Body Dysmorphic Disorder (BDD) is an under-diagnosed and often misdiagnosed mental health condition due to the similarity of symptoms it shares with other psychiatric disorders. These include depression, anxiety, agoraphobia, social anxiety disorder and obsessive-compulsive disorder, to name a few.
People who suffer from Body Dysmorphic Disorder believe there is something wrong with their physical appearance, usually concentrating on one “defect” such as their nose, skin, teeth or weight. The extreme discontent in their looks is not realistic, and arises from various psychological, biological, and socio-cultural factors.
Recommended course: Basic Psychiatric Concepts
To some, cosmetic interventions such as liposuction, dermatologic treatments, and even surgery seem like an easy solution to the problem. This is not the case. Research shows that these treatments should, in fact, be avoided, as the core issue is not physical. Usually after patients undergo any type of cosmetic intervention, they are either momentarily happy, or not happy at all. They may then seek another practice or physician to have more cosmetic enhancement. Alternatively, they may fixate and shift their attention to another body part altogether.
Patients often avert their anxiety, depression and negative emotions from their past and present onto their body as a way to heal themselves. This is why BDD is classified as a somatoform disorder.
Effective treatment for BDD
Pharmacologically, Selective Serotonin Reuptake Inhibitors (SSRIs) have been proven to effectively treat BDD. SSRIs help patients control their preoccupations, obsessions and repetitive behaviors associated with their “defect.”
Other researchers found that patients’ response to SSRIs also included a decrease in stress and an improvement in social and occupational functioning. Additional medications that may help include anxiolytics and antipsychotics.
A second form of effective treatment is cognitive behavioral therapy (also used to treat OCD). This may include:
- Self-monitoring of thoughts and behaviors related to appearance (e.g., monitoring the amount of time spent mirror gazing)
- Cognitive techniques (e.g., challenging distorted thoughts about one’s appearance)
- Behavioral exercises (e.g., exposing the patient to a feared situation and preventing engagement in compulsive behaviors)
A nurse’s role
Nurses working with patients experiencing BDD must learn the signs and symptoms, as well as effective techniques to build self-esteem and direct the patient toward proper treatment.
Most of the time, these individuals do not even realize they have the illness. By preventing people with BDD from undergoing cosmetic enhancement, nurses can help to prevent potential lawsuits by the clients.
A common issue nurses and other healthcare professionals face is in helping their patients see themselves in a more realistic way. In a patient interview, nurses should do the following:
- Observe the patient with their complete attention (notice body language, facial expressions, does patient actively cover the flaw?)
- Use questions effectively (open ended questions encourage the patient to give more detailed information regarding grooming rituals and habits)
- Be an active listener (evaluate patient’s stress, paraphrase comments verbalized by the patient)
- Know there is no quick fix
Nurses as educators
Nurses as educators can help these patients learn more about their disorder in a non-aggressive and non-intimidating way. Always acknowledge there is a problem. Telling these patients there is nothing wrong, or convincing patients that their beliefs are untrue or irrational will make them feel as if you are discounting their experiences and feelings.
Nurses can explain to their patients that they appear to have a body image problem known as BDD. This condition is recognized in the medical field and is treatable. Inform them that many people suffer from it, and that cosmetic treatments are usually ineffective.
Other suggestions include:
- Recommend reading material on BDD
- Educating family and friends where needed and applicable
- Referring the patient to a psychiatrist for treatment with an SSRI. 13
If patients do not use the referrals, the nurses themselves can speak to the patient. Focus the conversation on the amount of time [the patient spends obsessing about how they look. Gently point out the amount of distress it is causing them and how it is affecting their day-to-day life.
Cognitive behavioral therapy
In their seminal study, researchers K.A. Phillips KA and R.G. Dufresne acknowledged that cognitive behavioral therapy is effective in helping patients with BDD. Often, this type of therapy involves exposure and response techniques and prevention:
According to the study, “Exposure consists of having patients expose the perceived defect in social situations (going to formerly avoided restaurants or stores without a hat or heavy makeup or sitting in a crowded waiting room). Response prevention consists of helping patients avoid BDD behaviors, using techniques such as covering or removing mirrors, limiting grooming time, covering skin areas that are picked, and stopping makeup use and seeking reassurance.”
Nurses play a key role in this type of therapy simply by being there for the patients. They can provide them with reassurance and self-esteem. Once there is a well-established nurse-client relationship, these patients may be willing to express themselves, as well as feel more comfortable in their own skin. Therapy also helps patients with OCD, as it helps to decrease some of their compulsive tendencies.
Simple, effective treatments
Patients with BDD are sometimes misdiagnosed as having social anxiety disorder because of their tendency to avoid social situations Stefan G. Hofmann and Nina Heinrichs from the Department of Psychology at Boston University did a study regarding the effects of mirror manipulation on self-perception in patients with social phobia subtypes.
The study consisted of 82 individuals with social phobia. Half were asked to sit in front of a mirror for 5 minutes. After the 5 minutes were over, participants were given a sheet of paper and asked to record three positive and three negative characteristics to describe themselves. The mirror was still present during this task. The other half of the participants were given the same instructions without the presence of a mirror.
The study found that patients with mirror exposure had more positive and negative self-statements about their bodily appearance. Researchers concluded that mirror exposure enhances public self-awareness.
These findings highlight the ways in which nurses can help their patients enhance awareness of themselves and their “defect.” They might act as a helpful voice to raise their patient’s self-esteem. The presence of a mirror, even temporarily, forces people to continually correct their negative perception bias about themselves.”
Additional interventions for BDD
Another cost-effective way for nurses to help their patients suffering from BDD is to promote exercise and physical activity. Patients with BDD often suffer from depression. Their perceived defect consumes their mental state.
Recommended course: Out of Darkness: Symptoms and Treatments for Major Depressive Disorder
Research proves exercise is an effective treatment for patients suffering from depression. Studies done at Duke University show “30 minutes of brisk exercise 3 times a week is just as effective as drug therapy in relieving the symptoms of major depression in the short term, and also greatly reduces the chances of depression returning.”
Amy Morgan and Anthony Jorm published research regarding self-help interventions for depressive disorders and symptoms. They also found exercise to be an effective measure to help alleviate symptoms of depression.
The exact mechanism by which exercise helps to alleviate symptoms of depression is unclear, but proposed mechanisms by Morgan and Jorm include: “Physiological factors, such as effects on sleep regulation or serotonin and endorphins. Proposed psychological mechanisms include the interruption of negative thoughts that may prolong or worsen depression, or an increase in perceived coping ability.”
Exercise, therefore, serves as a free way for patients to try to help alleviate some of the sadness and distress they feel from their disorder, and nurses can serve as great motivators and educators to these patients.
Other interventions nurses can teach their patients include:
- Herbal remedies or dietary supplements
- Omega-3 fatty acids (fish oil)
- St. John’s wort
- Vitamins
- CHO-rich and protein-poor foods may lift moods
- Autogenic training
- Bibliotherapy
- Distraction
- Meditation
- Humor
- Pets
- Prayer
- Yoga
- Aromatherapy
- Hydrotherapy
- Light therapy
- Massage therapy
- Music
- Negative air ionization
- Singing
A happier life awaits
Body Dysmorphic Disorder is underrecognized in the medical profession. Healthcare professionals need to become more aware and educated regarding this psychiatric mental health issue.
With insight and knowledge into this disorder, nurses, doctors, and others can help identify patients with BDD, initiate effective treatment, and slowly decrease the prevalence of patients undergoing cosmetic enhancements. Researchers definitively agree upon the use of anti-depressants, specifically selective serotonin reuptake inhibitors (SSRIs) in treating patients with BDD.
Even if the patient was not suffering from major depression, these drugs alleviated the symptoms of sadness in patients and help to lift their mood. This in turn affects their views of themselves and their imagined ugliness. Psychiatric therapy was also a major factor throughout the literature that was used in these patients to help alleviate and treat BDD.
Since most patients suffering from BDD in actuality do not have any real defect in their appearance, their disorder is more psychologically based and in their mind. Therefore, it is understandable why patients seeing a psychiatrist and a therapist respond with better treatment outcomes than those who undergo cosmetic intervention.
The goal is to identify these patients as soon as possible and intervene early before they choose to undergo any cosmetic procedures. Nurses can help these patients recognize their need for treatment from other sources such as psychiatry, therapy, pharmacological and non-pharmacological intervention.
Most importantly, nurses need to affirm to patients there is indeed a problem. Denial can make matters worse and will make them feel as if the feelings they undergo are not real or meaningful to the nurse.
These patients have a serious mental health disorder that can be effectively treated when healthcare professionals work together to guide the patient in the right direction to a happy and healthy life through education and intervention.
Valeria Dworkowitz is a staff nurse on the TBI unit at the Kessler Institute for Rehabilitation, West Orange, NJ.
