Body Dysmorphic Disorder: Interview with Scott Granet, LCSW
How often do you or a loved one look in the mirror and think, "Ugh...I am so fat!"..."Look at this ugly nose!"..."I am just not pretty at all."? These are passing thoughts for some people. For others, these thoughts linger and begin to affect them mentally, emotionally, and even physically. These individuals may actually suffer from body dysmorphic disorder(BDD). Get an inside look at this disorder so you can understand what you or a loved one may be struggling with inside.
Meet Scott M. Granet, LCSW
Scott M. Granet, LCSW is a clinical social worker with Palo Alto Medical Foundation Department of Psychiatry and Behavioral Health. He opened the OCD-BDD Clinic of Northern California in Redwood City in 2008, where he facilitates cognitive-behavioral group therapy. In 2005, Granet organized the first BDD conference in North America at UCLA. He is also a member of the National Association of Social Workers, the International Obsessive-Compulsive Foundation and the Anxiety Disorder Association of America.
Understanding Body Dysmorphic Disorder
LoveToKnow (LTK): What does it mean to have BDD?
Scott M. Granet, LCSW (SG): The essence of BDD is the belief that one or more parts of someone's appearance are flawed in some way. Typically, no one besides the sufferer will notice such a flaw, and if one does exist, it is usually slight with the person's concern being markedly excessive.
LTK: What's the difference between being self-conscious and having BDD?
SG: Who isn't self-conscious over appearance at times? It's perfectly normal. It becomes BDD when the preoccupation is time consuming and contributes to considerable disruption in important area of someone's life, such as work, school and relationships.
LTK: What are some of the symptoms of BDD?
SG: The primary symptom, of course, is the obsessional thinking about a part of the body being flawed in some way. While BDD can center on any part of the body, people most commonly are concerned with features around the head and face, such as hair, skin tone and the shape of the nose.
There are also many behaviors symptomatic of BDD such as:
- Excessive mirror checking or avoidance
- Grooming rituals
- Comparing the body part to that of others
- Excessive use of cosmetic products
One behavior that is known to be particularly problematic is the pursuit of plastic surgery. While it is understandable that someone with a concern about appearance would pursue such treatment, BDD is a complicated psychological problem, and not one that can be simply fixed by altering one's appearance. In fact, plastic surgery needs to be discouraged for BDD patients since the most likely outcome of such is that the person doesn't like the result and then goes on to pursue corrective surgery. There are some reports of people liking the change, but in those cases the BDD tends to shift to another part of the body. That too is an indication that the BDD itself can't be resolved by simply trying to fix the body part.
Causes of BDD
LTK: What are the causes of BDD?
SG: We don't really know at this point what causes BDD. It is believed, however, that biological, developmental, genetic and sociocultural factors all probably play some role.
LTK: How do genetic/biological factors contribute to BDD?
SG: Genetics do seem to be a contributing factor because there is a higher incidence of BDD in families that have a first degree relative with BDD than those without. Since Selective Serotonin Reuptake Inhibitors (SSRIs) are often used successfully in treating BDD, it appears that the brain's serotonin system also plays some role as well.
LTK: How does media affect the disorder?
SG: Given our societal obsession with physical appearance, it seems likely that the media has an adverse impact on people who already have BDD in some adverse ways. However, this alone is not seen as a primary cause of BDD. It's important to recognize that everyone is exposed to the same images of "beautiful people" on TV, in magazines and in movies, yet only a relatively small percentage of people ever develop BDD.
Consequences of the Disorder
LTK: What are some of the dangers of having BDD?
SG: The dangers associated with BDD are many. The most concerning is the incidence of depression and suicide attempts as approximately 25% of those with BDD make attempts to end their lives. Additionally, it is not unusual for someone with BDD to become socially isolated and experience considerable diffculties with intimate relationships, school and employment. As I have said to many of my clients, it is difficult to have a relationship with another person while you're also having a relationship with a part of your body.
Treatment Options
LTK: What are some of the treatment options for BDD?
SG: The psychiatric literature focuses mostly on medication and cognitive-behavioral therapy. The drugs that work on the brain's serotonin system are the ones that are recommended first. These are called Selective Serotonin Reuptake Inhibitors (SSRIs), and include:
- Celexa
- Luvox
- Lexapro
- Paxil
- Prozac
- Zoloft
Cognitive-behavioral therapy, or CBT, helps someone identify the faulty patterns of thinking associated with their body and to confront their maladaptive behaviors.
Exposure therapy can be especially useful because it can help the person learn that appearance may not be as important as he or she believes it to be. An example of how this would work with someone with concerns about hair may be to go outside when it is windy and go about your day without fixing your hair after it has been wind-blown. While that may be difficult for many people to do, the reason to people with BDD do this is to:
1) Get a realistic assessment of how others may treat them
2) Learn that they can probably do just about anything even if they believe they don't look acceptable
If they can tolerate the discomfort long enough they will see that the anxiety associated with the exercise will generally diminish over time. Avoidance and the various compulsive behaviors associated with the body part typically just interfere with the person being able to learn those concepts.
I also believe that an important part of treatment is the inclusion of more in-depth psychotherapy. This can be very useful in attempting to further understand why someone has developed such an acute focus on his or her appearance, and to more fully grasp how that focus impacts his or her current functioning. While we still have much to learn about treating this complicated disorder, it does appear that the best approach requires utilizing a variety of strategies.
LTK: Does someone ever really recover from BDD, or is it something that a person needs to learn to deal with effectively?
SG: At this point in time, there is no cure for BDD. The goal of treatment is one of management and allowing someone to get on with his or her life. That need not be seen as bad news, however, since there are many problems with which people need to learn to live. Just as medications allow people with medical problems such as diabetes and heart disease to live effective lives, much the same can be said for those with BDD. Medications and psychotherapy have proven to be very effective. The challenge, however, lies in finding a clinician skilled in treating the disorder.
Helping a Loved One with BDD
LTK: How can someone identify BDD in a loved one?
SG: Here are some warning signs of possible BDD.
- The biggest clue is the time-consuming preoccupation with a part(s) of the body.
- Repeated seeking of reassurance may be an indication that the concern is beyond what is believed to be normal.
- Becoming depressed and withdrawn as a result of the concern is often another indicator that there is a problem.
- Someone buying and using an excessive amount of cosmetic products can be a sign of BDD, as can searching for plastic surgery procedures on the web.
LTK: How can people approach someone who they believe has this disorder?
SG: This is often a very sensitive matter. If you feel the person would respond favorably to hearing that she may have a disorder called BDD, having a discussion on the subject may be perfectly fine. I would then refer her to some information about BDD, such as the book The Broken Mirror by Katharine Phillips, M.D. If, however, such a discussion is not possible, I would just focus on the suffering, such as feeling depressed and not being able to socialize or work effectively. This can be an effective way to get someone into treatment, and at that point it's up to the therapist to address the matter of BDD.
LTK: How can someone help her loved one in treatment?
SG: First, it's most important to recognize that the person is truly suffering. It may appear to others that the worry is just plain silly, although it feels very real to a person with BDD. It may be helpful for loved ones to participate in therapy sessions at times, both to understand the disorder better and to discuss ways to respond when discussions turn to the BDD. This can be especially useful in addressing the reassurance seeking. If it worked, people wouldn't have to ask for it so often. Since giving reassurance interferes with someone learning to do that for themselves, it can become an endless loop which is best avoided. Given that this is often a difficult issue, it may be best to discuss it with the therapist present.
A Warning from Scott M. Granet, LCSW
This disorder is very real. It is often so tormenting to sufferers that they may begin to feel that suicide is the only option. Fortunately, the majority of BDD sufferers don't reach that point, but enough people do to make it necessary to ask if someone is feeling that way. Asking that is understandably difficult, but the risk of not doing so is too great.
While treatment can be very effective for BDD, the bigger challenge perhaps is in finding a therapist who truly understands the disorder. This remains an under-recognized psychiatric illness, and there are too few therapists skilled in its treatment. Some good websites to visit are the International OCD Foundation and BDDCentral.com. The latter is especially useful in getting support from others with similar problems.
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