Body dysmorphic disorder often goes undiagnosed as it can be cloaked behind other mental health conditions, says this researcher. Uncovering it is all about asking the right questions.
Body dysmorphic disorder (BDD) is a mental health condition whereby people obsess, often compulsively, over perceived flaws in their physical appearance.
Despite around two per cent of the general population experiencing some form of BDD – that's over 150 million people – it continues to be a misunderstood condition, says Susan Rossell, Professor of Cognitive Neuropsychology and Director of Clinical Trials at Swinburne University.
These misconceptions tend to spur from either patient-related factors or practitioner-related factors, she says.
"The patient-related [factors] are usually that people feel very ashamed about the beliefs they hold about their bodies, or they perceive it as vanity or narcissism," says Professor Rossell, who recently spoke at the APS College of Clinical Psychologists Conference and sits on the National Institute of Mental Health International Body Dysmorphic Disorder Scientific Advisory Group.
"I hear so many people say, 'Oh, it's just this silly thought I have that I can't get rid of.' They often feel so ashamed about paying so much attention to a particular body part, that they won't talk to a health professional about it."
Because people with BDD assume these thoughts are 'silly', they often don't recognise that what they're experiencing is a mental health condition.
"They're very, very convinced that it's a physical problem," she says. "They might think, 'My nose is ugly; it's misshapen or deformed.' Public awareness of what BDD is just not there. That's why I really want to run a big public health campaign."
In terms of practitioner-related misconceptions, Professor Rossell says BDD is often not emphasised enough when training psychologists and psychiatrists.
"And in GP training, which is where we really should be looking because people go to the GP first, it's just not taught at all."
Diagnosis challenges
BDD often flies under the radar with health practitioners due to being masked by other mental health conditions.
"Two symptoms that are quite common with people with BDD are anxiety and depression. So they're [more comfortable] to talk to their GP about anxiety and depression, and then some GPs won't ask about their body image as part of that."
Beyond comorbidities such as anxiety and depression, symptoms of BDD can include:
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Constantly checking and assessing their bodies
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Avoiding mirrors
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Picking at skin with fingers or tweezers
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Hiding parts of the body with baggy clothing, scarves, etc.
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Excessive grooming or exercising
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Constant comparison with other people's bodies
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Asking people to assess how you look often
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Social withdrawal
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Isolation from others/ not leaving the house
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Unnecessary or excessive plastic surgery
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Thoughts of suicide
When it comes to providing diagnosis, Professor Rossell refers to a questionnaire called the 'Dysmorphic Concern Questionnaire'.
"If people score over 11, it's very indicative of them having BDD."
It's also very common for delays in diagnosis for people with BDD, she adds.
"It can sometimes take 10-15 years after symptoms start [before people get diagnosed]," she says.
"We have this intervention gap which is the reason why I'm researching in this field. These are gaps that need to be filled." - Professor Susan Rossell
Often it's because people go to a GP or psychologist seeking support for anxiety or depression that their BDD is finally uncovered. That's why Professor Rossell says it's critical to ask patients about their feelings about their bodies.
"If you're meeting a new client who has been referred to you with long-term anxiety and depression, you need to ask them how they feel about their body. And keep asking them because they are very ashamed to talk about it."
Good questions to ask, according to the Body Dysmorphic Disorder Foundation, include:
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Do you spend more than an hour per day worrying about your appearance?
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Do appearance worries ever lead you to feel miserable?
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Do you ever carry out behaviours such as constantly checking the mirror or grooming yourself?
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Do you often spend a lot of time comparing your body to others' in an effort to cope with concerns about your body?
"There are some cases of people with BDD who've been seeing their psychologists for five or six years until they feel comfortable [to disclose]. That's why revisiting the question every now and then is super important."
Mirror exposure work
Treatment for BDD is still in its early stages, says Professor Rossell.
"The standard at the moment is to help relieve anxiety and depression in the first instance, so most clients get some relief from going on SSRIs [selective serotonin reuptake inhibitors]. That can help to facilitate the process of them talking about their body image distress."
If a patient does open up, she says to be mindful of the fact that this might be the first time they've ever talked about their body before.
"One of the key things to do in the first few stages is to reduce people's anxieties around talking about it. So introduce the topic carefully."
Standard Cognitive Behavioural Therapy is also a common approach, she says.
"One of the key elements that is very different from CBT for other conditions would be mirror exposure work where you get someone to look at the mirror and describe their body as neutrally as possible and then you keep revisiting that, looking at [the body] neutrally."
Professor Rossell refers to workbooks created by a Harvard Psychologist named Sabine Wilhelm that walk people through how to do mirror exposure therapy.
"I encourage people to read up on it."
However, she notes that many people will be hesitant to engage with mirror exposure therapy and that even when combined with SSRIs, it's only effective in about 40 per cent of cases.
"We have this intervention gap which is the reason why I'm researching in this field. These are gaps that need to be filled."
In the meantime, she says it's important that health practitioners engage in more screening processes.
"We need to be asking people about their body image and understanding how that fits alongside their other mental health symptoms like anxiety and depression."
