On the last track, we discussed three theories related to the root causes of BDD. These three concepts related to the root causes of BDD included: displacement; teasing; and familial expectations.
On this track, we will examine three triggers of BDD symptoms. These three triggers of BDD symptoms include: comments; stress; and grudges.
3 Triggers of BDD Symptoms
1. Comment Triggers
The first trigger of BDD symptoms is comments. In some clients, a chance remark about appearance may acutely trigger the onset of BDD symptoms or increase the severity of the symptoms. When a client who is already susceptible to BDD hears a negative comment regarding his or her appearance, he or she may become convinced that the negativity attached to the comment directly reflects his or her self-worth.
Dr. Hay reported that as early as the 1970’s such remarks were at least partly responsible for the onset of BDD symptoms in 9 of 17 clients. Unlike teasing, which we discussed on the last track, comments are more or less random remarks that are not repeated.
However, the client internalizes the comment as a universal truth and subsequently adheres it to his or her identity. If the client is already young and susceptible, he or she will be more likely to absorb these "truths" into his or her identity.
The Sagging Face
Kyle age 28, linked his BDD to a comment his father made to him when he was six. Kyle stated, "My parents split up unexpectedly. It was especially rough on me, because my father blamed me for the breakup. I remember in the middle of their divorce, when he was really angry about something, he said to me, ‘You’re no longer my son.’ I looked in the mirror and I thought I looked different. My whole face seemed to be sagging. I’ve never looked the same since."
Although Kyle’s father did not specifically refer to his face, Kyle’s low self-esteem manifested itself in his own perception of his sagging face. It was more of an attack on Kyle himself, but because Kyle felt his self-worth decline, he also believed his outer appearance deteriorated as well. Think of your Kyle. What kind of comments triggered the onset of their BDD symptoms?
2. Stress Trigger
The second trigger of BDD symptoms is stress. As you already know, when a client is under a great deal of stress he or she becomes less resistant to negative self-talk. Precipitating stressors are sometimes related to psychological themes that appear particularly relevant to BDD—for example, rejection by other people.
Geraldine began to experience her BDD symptoms after her boyfriend ended their relationship. She stated, "I was dating a man five years younger than me, and I was worried about being older than him. I was afraid he wouldn’t want me because I was older. Shortly after he found out I was five years older, he broke up with me. I wondered if that was why, and I started being preoccupied with my appearance after that—because I looked too old."
Sometimes, the stressor seems more general such as marital or job stress. Stress such as this, especially when coupled with BDD symptoms, affects the client’s own belief in his or her financial and emotional security. They may become less confident about their ability to function which then further affects their self-esteem.
Vince stated, "My wife and I couldn’t agree about whether to have children. I didn’t want them because I didn’t want to have them go through the same trauma I did. I would probably just find something wrong with their looks. Plus, I haven’t exactly held a stable job. I don’t want to bring them into a poverty-stricken life." Think of your Vince. What kind of stress triggers his or her BDD symptoms?
3. Grudge Trigger
In addition to comments and stress, the third trigger of BDD symptoms is grudges. A precipitating comment is often recalled in great detail, with supreme clarity and intense, emotional anguish, even though it may have occurred decades earlier. Sometimes, BDD clients feel extremely angry and resentful toward the commenting person. They may obsess about the precipitating comment and consider getting revenge.
Reactions such as these seem to reflect an unusual sensitivity to negative comments, criticism, and rejection. Instead of forgiving and forgetting wounding comments, clients with BDD tend to feel them deeply, harbor them, and sometimes experience enduring emotional pain as a result.
Case Study: Cindy
Cindy, age 34, was told by her mother that she could never be skinny. Cindy stated, "She didn’t tell me I was fat, in a way. She just told me that I was not built to be skinny. I’ve held it against her ever since. Why would anyone tell their daughter that! I was so angry, I stomped out, and I was only eight! I’ve never really forgiven her because now I believe that I’ll never be attractive!"
I stated to Cindy, "That was about 26 years ago. Do you honestly believe that your body type has not changed or do you still believe that you are that eight year old?" She stated, "Well I have grown up, but I’m still not skinny."
I stated, "But your mother never said you needed to be skinny, just that you did not have that body type. Would you agree that it is your own interpretation of her comment that twisted your own perception of yourself?" Think of your Cindy. How has he or she held a grudge?
Technique: Mirror Affirmations or "Mirror, Mirror on the Wall..."
To help clients like Kyle, Geraldine, Vince, and Cindy, I ask that they try "Mirror Affirmations." This exercise involves the client standing in front of a mirror and repeating certain affirmations that they have created during therapy. This exercise consists of the following two parts:
Client stands quietly before the mirror and gazes into his or her eyes. Client then repeats affirmation several times out loud.
Client chooses a specific body part to praise and silently rehearses the "praise phrase" each time he or she approaches the mirror. After a few weeks, replace the phrase with another phrase praising another part of the body.
For the first part of this exercise, Cindy stated, "I, Cindy, can look feminine whatever the shape of my body." For the second part of the exercise, Cindy stated, "My eyes are a great color." Think of your BDD client. How could he or she benefit from "Mirror Affirmations?"
On this track, we discussed three triggers of BDD symptoms. These three triggers of BDD symptoms included: comments; stress; and grudges.
On the next track, we will examine three difficulties in exposing BDD clients to anxiety-provoking situations. These three difficulties in exposing BDD clients to anxiety-provoking situations include: social anxiety; self-esteem; and behavioral experiments.
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.
Veldhuis, J., Alleva, J. M., Bij de Vaate, A. J. D. (N.), Keijer, M., & Konijn, E. A. (2020). Me, my selfie, and I: The relations between selfie behaviors, body image, self-objectification, and self-esteem in young women. Psychology of Popular Media, 9(1), 3–13.
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 8
What are three triggers of BDD symptoms?
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