They may be avoiding a wide range of situations or activities, or they’re using lots of what we call ‘safety seeking behaviours’. That is things that you do to perhaps try and camouflage or to constantly check on how exactly you do look.
So there are lots of things that maintain and keep the preoccupation, the distress going and it’s these things that we try to target.
Lucy: I asked Gareth about his experience of cognitive behavioural therapy.
Gareth: So I had CBT and it was probably a little bit different from most people’s experiences of CBT in that it was residential CBT, so I lived in a unit for – ‘unit’ sounds very institutional doesn’t it? I lived there for five days a week, so Monday to Friday and went home on the weekends, for 12 weeks.
The treatment really involved the therapist helping me to understand what sorts of things might be maintaining the anxiety in terms of my own thoughts, thought processes and how I engage with them. And then the things that then responds to those thoughts, or to the anxiety.
So understanding how those things might be keeping the problem going and then starting to make some changes to those things and learning ways of doing things differently. A different relationship with my thoughts, I guess, and different behaviours, just to help me feel better.
Lucy: Part of it was about understanding what might be keeping things going and then changing things. What sort of things were you asked to try to do differently?
Gareth: I think the first step was to start to understand the thoughts, my feelings, the problem, and start to spot when they were coming into my head. And then to start to distance myself from those thoughts a little bit.
I think in some therapy for other disorders you might try to challenge the thought, but in BDD, I think because the thoughts are so strong and the belief in them is so strong, that’s a bit of a futile task. So rather than trying to challenge the thoughts, learn to take a step back from them, see them just as thoughts and then not engage with them, not get on board with them.
Lucy: That sounds quite useful for lots of different situations actually.
Gareth: Indeed. It was.
Lucy: What were the behaviours you mentioned that you were asked to do differently?
Gareth: One of them was in relation to the use of mirrors. Rather than looking in the mirror and using that as a tool to scrutinise my appearance and critique my appearance, just using it in the way that normal people would. And I had to re-train myself to do that.
That involved some relatively unpleasant experiments I have to say. So standing in a three-way mirror, which to me was the worst thing imaginable, but then learning to – when the thoughts came up – to detach myself from them by focusing my attention elsewhere. And then just to use the mirror just to do whatever I was supposed to be doing. And then walk away and switch off the thoughts.
Lucy: When you say using a mirror like normal people, what do you mean by that?
Gareth: I guess in the context of the three-way mirror, initially the practice was just to detach from the thoughts and distance myself from the thoughts. But I guess ultimately in that situation it would be to try on a jumper and see if it fitted properly. And then either buy it or put it back, but leave the mirror.
Or with general mirrors in bathrooms and things, just to sort of, you might check your hair if you’re at work just to make sure it’s not sticking up. Or in the morning, just to brush your hair, to get a normal level of grooming that most people would, rather than spending an excessive time there simply focusing on what’s wrong and thinking about how you could fix that.
Lucy: It sounds pretty full-on actually.
Gareth: It was full-on. I remember when people used to ask me about the treatment, what it was like, I remember saying it was brutal. It really was. I think having to confront the things you least want to think about on a daily basis for weeks on end, it’s pretty tough.
It’s just like you going cage diving with sharks every day. I think because some of the avoidance, there was so much avoidance in my life that having to challenge that and go against it and put myself in the situations that I had been avoiding, I was very fearful of, it did feel very, very hard.
But that’s not to say that it wasn’t worthwhile because it’s completely changed my life. So I wouldn’t want that to put anybody off.
Lucy: Did you experience changes in how you thought and felt by the end of those weeks?
Gareth: Yeah, definitely. I think my anxiety level was greatly reduced in some situations, I think even after 6-8 weeks. After 12 weeks, things had markedly improved. But then some of the things had taken longer, obviously, for me to feel more comfortable with.
Now years on, I have virtually no anxiety, which is a surprise from where I was back then.
I also got quite involved with some support groups near where I lived in Bolton, for people with different disorders. It was just a support for people with self-esteem problems or depressions.
I guess I’m mentioning that because it was really useful being able to speak with people who had similar problems at the unit where I had the CBT. It really normalised the way I was feeling, it made me feel that actually this is okay, this is on the spectrum of human experience. I am a person like everybody else, not some weirdo. I’ve got mental health problems.
But I think for me that was started much sooner by getting involved with local support groups and some online support groups and things. I think that really helped.
Lucy: Do you think it helps with worries – particularly about your appearance – does it help you to see other people who have a similar worry about their appearance, but that you don’t see in the same way?
Gareth: Yeah, that was really interesting. I think particularly to see people who you find attractive who have BDD, I think that’s really like, “Oh god, really?”
Lucy: I guess we live increasingly in a social media environment where there are a lot of selfies and you can airbrush yourself, even put ears on yourself and things like that. Do you think that change in the way we interact online has an impact at all?
Gareth: I think it must do and thankfully I kind of missed this. I think Facebook was becoming more popular, maybe just before I had treatment or just after I had treatment, so it wasn’t a big issue. But I think it must definitely have an impact.
I think there is research that shows that people’s concern about their image is becoming more prevalent with the rise of social media. But I think because it is essentially like a self-propaganda tool and nobody ever posts the worst picture, it’s all about trying to make yourself look good. It’s inconceivable that it couldn’t have an impact.
Lucy: I also asked David what he thought about the impact of social media. It tends to get blamed for a lot, but David had some ideas about how it’s not the media itself, but the way it’s used that can be problematic.
David: The way people with BDD tend to use selfies and so on is usually very much on their own. They’re not going to be doing it with others. And then they store hundreds of them on their phone or in a way that is unhelpful. It’s like a constant check as if you’re in the mirror.
And so again, usually emotional criteria are used, that you may carry on doing it or looking at it until it feels just right or ‘just so’, in some way.
It’s not used in the same way as it might be on Instagram or Facebook or something because they’re not going to post them anywhere. They’re primarily there to check exactly how they look.
However, they may well be using Instagram and Facebook to constantly compare themselves in their own mind’s eye with what they see on other pictures on Facebook and Instagram.
So this is another thing for constant ranking. And of course people with BDD tend to rank themselves at the bottom and other people are always better than them, so that it’s not helpful because it’s exactly the same thing they’re doing as they walk down the street and focusing in on a particular feature and then ranking themselves according to that feature. They see themselves as that feature or sometimes we call this, ‘I’m just a walking nose, that’s all that I am.’
Lucy: What’s the evidence base like for cognitive behavioral therapy for BDD?
David: There’s been a few trials now, we’ve certain done one that compares CBT against a comparison like anxiety management, which was rated just as credible. But that was only 12 sessions. We were able to demonstrate that it was better than anxiety management and I and others have also demonstrated that it’s better than a waiting list.
It’s not fantastic and that’s why we’re saying we probably need a lot more sessions, often treating other types of problems because by the time they get to see you, they often have additional problems.
Lucy: Do you feel like there has been progress made in the treatment?
David: I think we’ve got a much better understanding of what it is and the different variations and forms of it. And I think we certainly got some better interventions, particularly trying to identify some of the earlier aversive experiences that often people have had a lot of teasing and bullying and so on about being different in some way during adolescence.
And we can sometimes try and focus in on those and try to help them, what we call ‘emotionally process’ them, a bit like trauma memories and that’s certainly been quite exciting.
And sometimes helping perhaps a more compassionate approach to themselves, particularly those people who are very self-critical and ruminating all the time. Again, that may be more promising. I think these things are very slow, but it’s definitely, I think, the outlook is a lot better than it used to be.
Lucy: Is there anything else you would advise people who are thinking about cognitive behavioural therapy for BDD?
David: I think you do have to do it when you’re ready. In other words, it’s not worth doing if you’re just trying to get your parents or the cosmetic surgeons off your back.
I think you do have to go into it being open and accepting that it may be a different problem to what you think of it as yourself. And just accepting that there’s maybe more of a body image problem rather than necessarily an appearance problem and just trust perhaps, the people that you love and love you, around you, that they have your best interests at heart.
BDD is a recognised problem. It is treatable and sometimes if the therapy is not working, then sometimes you might add different medications as well. It’s definitely worth seeking help.
Lucy: I asked Gareth what he would advise too.
Gareth: I would have liked somebody to have said to me, “This is going to be very hard, but it’s going to be very worthwhile.”
In terms of what it’s like, going back to what I said earlier about it being brutal. I also felt very supported through that, I had a really good connection with my therapist and I think that’s really important. I think if you don’t have a good connection with your therapist, I think it’s really important to try to talk to them about it if you can.
What happened for me, before I had the effective treatment, I had therapists who I didn’t get on with very well or I didn’t feel able to talk to or who perhaps weren’t working on the right stuff and I didn’t feel able to say that.
I think because of that I wasted time, I wasted my allocated resources from the NHS and I wasted years of my life, as well as I was stuck with the problem.
I suppose I want to say that things can get better and it’s hard to know that sometimes. I think particularly with mental health problems, I think with physical health problems it’s a bit easier, but I think with mental health problems there’s a lot of stigma still.
We all tend to grow up trusting our mind. I think when things get difficult or we become more anxious it can be very hard to feel stuck with the problem. So do get some treatment and give it your all if you can.
Lucy: Thank you. This problem in particular has a huge impact on people’s mood doesn’t it? It’s really important that people are able to realise that there’s help out there.
Gareth: It does, yeah, and I think there’s an increased suicide rate as well. I think it’s even higher than it is with depression, so I think for that reason it’s really important to realise that there is treatment out there that can help however catastrophic things seem, so get the treatment.
Lucy: That’s great, thank you so much for sharing your experiences, it’s really appreciated.
Gareth: That’s okay, my pleasure.
Lucy: If you’d like more information on CBT for BDD, have a look at the show notes for loads of resources.
For more on CBT in general and for a register of accredited therapists, check out BABCP.com and have a listen to our other podcast episodes too for more on different types of CBT and problems it can help with.
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