Podcast: Facing Insecurities With Body Dysmorphic Disorder

Jenn talks to Dr. Roberto Olivardia about body dysmorphic disorder. They discuss common signs and symptoms as well as conditions that occur alongside BDD. Roberto provides insight into technology’s impact on our self-image, as well as ways to support loved ones who have a BDD diagnosis.

Roberto Olivardia, PhD, has been treating patients for the last 20 years since his internship at McLean Hospital. He runs a private practice in Lexington, Massachusetts, where he specializes in the treatment of body dysmorphic disorder, obsessive compulsive disorder, ADD/ADHD, skin picking disorder, and males with eating disorders. Dr. Olivardia also treats patients with other anxiety and mood disorders.

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Episode Transcript

Jenn: Welcome to Mindful Things.

The Mindful Things podcast is brought to you by the Deconstructing Stigma team at McLean Hospital. You can help us change attitudes about mental health by visiting deconstructingstigma.org. Now on to the show.

Hi folks. Good morning, good afternoon, good evening wherever you’re joining us from and whatever time you’re joining us, thank you for joining to take the time and tune in to our chat about, “Facing Insecurities With Body Dysmorphic Disorder.”

I’m Jenn Kearney, and I am a digital communications manager for McLean Hospital. My co-host today is the marvelous Dr. Roberto Olivardia who actually specializes in the treatment of body dysmorphic disorder, so who better to join me than him.

Throughout our chat today, we may refer to it as BDD. So if you hear that, that’s entirely possible that it’s just body dysmorphic disorder. So like I just said, BDD it’s so much more than somebody saying that they feel like they don’t look great today or complaining about how their hair reacts to the humidity.

It’s more than just being fixated on one part of your image. It’s an actual disorder. It can go years without a diagnosis where somebody can be so preoccupied about something that you might find to be a small part of how they look, but to them, it can be crippling, it can be distressing, it can be depressing, anxiety inducing, embarrassing, and way more than that.

So today, Roberto and I are going to chat all about BDD, signs and symptoms, how it’s treated, ways to work both with and through it, and whatever else gets thrown our way for questions.

So if you are unfamiliar with Dr. Olivardia you are in for a huge treat because as I like to think of him, he is a never-ending fountain of knowledge but he’s also been treating patients for the last 20 years since his internship at McLean.

He runs a private practice in Lexington, Massachusetts and specializes in treatment of BDD, obsessive compulsive disorder, ADD, ADHD, skin picking disorder and males with eating disorders. And as if that’s not enough that he does in a day, he also treats patients with other anxiety and mood disorders.

So Roberto, I am so excited for you to be back. So thank you so much for joining. I want to get started this is a really complex condition, I want to get started, let’s just lay the groundwork right out. What is body dysmorphic disorder and what are some of the most common misunderstandings about the condition?

Roberto: Sure so first it’s great to be back. I always love doing these webinars with you and I’m really happy that we’re talking about this because there’s still so much misconception, misunderstanding and a lot of under identification of BDD.

So body dysmorphic disorder it’s a psychiatric condition that’s characterized by an individual who has a preoccupation with a part or multiple parts of their body. And this preoccupation often takes the form of significant distortion in how they perceive that body part or how they evaluate or feel about that body part.

So sometimes it can range from let’s say somebody who has a full head of hair who sees that and thinks that their hair is thinning or that they’re going bald. So there’s clearly a distortion of appearance.

Sometimes people with body dysmorphic disorder could, let’s say somebody who, I treated someone years ago who had freckles. They had freckles but they thought they looked ugly and deformed because of the freckles. So the evaluation of that part of their appearance significantly impacted them.

So you have this preoccupation and then accompanying that preoccupation are a lot of sort of obsessive thoughts around it. Individuals with BDD will often say, multiple hours in the day they’re thinking about that body part. They’re thinking about how other people are thinking or how they think other people are thinking about that body part.

So there’s a lot of sort of obsessive kind of thinking around it and then a lot of either compulsive or avoidant behavior.

So compulsive behaviors could be things like excessive grooming, it could be mirror checking, it could be trying on different outfits like multiple times, it could be taking hours to apply makeup, it could be compulsions around sort of where they stand or sit in terms of how they think that that may either flatter their appearance or not or a lot of avoidant behaviors.

So it could be mirror avoidance, not having pictures taken of them, not leaving the house, which I can talk about how BDD can look like other conditions and not speaking in public, not looking people in the eye.

So a lot of conditions and then a lot of ways of just kind of everyday living that this can really impact. And as many patients I’ve worked with over the years have said, with BDD, it’s you and your body that you find to be ugly or offensive and you’re always with yourself and so it’s going to impact multiple areas of one’s life.

And so with body dysmorphic disorder, you have this condition that also doesn’t get identified despite the fact that anywhere from 1.7 to 2.5% of the population. So we say about 2% of the general population has BDD. And that’s a significant number of people that’s anywhere from 5 to 10 million Americans alone that have body dysmorphic disorder.

However, it’s still not fully identified and diagnosed and BDD can look like a lot of other conditions. And I’ve treated many people over the years who have lived with BDD for years before it was diagnosed.

Now, having said that, certainly we see comorbid disorders with BDD but it can look like depression. Now, granted many people with BDD are depressed. But if we understand that the depression is caused by the BDD as opposed to thinking, “Oh, here’s somebody who’s depressed.”

So there are going to be multiple things about their lives they don’t like including their appearance that’s going to be, that’s not going to hit it on the mark. Similarly, a lot of people with BDD have social anxiety and social anxiety disorder.

But if we don’t understand that the BDD is the driver of that, we’re going to be treating social anxiety disorder without understanding that there’s this major preoccupation in terms of body image.

So a lot of the treatment methods that would just work with someone with social anxiety in the absence of BDD is not going to work well.

Agoraphobia. I’ve worked with people who haven’t left their house in months, in years sometimes but not because they fear having a panic attack, which is typically what you would see with agoraphobia, but because they feel they’re too ugly to be seen.

And so this, it can look like and be accompanied by these other disorders including eating disorders. Now, most people with body dysmorphic disorder don’t have an eating disorder, however, if the BDD is...

If body parts that are implicated that for that individual might result in them compulsively watching what they eat or avoiding certain things. And it’s not just around let’s say like stomach, thighs, or things like that I mean, I once worked with a young man who his BDD was around his face and he thought his face did not look masculine enough.

And so he was very concerned about how his jaw looked and he didn’t think it looked strong enough, masculine enough. He thankfully didn’t have the money for any kind of cosmetic surgery which we can talk about later why that’s not useful for people with BDD.

He had read, “Oh, well, if you lose a little weight in your face, then it makes your jawline look stronger.” And that began a trajectory of a full-blown anorexia nervosa for this individual. But the anorexia was not about him thinking he was too fat.

He said he could care less if he had Santa Claus’s belly, he said. He goes, as long as my jawline is masculine. So when I started working with him, it was sort of in the middle of him being in the throes of anorexia and it was only then that when I would assess for BDD that I realized, oh, wait a minute.

He’s right when he says he doesn’t have a fear of gaining weight because people didn’t believe that, that it really was around the BDD. So it’s so important when for clinicians, when they have clients who talk about negative body image to really assess for this.

And similarly working with people who are depressed or social anxiety, all of these other things just to ask those questions just to make sure that it’s being identified.

Jenn: If a clinician is treating or believes that there is an eating disorder diagnosis, how can they separate that from BDD or rather how can you tease that out in evaluation to see if it’s an eating disorder, BDD, or an amalgamation of the two?

Roberto: That’s a great question.

So I personally, I think that anorexia nervosa is a form of body dysmorphic disorder in the sense that I would say most of the people that I’ve treated with anorexia it may be the obvious things that you would see for people who might have preoccupation with how their stomach looks or but oftentimes if you ask the question, there are multiple parts.

I’ve had patients who talk about how their nose looks, how their skin, their eyes, the shape of their head, their genitals, like multiple kinds of things.

And so what I always want to do is have an assessment of when the negative body image sort of began like how they were thinking of themselves and whether it started with, “Oh, I don’t like the way, like where my weight is or my body shape is.”

Versus did it start with a specific preoccupation that was accompanied by let’s say neuro checking or camouflaging behaviors or whatnot. And then the restrictive eating became almost like, well here’s yet another kind of compulsion or avoidance depending on how I guess the compulsivity around thinking about calories and all of that.

And similarly, to be aware that when people recover from the eating disorder, the BDD might still be there. And I’ve seen that many times where people they can recover from the eating disorder but there’s still this significant BDD, these significant BDD symptoms that could be around other parts of their body.

Whereas like with bulimia nervosa and binge eating disorder, you’ll, you often even if people are very dissatisfied with their weight and their shape, I would say it could certainly exist. We always want to tease out like are there other parts of your body that maybe are not even necessarily related to like your weight or your body shape?

And that’s when we would tease out. ‘Cause there’s an element diagnostically in eating disorders where obviously negative body image is a component to it but we, it can also be BDD in addition to those parts of the body that are even going to really be impacted by weight in that way.

Jenn: You had mentioned before that BDD can occur with other disorders. So let’s say one of your patients has depression, which may or may not be treated by behavioral therapy as well as some type of medication.

But let’s say that you also discover that BDD is part of that diagnosis. Do you find that then a different, different route of treatment would be required because the root cause might not necessarily be the depression but it’s the BDD instead?

Roberto: Definitely and what studies actually show. So you’ll often see depression, social anxiety disorder are probably the two most common comorbid conditions that you would see with BDD. But what studies actually show is that...

Oh and obsessive compulsive disorder as well. But I also want to say that the majority of people that I’ve worked with with BDD don’t have OCD even though sometimes that often gets confused where it’s not looked at as BDD but looked at as OCD.

And what studies actually show is that even let’s say with medication from a pharmacological perspective, that people with BDD as compared to people with OCD people with depression, that people with BDD tend to need higher dosages of SSRIs for efficacy and often need a little bit longer time before patients say that they kind of like are kicking in in a way.

So it’s often longer trials for people to feel some benefits from antidepressants. And certainly and then with the BDD part of the therapy, which we can get into is behavioral kind of therapy similar to what you would see with OCD.

‘Cause BDD is, we often think, we think of it as like a cousin of OCD, it’s in that obsessive compulsive disorder spectrum although it’s not the exact same as OCD but in terms of treatment. Whereas like with depression, certainly part of depression may be helping a client, activate a client in terms of having them get moving throughout the day and doing things.

But in let’s say a typical depression in the absence of BDD, it’s somebody that might have a hard time getting out of bed because they just lack the energy, maybe they have thoughts of worthlessness and they can’t really connect to those things.

Whereas when BDD is present some of my patients even if they say that they might have the energy they’re like, “I can’t leave the house. Like I can’t be seen today even if I have the energy to do that. Even if I have the wherewithal to do it, like I can’t leave the house.”

So meaning that what we’re dealing with is now working with the BDD. It’s so important to identify to know that that’s the thing that we’re really, from a cognitive perspective and behavioral perspective, an interpersonal perspective, we have to really get at to help that person.

Jenn: This is a very basic question but because BDD is such a complex condition, can you talk a little bit about some of the more common symptoms that would either indicate that you or somebody that’s close to you might be struggling with body dysmorphia?

Roberto: Yeah so, and this is a good question especially I get asked with parents who have teenagers because as adolescents all of us are insecure about our appearance and our body image, we’re going through puberty, it’s not fun.

At least it wasn’t for me, for a lot of people it’s not a fun thing. So there is this attention that we place on our appearance that can feel overvalued. And so it is something that can be tricky because it’s like, “Well, how do we distinguish between kind of typical adolescence and BDD.”

And I think of it in these different categories. So one is the sort of extent of distortions and body image that certainly someone might be like, “Oh, I look really ugly today.” Let’s say a teenager or someone might be like, “Oh, I look heinous today. I look ugly.”

And the question is do they really think that they look ugly? Is it something that they’re just saying? And maybe they might feel that way because of how their hair looks that day or the clothes that they’re wearing. But they, later that day or the next day they feel fine and they think they actually look great.

And so a lot of times you won’t see as much of that inconsistency with BDD. Usually the inconsistency is I feel horrible and ugly and at best I feel like I’m neutral, like I’m not standing out as much. People with BDD often don’t see themselves as ever looking great, they just see it as like I can at least blend in or I’m standing out because I’m so ugly.

So the extent of the distortions that become, that are very consistent that you kind of see day to day that somebody’s saying no, like I don’t and where people genuinely don’t understand how people could see them as looking attractive.

So people with BDD in one hand you would think that what would be helpful for them is to be someone telling them, you look fine, you look great, what are you talking about?

It often doesn’t get absorbed to that person because they’re like, yeah, if you saw me up close or if you saw me without makeup on or if you saw this, if this, this, this, this, and this you would see it the way that I see it.

And body image is a, it’s a very interesting phenomenon because it’s not psychosis when we have these sort of body image distortions. Although you can see psychotic thinking in BDD but it’s not a psychotic disorder.

Body image is this kind of complex interplay of our attitudes about the way we look, the social cultural imagery of what we think we should look like, all of these kinds of things. So if we see ourselves a certain way and somebody is telling us that we look fine a.k.a. we look different than how we see ourselves, there’s a dilemma there.

The dilemma is, “Well, either I’m wrong and I’m not perceiving myself correctly or they’re wrong.” And it’s almost like more human nature we want to see ourselves as rational even though it would be better in some ways for a person to think, at the end of the day I don’t want to feel ugly so it would be better for me to almost buy into that this other person’s perception of me is accurate.

But I think it’s human nature we want to see ourselves as rational and so people end up thinking, “No, the way I am seeing myself is the correct way.” So there’s that rigidity with the body image distortions.

The second is the amount of value that somebody attributes and in terms of their self-worth how much it’s connected to their appearance. Obviously feeling good and looking good is going to be part of our self-esteem and how we see ourselves.

But the patients that I work with with BDD, it is the number one thing on top of things that they can even see, they can say, “Yes, you know, I’m a straight A student.” Or, “I’m really good at my work and I know that my kids love me and I’m a good father.”

But with the pathology of BDD is it has people easily dismiss all of those accomplishments as if they don’t mean anything because they, “Look ugly.” That all of those things would be fine if I look good but those things either don’t matter or they’re not getting absorbed and internalized.

So the appearance becomes a very, very paramount part of their self-esteem to the degree that they can’t even internalize those things that anyone of us would say, this is a really great thing about you.

The other piece is the extent of compulsive behaviors and avoidant behaviors that the person is engaging in. It’s one thing to be, to take an hour to get ready for a party that you’re going to you want to look your best. It’s another thing when it’s three, four, five hours.

I’ve had patients who have taken five wake up at 3:00 in the morning to be able to leave their house at 8:00 A.M. to go to work because of all the rituals that they feel they need to do for something. And it’s tormenting.

BDD is an incredibly, incredibly difficult disorder for people to be struggling with. And even when that person leaves the house, they don’t feel great. It’s not like, they’re like, okay, great. They just feel like not as bad as they would in their minds if they just had to just leave the house.

So when you have those kinds of behaviors and then avoidant behaviors, people are like, “No, I’m not going to go out today.” Or “I don’t like to go to that place because the fluorescent lighting highlights wrinkles in my face.” Or you kind of hear these very, these intricacies of kind of all these behavioral kind of manipulation and there’s so much thinking.

I mean, I am working with these patients, I connect to how exhausted they feel, honestly there’s so, and that’s where depression can come in, is just, they’re depleted of so much energy because of these kinds of behaviors.

And then the other part of the obsessive thinking, is it something, even for all of us, all of us can point to things that we don’t like about the way we look but is this something that is on our mind continuously?

Is this something that we assume when someone first sees us, that’s going to be the first thing they see and if it is the thing they see that they’re going to judge us as being worthless or ugly, that, “Oh, that person is not worth having a relationship with and should never get married or have children.”

People with BDD have very, very, very harsh self-talk. And then the last part would be particularly very like dangerous kind of behaviors that you can see with BDD. And you’ll see things like skin picking, very compulsive skin picking or people who will buy anything.

I mean there’s a lot of industries that make a ton of money off of people’s insecurities and appearance concerns. And patients with BDD are a prime vulnerable population for snake oil, for anything that will lighten skin, get rid of wrinkles, get rid of cellulite, grow hair, increase penis size, you name it.

I’ve had patients buy things that at best don’t help with anything but don’t harm at worst have caused significant medical harm to them because they’re just buying things, just hoping. And then this is also a population that coupled with financial resources are highly prone to getting plastic surgery.

And a lot of times I’ll see a patient after they’ve gone to a cosmetic surgeon. So cosmetic surgeons often are at the front line sometimes of first seeing these patients who come in but they find out pretty quickly that these are also patients that unfortunately are never going to be satisfied by it.

Jenn: So what is... I want you to talk a little bit more about the relationship between getting plastic surgeries and what some cable networks will refer to as plastic surgery addiction without even addressing body dysmorphic disorder.

Is that a different type of disorder or is it just, is it BDD manifesting in compulsive surgery habits? You got to help me out here. I’m running out of ways to describe it

Roberto: No, you’re doing, you’re right on the money. It’s actually called the poly surgery addiction is the term that’s used.

And it often, I wouldn’t say that all poly surgery addicts have BDD because there could be other reasons that people are, but that would be the first thing that I would want to assess if I were a cosmetic surgeon and, years ago, it was never assessed in the field of cosmetic surgery and this is going to sound a little cynical but there’s a lot of profit made from cosmetic surgery.

It’s not covered by insurance, it could be very lucrative especially if you have a repeat customer and BDD patients who have the financial resources are going to be repeat customers.

Now where the tide started to turn was that patients with BDD could be quite litigious sometimes if they get it because again you’re dealing with someone who doesn’t have an accurate sort of perception of their body image to begin with and/or the evaluation.

What they’re really looking for sometimes isn’t even around the way they look as much as how they want to feel. And you can do a rhinoplasty, a nose job 10 times you’re not going to guarantee that someone’s going to feel differently. You can guarantee that the shape of their nose is going to be different, but how they’re going to feel, that’s a whole other thing.

So BDD patients, there are multiple cases of them suing cosmetic surgeons for malpractice. There have been cases of patients with BDD who have harmed their cosmetic surgeons even in the form of homicide because of just them feeling so distraught.

And I don’t want to paint this picture that all people with BDD are capable of violence, that’s not. But I think it’s for a certain subset of individuals, the desperation for them and all their hopes going into this idea that cosmetic surgery is going to fix everything.

The cosmetic surgery industry definitely started to take a different look at it and there is more assessment. Although you’ll always find surgeons that even when they know that somebody has this condition will take the approach of it’s not my place to tell someone whether or not to have surgery, there could be a debate about that.

I think we absolutely should be assessing for that because ultimately we want to do no harm and we want to help people and I’m not slamming cosmetic surgery. Studies actually show that the majority of people who get cosmetic surgery, people without BDD who get cosmetic surgery feel quite positive after it.

However, the overwhelming majority, studies show over 90% of people with BDD when they get cosmetic surgery either they will feel more negative or in six month follow-up feel more negative about it or start to feel preoccupied with another body part.

So I had a patient multiple patients who may have against my advice and recommendation might’ve gotten a cosmetic surgery procedure and then they’re like, “Well, I like my new nose, but now my cheekbones don’t look right. So I’m thinking of getting my fat sucked out of my face or whatnot.”

It could be a never-ending kind of cycle. So it’s definitely, it can be very problematic. And something also to keep in mind that cosmetic surgery is surgery.

I mean, some of the things that patients of mine have subjected themselves to are quite harmful and it can be months of recovery, and it’s not uncommon to then see sometimes dependencies on certain substances like opiates to just recover from pain with some of the surgeries that they’ve endured.

So I think we still need to do a better job at assessing for that and within that industry and really having discussions around it.

Jenn: So do you have any recommendations on treating someone with BDD that has continued to go through multiple surgeries?

Roberto: Really, I mean the treatment, when I’ve had patients who have had surgeries, and in my treatment model is really to help them to regulate their expectations about it.

Again, I wouldn’t be recommending that somebody get surgery but if somebody does, I see my role as, okay, first of all what is it that you think is, how much of your life is going to change because of it? And a lot of times you’ll hear these assumptions that are almost like red flags for anyone.

“Oh I know that once I get this done I’m going to I’m going to have the confidence to be able to do all these things or people are going to approach me,” because maybe the person is socially anxious, even independent of their BDD that they assume if I look a certain way then people will just kind of gravitate to me and it’ll make everything easier, it’s going to make everything easier.

It’s like if, again, if you look at the data people who get cosmetic surgery, they might feel a heightened positive impact of their body image if they change a certain part, but it’s often not the sort of like life changing kind of thing.

And I’m talking about cosmetic surgery not reconstructive surgery, which is different. That’s more when people have had injuries and things like that. So I try to help that person regulate their expectations. I have to say you know, generally speaking, it’s very, very difficult to do that.

Like because I mean again, when we understand even how behavioral psychology works is if you’re going to pay 10, $15,000 let’s say for a procedure and you’re going to subject your body, you’re going to put yourself under anesthesia, you’re going to recover from pain from that, it has to be worth it in your mind, you have to on some degree think that this is going to make a major difference to be able to subject yourself through that.

So I recognize it can feel very pointless sometimes to do that but that’s what I’m trying to do. And then more importantly, if I’m working with someone, post-surgery how to help with the fallout of what the expectations that don’t get met, the emergence perhaps of other body parts that they start to get preoccupied with and really urging them.

That if let’s say they’re hoping that the surgery makes them more assertive. It’s like, well, we can work on assertiveness skills right now, we don’t have to wait till your breasts are bigger or until you have pec implants, like we can work on that right now.

I want to be able to leave the house, we can work on that right now. And so that’s what I try to get somebody back to is like all of those things we can do, there’s nothing that we can’t do right now.

Jenn: It’s almost like you have to have the discussion that a lot of the work needs to be done internally before anything regardless of what is going to change externally, right?

Roberto: 100%, absolutely.

Jenn: Are you familiar with research or statistics around BDD and transgender populations?

Roberto: So that’s a great question. Years ago, I did this show for National Geographic and it was about body image and they featured various people including a woman who had BDD, who had very large breast implants, a woman with anorexia, a woman who had leg lengthening surgery.

And they featured a transgender woman who wanted facial feminization surgery. And I had a real problem with them including that particular person with these other individuals. Now, this was years ago where I think just trans visibility was very, very different than what it is now.

And I said, well, I just want to be clear. I wouldn’t carry, from what I know, I didn’t evaluate the person personally, but just they show me all the video interviews and everything. I said, I wouldn’t characterize this person as having body dysmorphic disorder.

That someone who’s trans, who is, for this individual is a trans woman wanted facial feminization surgery because that was the sort of the body that this person connected with and identified with. And as we know, the rate of violence is so high amongst trans populations that it’s connected to a level of survival in some ways.

To look and have the certain, the appearance and the body of the gender that you identify with. I said, I wouldn’t put this in with that.

They disagreed with that at the end and this person was placed in that which I, it still bothers me to this day that that, because I think it put into this sort of a very different kind of topic which is now that’s not to say that trans individuals can’t have BBD, but we do want to clarify for someone who’s trans who, certainly we see a lot of body image issues understandably because they’re not connected to sort of the gender that they were assigned at birth.

So whether it’s someone who’s going through hormone treatment or genital surgery, top surgery, those kinds of things, that is a very different thing than with body dysmorphic disorder.

Now, again, you always want to assess like, okay, the parts of them that are feeling negative about their body image or where cosmetic surgery is involved is this related to them in promoting their trans identity which is not a psychiatric disorder or is this somebody that even when their trans identity is sort of solid like there’s significant body dysmorphic disorder concerns.

So you could also have BBD. But that’s something that’s very, I mean it’s a great question because it’s something that it still bothers me that that happened. But again, hopefully nowadays that wouldn’t be included in there with more visibility.

Jenn: Hopefully that’s something that they changed as it’s existed maybe they’ve redacted. One could only hope.

Roberto: Yes.

Jenn: Can you talk a bit about BDD in men? One of the things I wanted to touch on in this session is muscle dysphoria.

‘Cause a lot of times if somebody is vaguely aware of BDD a lot of times your mind goes to a female with an eating disorder because that tends to be the more popularized idea of BDD but it happens a lot in men. Can you speak a little bit more to that?

Roberto: I can speak a lot more and I know you and I have a webinar next month on male body image that we can definitely dive deeper.

So my interest actually in this came from almost 30 years of working with men, in researching men and boys with eating disorders and with BDD and Dr. Harrison Pope who’s a psychiatrist at McLean who has been, was a mentor since I was 19 when I was at Tufts University, fantastic, brilliant individual and we have done a lot of work over the years and we co-authored a book years ago called, “The Adonis Complex.”

And which talks about all the different manifestations of body image issues that you see in men. With BDD, with the male body image webinar we can get into sort of some of the other parts but with BDD specifically, what surprises people is BDD is pretty even in terms of gender distribution.

Years ago it was like you’d see 51% male, 49% female. Some studies today might say like 60% female, 40% male. I could tell you from my experience, it’s been pretty even, and with colleagues of mine who treat people with BDD, they see just as many men as women.

If anything it’s probably even less identified in men because there’s so much shame that for a lot of the men that I work with, I may be the only person that they have shared that they have BDD because for fear that people might think they’re too vain or that they’re being silly or things like that.

So you see all of the same, it could be issues with preoccupation with skin and with hair, with all the different parts of the body with genital size and things like that.

But one specifically where Dr. Pope and I, we were noticing and this was in the ‘90s ,we were seeing men in research studies who may have had anorexia as boys but then they sort of resolved the anorexia but they would have something that at first was called reverse anorexia, which is that they were just as obsessed with their body image and counting calories and everything except they weren’t looking to be skinny they want to really be big and really be muscular.

And Dr. Pope is one of the leading authorities on anabolic steroid use. And we would also find that these were men who would often engage in anabolic steroid use to really bulk themselves up. But these were individuals who no matter how big they got, they didn’t, they couldn’t see it. They had distortions and thinking that they look too small or they have the fear that they were looking too scrawny.

And so we wanted to change the name because we thought reverse anorexia made it sound too much like it was always about an eating disorder and not all of these men had eating disorders. So we coined this phrase, muscle dysmorphia, which is really a BDD, it is a body dysmorphic disorder but it’s one that specifically is around muscle mass muscle size.

And the majority of people who have muscle dysmorphia are men although there are some women that could have muscle dysmorphia as well. But these are not the guys though that you’re going to see with their shirts off parading on the beach or at Venice beach.

These despite being really muscular, a lot of the men that I work with will wear like long sleeve shirts. They go food shopping at nighttime. They don’t want to be seen during the day.

They just think they look like not just skinny but like in their minds like unusually scrawny, skinny or they might know they’re muscular but they fear one workout could easily put that all to shame in their minds and then suddenly they’re going to lose all their muscle mass.

And so a very high, about 50% of men with muscle dysmorphia use steroids. And so any clinician or physician who has a patient that’s using anabolic steroids for nonmedical purposes I think should assess or have that person be assessed for body dysmorphic disorder because it’s something that…

It makes a lot of sense like why they would gravitate to something like that because the truth is that steroids work from the perspective that they make you really muscular. Of course, they come with a whole host of adverse physical and psychological consequences and can lead to early death for people.

But absolutely, it’s definitely something and that in the bodybuilding community when we’ve done research and you’ll have some people that laugh it off and say, “Well, we’re all muscle dysmorphic,” and then they’re but that’s not true.

There are a lot of weightlifters and power lifters and bodybuilders that don’t have muscle dysmorphia but that can be a hard thing to tease apart as well.

Jenn: I’m curious because something that has been talked about mostly since the pandemic is people are experiencing Zoom distortion. They say, shut your camera off, don’t look at yourself for extended periods of time.

Do you think that there’s any relationship between BDD and our increased use of technology? Like I know Zoom now has filters. You can’t go on a social media app without being annihilated with a variety of filters. So do you think that there’s any relationship or that there may be in the future?

Roberto: Yes, one of the benefits of having done this work for as long as I have. So starting in this before social media when the internet was just, which makes me sound like I’m in the dark ages.

Before the internet was a thing, I can tell you there is without a doubt an inflection point when social media became sort of increasingly more popular and what I hear from patients particularly young patients, teenagers and the pressure I can just hear it.

And in terms of the vocabulary and I think it’s really important for people like myself who didn’t grow up with that it’s so important to keep in mind, okay, when I was young, like nobody walked around with cameras.

And so pictures were taken of you when you looked your best typically. When you’re going to a party or some kind of event. Maybe if you’re on a camping trip or like memories or things like that.

But now particularly young people, they could have their picture snapped at any moment and have it put on a platform where lots and lots of people are going to A see it and are going to evaluate it. Like they’re going to click--

Jenn: And it might be done without them even knowing that it happened.

Roberto: Exactly, so you can’t even smile for the camera, you can’t even strike a pose. And so you’re going to have people evaluate it and like it and then you’re going to have people that say really vile nasty things.

And cosmetic surgeons actually say that years ago they used to have patients come in with photos of celebrities saying, I want this butt of this person or this or that. Now, they’re coming in more with filtered Photoshop images of themselves and saying, “This is me.”

Of course, it’s not with all these filters. And this is what I want to look like. And there’s a good body of literature and if you watch the news recently with what’s been talked about with Facebook and Instagram and everything.

But there is an empirical research showing that a very strong correlation of Instagram use and social media use with negative body image. And for boys as well as girls this isn’t something that just affects girls.

I have a 16 and a, a 16-year-old son a 14-year-old daughter and all they have is Snapchat. And I’m trying, I’m going to, my goal is to get them through high school with, no, they don’t have Facebook, no Instagram and when I say that sometimes people are like, “Oh my gosh, like how?”

But I feel very, very strongly about that because that sort of just being subjected to like all of that sort of like imagery and everything. And what’s interesting is that the studies actually show even like with body positivity, so like on Instagram, let’s say you have an artist or a singer who might have a larger body or whatnot that is in a bikini and people are like, “That’s great.”

We’re not just looking at like size zero. The fact of the matter is studies show that even that still induces a level of body image dissatisfaction because it’s still objectifying like it’s still the sense of, “Oh, people are still noticing bodies at the end of the day.”

And it’s not to say that people shouldn’t be proud of their bodies and shouldn’t but the idea that we have to be aware of even like with body positivity, that there’s still this message of the body, the body, the body, the body that we’re looking at and we’re evaluating.

People are applauding you and people are like, and that messaging as opposed to well, are people posting other things on Instagram, like things they’re creating and music that they’re making, Legos that they’re building with their kids.

I mean, whatever it is. So there we have to really be very responsible and literate around that kind of messaging ‘cause studies show that even when people understand, “Oh, this is obviously photo-shopped.” And, “Oh yeah, Kim Kardashian is filtered here.”

Studies show it still makes an impact even when we know it because at the end of the day we’re still seeing an ideal image. If I see an image of a guy and I know, “Oh, that six pack is totally filtered.” The fact is I still see it and if I evaluate that is like, “Oh, that looks really nice.” That could easily reflect back to me to an individual to be like, “Oh, I don’t have that.”

And then it sort of goes. So it’s impossible obviously to shelter, it’s not like I’m realistic and that I’m not sheltering my kids from some of that, I’m just trying to mitigate it. And I just think with social media, we’re seeing something we’ve never seen like just this intensity of it that this world that people live in around it.

Jenn: And it’s also become just a public forum for anybody who has the accessibility to criticize from behind a screen whenever they want to.

Roberto: Yeah.

Jenn: It’s a lot.

Roberto: It’s a lot, it’s a lot, absolutely.

Jenn: It makes me think of I think was it Sunday that Adele was on Oprah? I feel like I’m dating myself. Like I don’t even know what date it was, but Adele has lost a substantial amount of weight over the last year and a half or so and one of the most popular conversations on my tailored Instagram feed was it’s so nice to see that Adele didn’t lose her singing voice when she lost weight.

And someone responded saying, “Well, she’s not Ursula from ‘The Little Mermaid’. It’s not like her voice and her weight are directly attributable.” But it’s astonishing to see how much society values somebody who has “the ideal” versus someone who is equally as talented who weighs more. It’s like, I still can’t wrap my head around it.

Roberto: Yeah, it is. It’s a tough thing because there’s, obviously we live in a culture that is it’s undeniable that we’re getting these imagery and these messages and celebrities.

We see these celebrities but we, I remember working with a woman years ago who had had a baby and two months after she, and she had BDD around lots of things, but one of the things she’s like, I can’t lose this baby weight.

And she had seen I think it was Heather Locklear had just given birth and was on “The Tonight Show” and looked like Heather Locklear like pre and she’s like, it’s like I saw her and looking like why can’t I do that?

And of course, right, like you’re having the same reaction I had it’s like, like you understand that Heather Locklear has a personal trainer, a nutritionist, she probably has many nannies. Like her life is a very, very different life and I’m not knocking Heather Locklear but we have to be realistic that that is not the sort of norm.

Like I will never have the body that Mark Wahlberg has ‘cause number one, I’m not waking up at 4:00 A.M. and doing what he’s doing, but also I’m not getting paid $20 million to have that body. This is their commodity, like this is their currency in a way. So we have to have those kind of conversations but...

And the good news is that there is more of a push with like embracing different bodies and different looks and different appearances but we also have to be careful again of does it always have to be about like the body in that sense. And it’s not that we should deny our bodies but, right?

Like Adele is like, has an amazing, amazing voice. Okay, she lost weight, but I’m sure that she’s probably going to be hearing, in every interview that’s probably going to be brought up and it’s like, okay, really? To me that’s not interesting. It’s like, okay, she lost weight.

If she’s healthy, I want her to be healthy. She has an amazing voice. I want her to keep recording albums. That’s what I’m interested in. But I’m sure she’s sick of talking about it but it’s one of those things that it’s like, it still amazes me why that becomes such an interesting point of conversation in that way.

Jenn: I’m curious. I want to know what are some of the things that you shouldn’t say or do when you’re interacting with someone who has BDD. And I have a personal anecdote for this, I have a friend who has body dysmorphic disorder and in my opinion, she is absolutely stunning. And she shared this in a group of friends and everybody immediately dismissed her.

You’re so tall, you’re so thin, you’re so beautiful, you have no reason to feel the way that you do. And she stopped being friends with a lot of them. And I can’t say I blame her, but based on that alone, clearly those are some of the things you shouldn’t say, but like what else should you avoid? How can you be more encouraging without being dismissive?

Roberto: Yeah so that is, I think what people have to keep in mind is that people with BDD are not looking at themselves and perceiving themselves in the ways that you may be. That’s part of what BDD is. It definitely can engender that response from people that are like, what are you talking about?

Like, I mean, sometimes there’s hostility. I’ve had patients who right that objectively people would look at and think this is not only not an unattractive person, but this is a very attractive person. And sometimes there’s hostility among people like, what are you talking about?

Like your friend there people are sort of projecting like, because their assumption is, well maybe if I look that way I’d be totally fine. Like, I’d be happy. So it is very dismissive or to just be like, and this is definitely teenagers with BDD encounter this but it could be anyone it’s like, oh, that’s like a phase you’ll get over it.

There are misperceptions that this is vanity, that somebody is sort of being self-centered that they might be saying that ‘cause they’re really looking for compliments and whatnot. That’s not the case. Like even with re...

So reassurance seeking is a very common compulsive behavior that people with BDD do but it’s not in the same way like, oh, shower me with praise ‘cause I know I look great and I want to hear it.

They’re almost like, there’s this interesting dilemma with reassurance seeking ‘cause it could be, do I, do my lips look weird or do they not? And if someone’s like, no, they look fine.

Maybe for a second, that will feel good for the person but that’s it and it fades and reassurance seeking, it can become like, I remember years ago a dad had called me and he said, I have a son and he has literally asked me in the last hour, I counted 100 times he has asked me whether he looks muscular enough, whether he’s shrinking 100 times, he literally tallied it.

And he said and I think I probably made the mistake because at the beginning when this happens, I would say, oh yeah, you look great, you look fine. And always commenting as opposed to saying, I’m not going to, like what I recommend to partners and loved ones when someone with BDD asks for that is to say, I’m not going to comment on that.

Because anything can be and this isn’t the fault of the patient it’s just the nature of the disorder that if you say, oh yeah, you look great today. Well, today does that mean yesterday I didn’t look good.

Like, do I look better than yesterday? Then what made me look better and it can, and then you find yourself in sort of this rabbit hole in that way. So you don’t want to dismiss it and I think especially what people with BDD, probably the number one thing that people with BDD hate hearing the most is looks don’t matter.

This idea of like, oh, it looks don’t matter. Especially, again if you’re telling an adolescent that you are immediately going to be discredited and as a therapist, clinicians, I’ve had patients that have said that they’ve had clinicians say that and they’re like, you don’t live in the real world.

Now, my take is what I tell patients is of course we live in a culture where people are discriminated against based upon appearance and body size and whatnot. And at the same time, I’m not saying that because somebody looks a certain way that they’re automatically not going to be loved or get a job or those kinds of things.

So we have to look at the in between. Like, for example there are studies in the body image literature that have shown that assertiveness, for example, like when they looked at men in height, that they found that men who are taller tended to make more money.

But then luckily someone, another team of researchers followed up on that study and looked at the role that assertiveness played and it turns out it wasn’t height per se, but it was the role of being assertive.

So if you were a shorter guy who was more assertive, you are more likely to get the higher salary ask for promotions and things like that. So that’s probably the number one thing. If you’re like looks don’t matter, it’s like, well, they do and at the same time they don’t matter to the degree that the person with BDD thinks that they play out for people.

Jenn: I would be remiss not to ask you with full understanding that we don’t have a ton of time left, but can you talk about some of the ways that body dysmorphia can be treated with the full understanding that every individual with it is going to have a different approach to treatment. What is going to work for my next door neighbor is not going to work for me and so on and so forth.

Roberto: Yeah, so BDD is really the primary mode of treatment would be cognitive behavioral therapy. So you’re really targeting the thoughts, the cognitive part would be the thoughts and sometimes the distortions and thoughts that people have, the assumptions that people have.

If I don’t look a certain way then I can’t be loved. I can only leave the house if I look good. These kinds of thoughts that you want to challenge. But the real, for me, the primary thing for most people is the behavioral work.

If somebody is in the bathroom for hours mirror checking, they’re not going to be able to do anything else. So we need to get them out of the bathroom. If somebody is not leaving their house, we need to get them out of the house.

If somebody is spending five hours a day applying makeup, we need to get that down to 20 minutes. And so it’s very similar to what you would see with obsessive compulsive disorder, exposure and response prevention treatment, very, very difficult. It’s very hard and it could be anything.

Whatever the issue is, it could be having patients stand under a fluorescent light let’s say if they’ve been avoiding it. There’s something called mirror retraining which is where, ‘cause you don’t want someone stuck in the mirror but you don’t want someone avoiding them mirror either.

So it’s looking in the mirror but then how do they assess their appearance objectively which is hard for most of us to do, but really what you want the mirror to be is, okay, do I have spinach in my teeth? Is my hair brushed well? This tie goes with this shirt, boom, I’m done.

But we don’t want to get internal with it of, I look so this or anticipating all the events that could happen in that day based on how you look ‘cause then you’re now, it’s like caught going down a rabbit hole.

So the cognitive work, behavioral work, a lot of sort of interpersonal therapy. Again, you’ll often see issues with self-esteem, sometimes you can see issues of trauma, issues around assertiveness, anxiety, mood disorders.

We want to make sure that we’re treating that aspect and how these individuals relate to people. There’s a relational aspect to BDD as well that somebody in a sense is reducing themselves to like their nose or their hair or whatnot and kind of discounting all of these parts of themselves that they’re not really expressing relationally to other people.

And so it becomes this self-fulfilling prophecy ‘cause if I walk in a room and I’m not going to say anything because I fear you’re going to think I’m ugly and I don’t say anything I’m not showing you all those parts of me which means you’re probably not going to approach me if we were at a cocktail party or something.

But then I could leave with the impression of, oh nobody talked to me because I look so ugly as opposed to understanding, oh, wait a minute this is how we need to sort of break that behavioral pattern.

And then for people with significant anxiety, depression, medication is often used in adjunct to that other treatment. That’s basically in a nutshell and education. Books like “The Broken Mirror,” a classic book by Katharine Phillips who also co-authored “The Adonis Complex” with Dr. Pope and I just learning about BDD and getting support.

Jenn: Last but certainly not least any other books or resources that you would recommend if folks want to learn more about BDD?

Roberto: So the classic book is “The Broken Mirror” that Katharine Phillips who really is the main, really put BDD on the map in terms of what we know about it psychiatrically.

“Feeling Good About the Way You Look” I believe is another book, Dr. Sabine Wilhelm who’s actually here at Mass General Hospital who has done a significant amount of work with BDD. That’s a fantastic book.

“Adonis Complex” I guess a plug for my book. That’s tailored to men and we talk about BDD but we talk about body image and issues with boys and men in general. Those are the ones that definitely come to mind but those are very comprehensive books.

Particularly the “Feeling Good About the Way You Look” has a lot of self-help exercises in it as well that could be very helpful for people to even examine what their thoughts are about their appearance. So even be mindful of what they’re saying to themselves when they look in a mirror or something like that.

Jenn: Fabulous, no surprise on this end but this was marvelous and I really cannot thank you enough. So Roberto, from the bottom of my heart, thank you so much for sharing all of your knowledge and experience with us.

And if you are tuning in this actually concludes our session. So until next time, be nice to one another but more importantly, be nice to yourself. Thank you and thanks again, Roberto. Take care.

Roberto: Thank you.

Jenn: Thanks for tuning in to Mindful Things! Please subscribe to us and rate us on iTunes, Spotify, or wherever you listen to podcasts.

Don’t forget, mental health is everyone’s responsibility. If you or a loved one are in crisis, the Samaritans are available 24 hours a day at 877.870.4673. Again, that’s 877.870.4673.

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The McLean Hospital podcast Mindful Things is intended to provide general information and to help listeners learn about mental health, educational opportunities, and research initiatives. This podcast is not an attempt to practice medicine or to provide specific medical advice.

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