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Body Dysmorphic Disorder Techniques for Treating Obesessions with Body Perfection
Body Dysmorphic Disorder: Diagnosis & Treatment - 10 CEUs

Section 2
Appearance-Related Safety Behaviors in Body Dysmorphic Disorder

CEU Question 2 | CE Test | Table of Contents | Body Dysmorphia
Social Worker CEUs, Counselor CEUs, Psychologist CEs, MFT CEUs

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On the last track, we discussed the three basic criteria for clients with BDD.  These three criteria included:  preoccupation; distress; and differentiating from other disorders.

On this track, we will examine three types of obsessions that BDD clients often have.  These three obsessions include:  active thoughts; obsessive behaviors; and related to others.

3 Types of Obsessions of BDD Clients

1. Active Thoughts
The first type of obsession is active thoughts.  These are thoughts that clients will experience about their defect which are always disproportionate to reality.  Nonetheless, clients might spend hours obsessing about their skin or weight.  One reason preoccupations with the defect takes up so much time is that they are difficult to resist and control. 

Many clients do try to resist them by pushing them aside and trying to focus on something else, but other clients find their preoccupations so powerful that they don’t even try to divert their attention away from the obsession.  I have found that about a quarter of BDD clients usually try to resist the thoughts and a third makes some effort to resist them.  Another quarter rarely tries to resist them and about fifteen percent make no effort whatsoever to resist them.  They simply allow them to enter their mind.

Darren, age 38, had had a surgery on his nose recently.  However, he had been unhappy with the results and had begun to obsess about the appearance of his nose.  Darren stated, "I think ‘It’s not me.  Now it’s too short and too thin!  It looks like a woman’s nose, not a man’s nose!’  And I obsess about how angry I am at the doctor and how I shouldn’t have had the surgery!  I also think a lot about what all the different surgeons have told me. Things like, ‘You could have something done, but it’s not a good idea,’ or ‘Don’t do anything to it; it could get worse.’" 

Darren’s resentful and obsessive thoughts had also transferred to other people:  the doctor who had supposedly "botched" the operation, and the surgeons who hadn’t expressed to him strongly enough not to go through with the surgery.  Think of your Darren.  What does he or she obsess about and what other people has it expanded to?

2. Obsessive Behaviors
The second type of obsession is obsessive behaviors.  These are behaviors that clients will enact in order to alleviate the anxiety resulting from their active thoughts.  These can include picking, camouflaging, and dieting.  However, the most common obsessive behavior I have found is mirror checking

4 Factors Driving Mirror Checking
Mirror checking occurs when the client is driven by
1. The hope that they’ll look different
2. The desire to know exactly how they look
3. A belief that they’ll feel worse if they don’t look, and
4. A desire to camouflage themselves. 
Many times, clients won’t use a mirror but will take covert glances in any reflective surface such as a window or even dishes.  This type of obsessive behavior often destroys the client’s confidence and becomes an interference in their day.

"I can't resist checking!"
Briana, age 39, stated, "I can’t resist checking!  I have an overwhelming urge to do it.  I have to look to see if I look normal.  But sometimes I do it without thinking!  I’ll be walking by a store window and check myself without even knowing it!"  I asked Briana what she was checking.  She stated, "I’m making sure my butt isn’t too wide and that my hips aren’t sticking out.  Everyone tells me I’m petite, but sometimes I think that they’re just being polite.  Sometimes I check myself right after I’ve been complimented!  Usually, I disprove the person who’s complimenting me because I always notice my hips and butt!" 

I stated to Briana, "Your mirror checking is similar to behaviors completed by people diagnosed with obsessive compulsive disorder.  They feel an anxiety and must relieve it much like you do.  However, you can pinpoint the cause of your anxiety whereas many obsessive compulsives have more generalized anxiety."  Think of your Briana.  How could you explain his or her obsessive behaviors in a more clarifying way?

Technique:  Counterarguments
To help clients like Briana and Darren, I ask that they try forming Counterarguments when they begin to obsess about their looks.  For this exercise, I give my clients a list of unfinished phrases.  I ask each client to finish the phrase and then we will examine the responses and form a counterargument. 

6 Unfinished Phrases for a Counterargument
These unfinished phrases include:
1. Because of my looks…
2. Attractive men/women…
3. I think my body…
4. I wish my body…
5. When I look good…
6. Unattractive men/women…

Briana finished the phrase, "Because of my looks…" with "I can’t succeed."  I asked Briana if she really felt she was a failure and if she felt that she was lacking in any other part of her life except her looks.  Briana stated, "I guess I’ve been successful sometimes and unsuccessful other times."  I stated, "And you’ve looked pretty much the same throughout your life, correct?"  She stated, "Well, yeah, I guess."  I stated, "So it’s not your looks but rather your attitude that is really holding you back in any way."  Think of your Briana and Darren.  Would they benefit from forming some of their own "Counterarguments"?

3. Related to Others
In addition to active thoughts and obsessive behaviors, the third obsession is related to others.  What I mean by "related to others" is that some clients become more obsessive when they are around other people and attending more social engagements.  Often, they perceive that those around them are staring at their deformity, which then leads them to active thoughts which then leads them to perform an obsessive behavior, such as check themselves in the mirror. 

This cycle of BDD can occur several dozen times during a social occasion.  Because of this, clients can become increasingly reclusive until they only leave the house once in a few years, often to leave they camouflage their perceived defect.  This inability to cope when others are around obviously interferes with the client’s social and occupational life. 

Luke, age 24, had not left the house in six years.  He stated, "My hatred of my appearance began when I was twelve.  I became obsessed with my nose!  It started when I heard a boy in my class make a comment about Jimmy Durante.  I can’t even remember what he said, but he was snickering, and I was sure it was a mean comment!  I thought he might be making fun of my nose.  I started skipping school and went from straight A’s to D’s and F’s.  I got very withdrawn, and I stopped seeing my friends.  After high school, I never went to college and shut myself up in my room!  My parents think I’m lazy, but really it’s because I can’t stand to see people look at me and laugh again."  Think of your Luke.  How did his or her reclusive behavior start?

On this track, we discussed three types of obsessions that BDD clients often have.  These three obsessions included:  active thoughts; obsessive behaviors; and related to others.

On the next track, we will examine three concepts related to a BDD client’s functionality.  These three concepts related to a BDD client’s functionality include:  awareness of dysfunctional behavior; bodily damage; and alcohol and drug use.

Peer-Reviewed Journal Article References:
Summers, B. J., & Cougle, J. R. (2018). An experimental test of the role of appearance-related safety behaviors in body dysmorphic disorder, social anxiety, and body dissatisfaction. Journal of Abnormal Psychology, 127(8), 770–780.

Wilver, N. L., Summers, B. J., & Cougle, J. R. (2020). Effects of safety behavior fading on appearance concerns and related symptoms. Journal of Consulting and Clinical Psychology, 88(1), 65–74.

Ryding, F. C., & Kuss, D. J. (2020). The use of social networking sites, body image dissatisfaction, and body dysmorphic disorder: A systematic review of psychological research. Psychology of Popular Media, 9(4), 412–435.

Online Continuing Education QUESTION 2
What are three types of obsessions that BDD clients often have? To select and enter your answer go to CE Test.

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