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

Section 4
Suicidal Behavior and Non-suicidal Self-Injury

CEU Question 4 | CE Test | Table of Contents | Body Dysmorphia
Social Worker CEUs, Psychologist CEs, Counselor CEUs, MFT CEUs

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

On this track, we will examine three concepts of suicide related to BDD.  These three concepts related to BDD include:  suicidal thoughts; self-loathing; and self-deprecation and hallucinations.

3 Concepts of Suicide

1. Suicidal Thoughts
The first concept of suicide related to BDD is suicidal thoughts.  It may, or perhaps may not, come as a surprise to you to learn that about eighty percent of BDD clients have thought about suicide as an answer to their suffering.  These thoughts included believing that life was not worth living, that they’d be better off dead, or wishing they were dead.  A majority of them attribute their thoughts to their BDD. 

About a quarter of BDD clients will attempt suicide.  I have found that the severity of the client’s preoccupation is not always directly proportionate to his or her risk for suicidal thoughts.  Rather, it is the degree to which the client experiences self-loathing and depression which determines his or her frequency of suicidal thoughts.

Don, age 44, had been burned on his cheek when he was a child and believed he was a modern day Quasimodo.  He stated, "It’s severely upsetting!  I fear I won’t be able to lead a normal life—date, have sex, and do the other things that people do.  I feel like a freak, a bad person because I have a defect in my appearance.  I fear that no one will ever love me—that I’ll be an outcast.  So what’s the point of going on!?  I’ve seriously considered buying a gun to kill myself." 

Although Don’s reaction may seem disproportionate to his malady, BDD clients prove to be much more likely than other disorders to attempt suicide due to the high rate of self-loathing.  Think of your Don.  Is he or she having suicidal thoughts?

2. Self-Loathing
The second concept of suicide related to BDD is self-loathing.  BDD symptoms usually involve a deep sense of shame, low self-esteem, and feelings of being unworthy, unacceptable, and unlovable.  These symptoms often lead to isolation from others and the feeling that others don’t understand which only contributes to the client’s own belief in their unworthiness.  Many clients have limited social support, poor functioning, and comorbid disorders such as major depression and substance use disorders—all of which, as you know, are risk factors for suicidal thoughts and suicide attempts.  

"My appearance is the source of all the pain!"
Sylvia, age 31, believed that she was one of the ugliest people she had ever met.  She once used the analogy of the Elephant Man to equate her own appearance and believed that she was just as unlovable as he had been. stated, "My appearance is the source of all the pain in my life!  I feel hopeless about it.  It’s a feeling that I’ll never belong anywhere or be happy.  I feel unacceptable because of it, and sometimes I feel that life isn’t worth living!" 

I responded, "But Sylvia, even the "Elephant Man", Joseph Merrick, had people who cared for him.  In his later years, he was given a permanent home in the London Hospital by Dr. Frederick Treves. He even had an audience with high members of the royal family.  You do not have to live in complete isolation from others because you feel they fear or loathe you.  You have assumed that people will reject you and have created this situation for yourself."  Think of your Sylvia.  How would you address his or her self-loathing?

3. Self-Deprecation and Hallucinations
In addition to suicidal thoughts and self-loathing, the third component of suicide related to BDD is self-deprecation and hallucinations.  Many clients diagnosed with BDD experience severe self-deprecation in which they perpetually criticize themselves through interior monologue.  They tell themselves in their own voice of their unworthiness and ugliness.  In very rare cases, this monologue can turn into a dialogue. 

Although auditory hallucinations are rare, they become extremely dangerous with regards to suicide risk.  Often these voices are more effective at harming the client’s self-esteem than anyone else could.  Coupled with that is the client’s realization that he or she is not well and possibly insane.  This increases the feelings of hopelessness and threaten the client’s willingness to recover.

Katie, age 22, was hearing voices when she tried to commit suicide because of her thighs and face.  She stated, "These two voices inside of me were talking to each other, saying, ‘Look at all the pimples she has on her face!  Look at her fat thighs!  Don’t you think she should kill herself?  You’re fat and ugly, and you should kill yourself.’  It’s all they talked about!  They were laughing at me because of how I looked."  Think of your Katie.  Is he or she experiencing self-deprecation or hallucinations?

Technique:   Sensory Reinforcements
To help clients like Don, Sylvia, and Katie soothe their suicidal thoughts, I suggested they try "Sensory Reinforcements."  These are small exercises that clients of mine can do in order to relieve their anxiety about their suicidal thoughts.  I give my clients a list of the following exercises.  Here’s how I introduced them.

  1. Rocking.  Gentle rhythmic movement has been known for centuries to be relaxing not only to small infants, but to adults as well.  You can use a swing, a rocking chair, a hammock, or gently rock yourself in a chair or in bed.  Try curling up on the floor, hug your knees to your chest, and slowly rock from side to side.
  2. Water Play.  Remember how fun it was to splash in the bath tub?  Put water play back into your life.  Try alternating hot and cold showers, Use a shower massage on different body parts and close your eyes to concentrate on the different sensations as you move around.  Take relaxation time in a warm tub and just yourself relax.
  3. Mind Clearing.  Get comfortable, close your eyes, and relax your muscles.  Breathe deeply.  Tuck yourself in for a nap and enjoy the pause by turning off radio, TV, and phone.  It can be as brief as two minutes or as long as you want.

Sylvia stated, "My favorite is the rocking.  I wrap myself in a blanket and I feel like someone is holding me and rocking.  I lose track of my appearance and for a little while I get a break from my self-hate voices."  Think of your BDD client.  Could he or she use some "Sensory Reinforcements"?

On this track, we discussed three concepts of suicide related to BDD.  These three concepts related to BDD included:  suicidal thoughts; self-loathing; and self-deprecation and hallucinations.

On the next track, we will examine three concepts related to gender and BDD.  These three concepts related to gender and BDD include:  similarities; differences; and

Peer-Reviewed Journal Article References:
Crow, S., Eisenberg, M. E., Story, M., & Neumark-Sztainer, D. (2008). Are body dissatisfaction, eating disturbance, and body mass index predictors of suicidal behavior in adolescents? A longitudinal study. Journal of Consulting and Clinical Psychology, 76(5), 887–892.

Smith, D. M., Wang, S. B., Carter, M. L., Fox, K. R., & Hooley, J. M. (2020). Longitudinal predictors of self-injurious thoughts and behaviors in sexual and gender minority adolescents. Journal of Abnormal Psychology, 129(1), 114–121.

Stanley, B., Currier, G. W., Chesin, M., Chaudhury, S., Jager-Hyman, S., Gafalvy, H., & Brown, G. K. (2018). Suicidal behavior and non-suicidal self-injury in emergency departments underestimated by administrative claims data. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 39(5), 318–325.

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.

Online Continuing Education QUESTION 4
What are three concepts of suicide related to BDD? To select and enter your answer go to CE Test.

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