Monday, February 27, 2012

Body Dysmorphic Disorder

Sabine Wilhelm, PhD and Jennifer L. Greenberg, Psy.D

In today’s society, we are inundated with media images of youth, perfection and beauty. It comes as no surprise that many of us are self-conscious about our physical appearance.  However, for patients with body dysmorphic disorder (BDD), a severe psychiatric disorder, it extends far beyond vanity. An estimated five to seven million people in the U.S. alone have this disorder. They often spend hours a day worrying about perceived defects in their physical appearance.

Sabine Wilhelm, Ph.D., director of the OCD and Related Disorders Program at the Massachusetts General Hospital and Harvard Medical SchoolPatients with BDD may be preoccupied with one specific part of their body. But, most have several areas of concern. Individuals may worry excessively that their hair is too frizzy, that their eyebrows are uneven, or that their cheeks are too full. Patients suffering from BDD often describe themselves as “hideous” and “deformed,” and these beliefs interfere with leading a good life. For example, patients are reluctant to go to school or out with friends because they are afraid others will laugh at them or reject them based on their looks. BDD can interfere with daily activities and is associated with high rates of depression and suicidal thoughts and behaviors.

Many people suffering from BDD may have elaborate grooming rituals and spend excessive amounts of money on appearance-related products. Many seek and receive cosmetic (e.g., surgical, dermatological, dental) treatments for BDD, but are often disappointed with the results given that their interpretation of the flaw may stem from an internal problem rather than a true physical deformity.

Take “Mark,” a 26-year-old man so concerned that his hair is uneven, dry and “repulsive,” he is convinced others gawk and stare when he is in public. He is fearful of going out with even his closest friends, and if he does leave the house – to go to work, or get groceries – he refuses to be seen in public without a baseball hat, strategically placed to mask his “brittle, scarecrow” hair. Mark is late to work almost every day after spending two hours shampooing, conditioning, and drying his hair, and he spends thousands of dollars a year for the newest treatments, weekly styling appointments, and rare shampoos and dyes. He describes feeling “guilty and ashamed” for caring so much about his hair when “there are bigger problems in the world,” but finds himself unable to stop worrying that he will end up alone because he is so ugly and undesirable. Mark’s appearance-related beliefs and social isolation have led him to question whether life is worth living. 

Signs of BDD:

1. Do you find yourself excessively concerned or distressed by appearance flaws that friends, family members or doctors tell you are minor or nonexistent?

2. Do your appearance concerns interfere with your ability to go to work or school, take care of things at home, maintain grades or socialize?

3. Do you spend a lot of time trying to fix or change your appearance, but still feel dissatisfied?

Jennifer L. Greenberg, Psy.D, staff psychologist at the Massachusetts General Hospital and instructor in Psychology at HMSFor those who struggle daily with these concerns, there is hope. BDD can be treated successfully with psychotherapy and/or medication. And now, the MGH Body Dysmorphic Disorder Clinic, in collaboration with Rhode Island Hospital, is conducting the first and largest study to examine the efficacy of psychotherapy treatment for BDD. We have received a $2.14 million award from the National Institute of Mental Health to conduct this five-year trial, which will test the effectiveness of the most promising psychosocial treatment for adults with BDD: cognitive behavioral therapy and supportive psychotherapy.

Cognitive behavioral therapy (CBT) for BDD primarily focuses on helping patients to change the way they think about their appearance – for example, helping patients to develop more helpful thoughts and beliefs. CBT also focuses on helping patients gradually enter into situations they currently have difficulty with or avoid as a result of body image concerns. Patients use skills learned in therapy to help them through these challenging situations. The treatment also aims to help patients control repetitive behaviors (such as mirror checking) that are related to body image concerns. For example, Mark might be encouraged to meet a friend for lunch despite feeling self-conscious (exposure) and without wearing a hat (ritual prevention).

Supportive psychotherapy (SPT) for BDD primarily focuses on the impact of a patient’s symptoms on their self-esteem, functioning and relationships. The focus of SPT is to help individuals learn about and cope with their body image concerns in conjunction with other challenging factors in their life (e.g., relationships and stress).  Patients are encouraged to express their struggles — related or unrelated to BDD — and toward adaptive coping efforts in order to improve self esteem For example, Mark might be praised for his efforts to discuss difficult topics, such as how his body image concerns have caused conflicts with his friends (e.g., when he cancels plans last minute).

If you think you or someone you know may have BDD, professional help is available. For more information on BDD, or to become enrolled this study, visit or contact 1-866-MGH-4BDD.

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