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

Section 12
Body Image with Symptoms of Depression

CEU Question 12 | CE Test | Table of Contents | Body Dysmorphia
Psychologist CEs, Counselor CEUs, Social Worker CEUs, MFT CEUs

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On the last track, we discussed three aspects of family members of BDD clients.  These three aspects of family members of BDD clients included: feelings of neglect; angry parents; and education.

On this track, we will examine three aspects of depression in BDD clients.  These aspects of depression in BDD clients include:  similarities, differences, and feelings of worthlessness.

As you may already know, major depression is the most common disorder to occur comorbidly with BDD.  I have found that three quarters of people with BDD have past or present major depression. 

3 Aspects of Depression in BDD Clients

1. Similarities
The first aspect of depression in BDD clients is similarities between depression and BDD.  Many researchers have theorized that because depression and BDD sometimes mimic each other, it may be possible that BDD is a side effect of depression.  For instance, both BDD and depressive clients experience low self-esteem, rejection sensitivity, and feelings of unworthiness and defectiveness. 

Like many clients with depression, some BDD clients have prominent feelings of guilt.  This usually stems from the fact that they feel that they should not be so obsessed with something as trivial as how they look, or because they feel responsible for ruining their appearance.  Because of these similarities, many theorists believe that BDD comes because of a client’s belief in his or her worthlessness resulting from his or her depression.  This worthlessness then manifests itself in a preoccupation in the client’s outer appearances.

"These sausages were the root of all my troubles."
Jody, age 32, first came to me because of her major depression.  She stated, "I can’t go out, I can’t do anything!  All I want to do is sleep!  I feel so worthless and ugly!"  I then asked Jody why she felt worthless and ugly.  She stated, "My fingers are huge and manly!  I feel so unfeminine and I know that these are the reason I’m all alone and no man will touch me!" 

I then asked her how long she has had this preoccupation with her fingers.  Jody stated, "It started when I went off to college.  I noticed that I was ignored quite a bit and that nobody would take me out on dates.  I began to suspect it was my fingers and the more I thought about it, the more I was convinced that these sausages were the root of all of my troubles." 

I then asked Jody if she could remember whether her depression came after or before her preoccupation with her fingers.  She stated, "I think it started just a little bit after, but I can’t be sure.  I was feeling pretty down on myself before I noticed my fingers, but after everything just spiraled out of control."  In Jody’s case, it is slightly difficult to discern whether or not her depression came as a result of her BDD or if her BDD is a consequence of her already low self-esteem.  Think of your Jody.  How is his or her depression related to his or her BDD?

2. Differences
The second aspect of depression in BDD clients is differences between depression and BDD.  Even though there are some striking similarities between depression and BDD that suggest BDD is a secondary disorder, I believe that the defining characteristics of BDD indicate differently. 

For instance, clients with BDD have prominent obsessional preoccupations and repetitive compulsive behavior.  Depressed clients, I have found, focus less, not more, on their appearance, even neglecting it.  They do not obsess about it as BDD clients do.  In addition, depression usually occurs later on in life than BDD and, when untreated, appears to often be more chronic. 

Also, BDD does not respond to the common treatments of depression.  If BDD was a symptom of depression, then these methods, such as electroconvulsive therapy, would be effective treatments, which they are not.  In conclusion, I believe that there are enough significant differences and exceptions to BDD to rule it out as a symptom of depression, even though depression may be a symptom of BDD.

Case Study: Claudia
Claudia, age 29, began to experience symptoms of major depression after preoccupations regarding her hip size arose.  Claudia stated, "Every time I looked in the mirror, I felt disheartened!  It was as though there would never be a ray of sunshine for me again for the rest of my life if I kept looking like this." 

When I asked Claudia if her depression came before her preoccupation, she stated, "Are you kidding?  I know my BDD is causing my hopeless feelings!  I don’t see how anyone with this disorder could not feel depressed!  You put everything into this one aspect of yourself and this one aspect looks hideous to you!"  By her own admission, Claudia knows that her depression came as a result of her BDD.  Think of your Claudia.  Can he or she pinpoint the source of his or her depression?

3. Feelings of Worthlessness
In addition to similarities and differences, the third aspect of depression in BDD clients is feelings of worthlessness.  In my experience, one of the main sources of depression in clients with BDD is the belief that they aren’t worth anything.  Even in my depressive clients, this is a common symptom and belief.  In BDD, however, it arises from an outward appearance which then translates itself onto the inner value system of the client.  However, I have found that addressing these beliefs of worthlessness helps to alleviate the depression as well as BDD symptoms in the client. 

Technique:  I am Worth It
To help clients like Claudia and Jody with their feelings of worthlessness, I ask that they try the "I am Worth It" Technique. 
1. First I ask them to make a list of little rewards they can give themselves throughout the day.  These can be treats such as rocking themselves as described on a earlier track or a nice warm bath
2. Next, I ask that every time they decide to give themselves a reward, they state loudly, "I am worth it!"  Claudia stated, "If I give myself something to eat as a reward, I’ll just feel fatter.  So, I decided to buy myself some new trinkets for my apartment whenever I feel as though I’ve done something that goes towards treatment.  My husband once said that it wasn’t necessary, but I told him that I’m worth it!  That shut him up but quick!" 

Think of your Claudia or Jody.  Would he or she benefit from the "I am Worth It" technique?

On this track, we discussed three aspects of depression in BDD clients.  These aspects of depression in BDD clients included:  similarities, differences, and feelings of worthlessness.

On the next track, we will examine three disorders that are similar to BDD.  These three disorders that are similar to BDD include:  hypochondria; obsessive compulsive disorder; and social phobia.

Peer-Reviewed Journal Article References:
Junne, F., Zipfel, S., Wild, B., Martus, P., Giel, K., Resmark, G., Friederich, H.-C., Teufel, M., de Zwaan, M., Dinkel, A., Herpertz, S., Burgmer, M., Tagay, S., Rothermund, E., Zeeck, A., Ziser, K., Herzog, W., & Löwe, B. (2016). The relationship of body image with symptoms of depression and anxiety in patients with anorexia nervosa during outpatient psychotherapy: Results of the ANTOP study. Psychotherapy, 53(2), 141–151.

Lydecker, J. A., White, M. A., & Grilo, C. M. (2017). Form and formulation: Examining the distinctiveness of body image constructs in treatment-seeking patients with binge-eating disorder. Journal of Consulting and Clinical Psychology, 85(11), 1095–1103.

Shanok, N. A., Reive, C., Mize, K. D., & Jones, N. A. (2020). Mindfulness meditation intervention alters neurophysiological symptoms of anxiety and depression in preadolescents. Journal of Psychophysiology, 34(3), 159–170.

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.

Stapleton, P., Crighton, G. J., Carter, B., & Pidgeon, A. (2017). Self-esteem and body image in females: The mediating role of self-compassion and appearance contingent self-worth. The Humanistic Psychologist, 45(3), 238–257.

Online Continuing Education QUESTION 12
What are three aspects of depression in BDD clients? To select and enter your answer go to CE Test.

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