Body Dysmorphic Disorder | NCMHCE Exam Review | Clinical Issues

Hey there everybody, and welcome to today's presentation on body dysmorphic disorder. I AM your host, Dr. Donnelly Snipes. In this presentation we're going to define body dysmorphic disorder, explore symptoms and issues experienced by people with body dysmorphic disorder, identify common co occurring issues and review literature on current treatment strategies for body dysmorphic disorder. Body dysmorphic disorder, or BDD is characterized by the belief that some aspects of a person's appearance are ugly, unacceptable or otherwise deformed, when in fact this is not the case. So it's important to recognize that to the average onlooker, this person does not have any sort of deformity, but to the person looking in the mirror, they see one. Those with BDD often over focus on details of visual stimuli rather than global aspects. So instead of focusing on their entire face, they focus maybe on their pore size or the size of their nose. And they're not able to or have great difficulty seeing anything else in their face. It's just their attention is drawn to that one area. BDD sufferers can become preoccupied with any aspect of their appearance, but the most common concerns relate to their facial features, including their nose, eyes, skin and hair. Well, this makes sense because that's one of those areas of our body that we have a lot more difficulty concealing. Preoccupations regarding perceived physical flaws may contain consume an average of three to eight hours per day. They're intrusive and are associated with significant anxiety and distress. So thinking about this perceived physical flaw takes three to eight hours per day. And it's not just a fleeting thought throughout the day. It's something that is extremely prevalent and all consuming in somebody's thought pattern. Compulsive behaviors designed to reduce the anxiety are repetitive and time consuming. About half of people with BDD spend three or more hours per day engaged in them and they are hard to control or resist. These preoccupations are associated with low self esteem. So whatever the person is preoccupied about, if it's their nose, their skin, their hair, their body shape, these preoccupations are associated with low self esteem, feelings of shame, depressive symptoms, anxiety and guilt. So let's talk about those, you know, just real quick. Low self esteem. People in our society today often base a lot of their self esteem on their physical appearance. So when a person feels like there is a part of them that that is not acceptable, then they may feel that they are not acceptable. It can contribute to difficulty in relationships. It can contribute to low self esteem because they want to be able to go out and do things, but they can't because they are overwhelmed with fear of people making fun of them, feelings of shame about their perceived disfigurement, and as well as about their awareness of their behaviors and their preoccupations. Depressive symptoms are associated with a feeling of hopelessness and helplessness. And when you're dealing with something that's a part of your body, it can feel hopeless and helpless. Anxiety often has to do with rejection, fear of people seeing you, fear of being made fun of. But it also can relate to fears of being alone, or fears of being abandoned, even by the people who do accept you right now. And guilt. A lot of people with BDD have a lot of guilt because they want to be able to go out and spend time with their friends. They want to be able to do things like the average person does, but they are so paralyzed by their fears that they are not able to do those things. And they may try sometimes and then end up canceling plans, which compounds their feelings of guilt. Individuals can be preoccupied with their overall appearance as well, including muscle dysmorphia, form of bdd. And muscle dysmorphia is the belief that one's body is too small and inadequately muscular. And we're going to talk about differential diagnosis in a little bit. BDD is different from eating disorders, but people can have both BDD and eating disorders at the same time. The average age of onset for BDD is 17 years, with a probability of full remission over four years with treatment is only about 20%. All right, that is a devastating number. That tells us we don't know enough about what's going on. And you're going to see as we go through today's presentation that BDD is grossly understudied. The prevalence of BDD is approximately 2% in the general population. So when you're, you know, out and about, or when you're at church or when you're at the store, two out of every 100 people struggles with BDD. Now, that's kind of a skewed perspective because a lot of times people with BDD aren't going to be at the store and at church and those places. But recognize that two out of every 100, that's, you know, really actually a lot of people. The estimate of the prevalence of BDD in the college as well as the clinical population, and I thought that was interesting, both, you know, the collegiate population at large, as well as people that are seen in clinic for mental health issues. The prevalence is 5%. So that's five out of every 100, more than double what we see in the general population. Which tells us that people who are in college or in their late adolescent period from 17 to 24, they are at very high risk for the development of BDD. And we need to acknowledge it. Early intervention is a whole lot more effective than later treatment. So we need to do what we can in order to try to identify and start addressing this early to the best of our abilities. The DSM 5 has recently reclassified BDD as being part of the obsessive compulsive disorder spectrum. Although insight is found to be lower in BDD than in ocd. And that sounds really derogatory, but what it means is people with BDD have less awareness of what may have caused their symptoms, and they may have less awareness of how their symptoms may be blocking them from achieving their goals and how their symptoms may not be actually based in fact. So it doesn't mean they can't develop it, but it's interesting to note that their insight is somewhat lower. So from a cognitive standpoint, there's more work to do with people with bdd. Treatment, however, is less of a challenge now that we have etherapy. Used to be when people had to come into the office for treatment, people with BDD would often want alternate entrances. They would want appointments at times when you didn't have anybody in the waiting room. And there was a lot of anxiety about even coming to treatment because they would have to be seen by the receptionist, by people in the hallway, by others. So with etherapy, it is possible to initiate treatment in a virtual, from a virtual standpoint. So they're only having to concern themselves with being seen by the therapist. Comorbidity with BDD includes major depressive disorder, which makes sense. You know, we talked about how if you are feeling very self conscious, if you are feeling like there's something about yourself that is unacceptable and unchangeable, that can contribute to feelings of hopelessness and helplessness. Anxiety disorders relating back to that fear of rejection, fear of being made fun of, fear of not being able to live the life that you had hoped. Obsessive compulsive disorder and substance use disorders. 48.9% of people with BDD were diagnosed with a substance disorder in their lifetime. So they may not have it all the time, but about 49%, about half of people with BDD have or have had or will have a substance use disorder. Let's think about that. Where does that come from? A lot of people engage in substance misuse in order to numb their feelings in order to self medicate concurrent mental health issues and those are the two big ones that we're really going to talk about. So it's important to recognize the substance use disorder is often a symptom of a much larger underlying problem. Unfortunately, when people start using substances it further messes up their neurotransmitters. And we are going to talk in a minute about how people with BDD are thought to have lower levels of dopamine and guess what? Substances increase dopamine. Major depressive disorder has a lifetime prevalence of co occurrence with BDD of about 75%. So three out of every four people with BDD also have major depressive disorder. Now that's differentiated from persistent depressive disorder or dysthymia we used to call it. Major depressive disorder involves significant impairment in functioning in energy, in feelings of helplessness and hopelessness, guilt, suicidal ideation. So we're not just talking about feeling sad, we are talking about intense depression. Many people with more severe BDD are unable to work, be in or attend school or have relationships. Difficulty in relationships and broader social functioning exists because of their perceived deformations. Patients often exhibit heightened rejection, sensitivity, believing themselves to be unacceptable and jumping ahead. There's so many things to tie together in this, but you're going to learn in a few minutes that people with BDD often have difficulty interpreting facial expressions of people and interpret those facial expressions as more disapproving and rejecting. So when they're interacting with people, they have these perceived deformations and then they perceive other people's facial expressions to be rejecting of them, which confirms their self hypothesis. People with BDD also experience academic or occupational difficulties because they have difficulty with those in person interactions. They are in some cases people with severe BDD are not able to go to work. The anxiety of about being seen is so overwhelming that they cannot go to work. Feelings of guilt and shame associated with BDD appear to contribute to high rates of suicidal ideation. BDD is not just being vain, which is, you know, I hate when I hear that because BDD is a very serious issue and again understudied. That contributes to a lot of psychosocial disability for people who have it and, and the emotional and interpersonal turmoil they experience has such devastating effects that they do have high rates of suicidal ideation and that's heart wrenching. Now differential diagnosis, eating disorders are not the same as bdd. Now people with eating disorders often do have an appearance preoccupation they are preoccupied with their weight and their size and their shape, which can lead to dysfunctional eating and compensatory behaviors in an attempt to lose weight. So they can spend a lot of time on that. But the differentiating characteristic is the dysfunctional eating behaviors. If we see those, then it you're going to diagnose an eating disorder if that dysfunctional eating is designed to try to address the discontent with their perceived body size or shape. Major depression also can co occur with bdd. But major depression itself can involve feelings of ugliness as part of their low self esteem. When people have major depressive disorder, their concerns about their appearance are not the primary preoccupation and are not typically associated with repetitive behaviors or the compulsions that are characteristic of bdd. So just because somebody is unhappy with the way they look does not necessarily mean that they've got bdd. It's important to differentiate between things like bdd, eating disorders, major depression, and for some which it wasn't mentioned in the literature. But for people with PTSD who have experienced especially sexual abuse, it's important to recognize that they may feel very ugly or they may feel like they are unacceptable looking. That's not always the case, but it is important to recognize that unhappiness with one's physical appearance can be a characteristic of a lot of different issues. The development of BDD is associated with past experiences of abuse, violence and trauma. A survey of people with BDD found high rates of emotional neglect and abuse at about 68%. So more than 2/3 of people with BDD have experienced emotional neglect or abuse, physical neglect or abuse in more than a third of the people, and sexual abuse in almost one third of the people with bdd. People with BDD are not only more likely to have a history of traumatic experiences, but are also likely to experience them as more painful and be able to recall them more clearly than people without bdd. Now this is really interesting because when we experience trauma, one of the things our brain does is release a whole bunch of glutamate and other neurochemicals that actually block or inhibit memory formation. Your brain says you really don't want to remember this. But with people with bdd, they actually do have very clear acute memories of what happened. So, you know, that indicates there is a difference in their fear processing potentially, or their brain structure, if you will. Compared to healthy controls, people with BDD tend to misinterpret neutral emotional expressions as contemptuous and angry. Now think about that. If you're going through life you know, or just going through a day. And every time you see somebody with a neutral emotional expression, you perceive it as contemptuous, ang, angry, rejecting. How distressful, how scary, how unwelcoming would life be? And I encourage you to think about that the next time you go out into public. You know, whether you're at the grocery store or riding the subway or whatever you're doing. Most people have a neutral expression. Some people even have a resting, unhappy face. I can't say the B Word or YouTube will get after me, because when we relax our face, the corners of our mouth just naturally turn down. It's not that we're unhappy, it's just that that's the way we are constructed. But think about how stressful that must be, because people don't usually walk down the street of Orlando or Nashville or New York City or wherever just smiling at one another. They often have a neutral look on their face. So that just imagining that and imagining every neutral face as well as every angry face to be interpreted as contemptuous and angry and personalized. Oh, my gosh, that's overwhelming. Neurocognitive assessments in BDD have found markedly higher levels of both impulsivity and compulsivity compared to controls. Now, impulsivity is when people do things, they react. They don't think it through, they just react. It's like, make it stop. Make it go away. Compulsivity is when people are acting intentionally. They are trying to hide that flaw. They are trying to avoid people, but they're doing it, and they have to do it in order to relieve their anxiety. Impulsivity and compulsivity are both behaviors that are very commonly seen in people with high levels of anxiety or anger or just basically a sense of unsafeness that triggers that fight or flight reaction. Well, going back to what we were just talking about, if you're looking around and most people you see feel threatening, feel rejecting, then that would be terrifying. I could see how that would keep people's fear, their HPA axis, their threat response system activated. Well, this also creates activation of what we call the default mode network. When the amygdala is activated, it has a lot of little projections into the default mode or the fight or flight mode. When we are in fight or flee, we are reacting to get away from a threat. We are not cognitively processing anything. We don't have that executive control thought. You know, what's the best course of action here? No, we are reacting in order to escape or evade the threat. So it's kind of interesting that we're noticing that people with BDD do have markedly higher levels of fear related behaviors. BDD was significantly associated with symptoms of ptsd, depression, adhd, generalized anxiety and social anxiety as well as, interestingly enough, compulsive sexual behavior. And the hypothesis for that is that people, people who perceive themselves to be disfigured in some way or unacceptable, may try to receive acceptance through compulsive sexual behavior. Additionally, given the fact that they are, they have a lot of stress with regard to interacting with other people, their levels of oxytocin are probably pretty low because they're not interacting with others, there's a lot of anxiety surrounding other people. So when people engage in sexual behavior, it is giving them a surge of oxytocin, which may be another form of self medication. Neuroimaging studies in BDD have implicated abnormal structure and function of the occipitotemporal and frontolimbic regions. Cortical gray matter thinning has also been demonstrated within the left temporal and left inferior parietal regions. Now I put that in there. So if you're interested in going and looking up all of the neuroanatomy, more power to you. But what I really want you to get out of that statement is the fact that people with bdd, their brains are structured differently. They are fundamentally different than the brains of people without bdd. So this is not something that is, and I hate to say all in their head because that's where your brain is, but this is not something that's just a thought oriented thing. People with BDD have structural differences. Additionally, and this is really fascinating, or I think it is impaired visual information processing may underscore the pathophysiology, the symptoms of BDD. Functional MRIs have found that people interpret visual information that is holistic in nature via neural pathways meant for detailed focused information. So there's a difference in the way people with bdd, their brain actually takes in information and processes it. Additionally, and I've talked about this in my depression presentations, but it's important to remember BDD has a 75% CO occurrence with major depressive disorder. Okay, so the chances of somebody with BDD having major depressive disorder, pretty dagum good. People who have major depressive disorder have problems in their visual contrast settings, sensitivity and so they may see things. The world seems dull or gray. But remember, you know, what we're talking about with BDD is visual processing. So if visually they're seeing things differently, then it may, you know, things may appear visually different to Those people. And the only way I can explain that, if you're like me and you've got to wear glasses, take your glasses off and look at black type on a white background, and then put your glasses on and look at that same black type on a white background. The first time I got glasses and, you know, I put my glasses on, I was like, flabbergasted at how crisp and dark everything was because I was used to seeing it as kind of, you know, fluctuating and kind of gray. So what they found is some of the visual disturbances or some people with major depressive disorder most, in fact, tend to have disruptions in their visual ability to see contrast, ability to see sharpness, things. Additionally, results suggest that people with BDD have normal retinal processing, so their eyes aren't broken. It's not like we're saying, oh, they need glasses. We're saying they get it in through the retina and it looks, quote, right through the retina. But then when it goes to the brain to be processed and recognized, that's when things get fuzzy. L PTSD is associated with reductions in cortical thickness, just like BDD is in some studies. But they found that people with BDD, but not ptsd, did not have the same brain structure. So when you add ptsd, you add another layer, if you will, of brain changes that may occur. The middle temporal area of the brain creates a complex mind body environment interplay that constantly changes a person's subjective experience. So the middle temporal area helps you recognize yourself in space. You can look and you can see. Can I fit into that chair? Can I fit through that little crack there? Can I do these things? And. And your brain is regularly perceiving size and shape and how things go together. The parietal lobe has the post central gyrus, which corresponds to the primary somatosensory cortex. So the parietal lobe. Sorry, I'm having difficulty saying these things. Communicates or helps process that visual input, the sensory stuff coming in and somato. Somatoform. Somatization means of the body. So sensory information of the body is processed there. And the corticocortical pathway from the striate cortex into the temporal lobe plays a crucial role in the visual perception of shape, color and contour. And all of these areas have been shown to have alterations in people with BDD and ptsd. Another interesting finding in the literature was that people with BDD often have reduced striatal dopamine. D2, D3 receptor availability is observed in BDD suggesting that the problems involve dopaminergic pathways and potential therapeutic target targets. So what have they done? There are a couple case studies where people with BDD have been given a drug that is called an ndri. Norepinephrine dopamine reuptake inhibitor, and one of those is bupropion and had some success with it. Modenafil is another drug that may be an effective adjunct strategy for people with certain psychiatric, neurological and medical conditions who experience a set of treatment resistant hypoarousal symptoms characterized by excessive sleepiness, fatigue, cognitive impairment, motivational and mood dysfunction. Modenafil is a dopamine agonist. It increases levels of dopamine activity in the brain. First line pharmacological treatments for BDD is generally centered around the use of guess what SSRIs or your antidepressants. That seems to be the go to for most things is if in doubt, throw an SSRI at it. Which I don't really like, but in studies there has been evidence that fluoxetine, which is one of your SSRIs, was effective in 53% of the people who took it. Now that's still only half. Okay, let's put that into perspective. But it's a whole lot bigger than the placebo that was only effective with 18%. So we can be pretty confident that for some of these people, and I can't math on the fly like this, but for somewhere around 30% of these people who were given an SSRI, that it was exceptionally helpful. Pharmacotherapy with antidepressants in concert with CBT has an effectiveness of 50 to 80%. So you're saying, all right, well if pharmacotherapy is supposed to be 53%, well that's for some people, you know, then you've got that other 47% who didn't respond. So you've got differences here. But we know with just about every mental health issue, a combination of pharmacotherapy and CBT often is helpful in the early stages of treatment because it can help increase dopamine and serotonin levels, which can increase motivation and, and energy levels. Now, not everybody is down to try a pharmacological intervention and that's cool. But the research, if you follow the research, does show that often, at least in the beginning, it can be helpful at getting people moving. You know, once you're moving it's easier to stay going, but sometimes it, it's really hard to get started. We do need to recognize that therapeutically effective dosages for BDD are often much, much higher than for other psychiatric disorders. So if somebody was taking an SSRI at like Zoloft at 50 milligrams for depression, they may need something much higher for a dosage much higher for BDD. Buspirone may also be helpful when added to an SSRI. Buspirone works on a different serotonin receptor than most SSRIs do. So you're activating different, different serotonin centers, if you will. It is important to recognize though, that currently no medication is approved by the FDA for the treatment of BDD because it hasn't been studied in BDD. 2% of the population, 5% of the college population, struggles with it. Why are we not studying this? Just. Just saying. Recent studies of treatment regimens incorporating techniques like repetitive transcranial magnetic stimulation, or rtms and bilateral deep brain stimulation show promise in the treatment of complex treatment resistant bdd, even in the context of profound comorbidities. So someone can have clinically significant major Depressive Disorder, ptsd, generalized anxiety and ddd, and they still are finding that RTMS can be somewhat helpful. So there's a lot to be learned about RTMs, but it's certainly something to explore, especially if the BDD is treatment resistant. In clinical trials, cognitive behavioral therapy for BDD typically involves 12 to 22 weekly sessions with key therapeutic strategies being exposure with response prevention, that is seeing this perceived defect, or having other people see this perceived defect while concurrently being prevented from camouflaging it, applying excess makeup, turning away, doing whatever they do to try to cope with the goal of achieving anxiety habituation. Now it's important, underscore important, that exposure with response prevention be done under the supervision of a licensed professional. If you do it too fast, it can be devastating. It's important to gradually work up to this. When I do response prevention activities, for example, I start out with just having the person imagine looking at themselves or imagine being seen by someone else and help them get to the point where they can imagine that situation and calm themselves down or not even get riled up. You know, it's like, okay, you know, I can imagine it, not a big deal. I can see that, and then moving to the next step. But it's super important that this be taken incrementally and that the person is desensitized, if you will, at each stage before progressing to the next one. Additional strategies that have been used in cognitive behavioral therapy include psychoeducation, motivational enhancement, cognitive restructuring, mirror training, and attention training. Remember, I said earlier that People with BDD often focus their attention on one aspect instead of seeing the whole face. They see their pores or their nose or their freckle or whatever it is that they perceive to be as disfiguring. Other treatment strategies, and these are strategies that can be used with a lot of different issues because we recognize that people with BDD have a lot of underlying stuff going on, depression and trauma for certain. So we want to explore with the person the course of their disorder and the initial triggers. So when did this start and what was going on at that point in time? You know, help me understand, you know, how this, did it happen overnight? Was it a gradual onset through your senior year? What happened? Explore the current triggers, exacerbating factors and vulnerabilities. So currently, what things increase your anxiety, what things increase your compulsions, your fears and your need to hide or to engage in those compulsive behaviors. And we'll find, or I have often found working with people, that it's not just things like seeing a mirror. You know, sometimes it can be if their hormone levels altered, they may be more sensitive to visual stimuli. We know that premenstrual dysphoric disorder, for example, produces depressive like symptoms and some anger and other feelings in people because they have extremely altered levels of their gonadal hormones. Well, we also know that people with major depressive disorder, which isn't the same, but they share a lot of similarities, have those visual disturbances. So it's possible that their sensory responsiveness is heightened or hyper, hyper vigilant when hormones are out of whack, when they're over tired, you know, under certain types of light, whatever it is. But exploring current triggers, exacerbating factors and vulnerabilities are important because then you can start making a plan to mitigate those as much as possible. People with BDD and PTSD and depression and anxiety often feel disempowered and unsafe. So what we want to do is understand how this may have developed. What makes it worse right now so we can help the person feel empowered, to create safety so they aren't triggered as often, or at least not to the same degree. We want to explore strengths and resources. What do they have going for them? What do they do that helps them cope with this? When they start feeling anxious, they can't engage in their compulsive rituals. What else do they do? You know, do they have, can they practice slower breathing or meditation in order to help them down regulate their anxiety? Some what has helped them survive until now physically? We want to look at nutrition, we know that there are alterations in levels of dopamine and serotonin and maybe some other neurochemicals that haven't been studied in relation to BDD yet. So the making sure that the body has the building blocks it needs to make those neurotransmitters should it want to, is really important. Healthy nutrition is important. And I have a lot of videos on the YouTube channel about the importance of nutrition for mental health. Hydration as well can be very important for mood stabilization as well as energy levels. Eliminating or at least minimizing alcohol is also important because alcohol, while it does temporarily increase dopamine levels, often leads to basically rebound. Low levels of dopamine and serotonin and other neurotransmitters, GABA and glutamate, get all out of whack. So alcohol is one of those impulsive strategies to try to feel better in the moment, but as soon as it starts wearing off, the person often feels a lot worse. Sleep and circadian rhythms are important. When people are feeling anxious, they have difficulty getting quality sleep, which, which is going to impair their mood and impair their cognitive abilities. When people are housebound because they are afraid of being seen, a lot of people with BDD are housebound. They are often not getting enough sunlight and their circadian rhythms get out of whack. When that happens, their body will start secreting hormones at all the wrong times. Cortisol will be secreted at the wrong time. Immunity kind of goes to crap. When immunity goes to crap, systemic inflammation can kick in which can increase depression. So there's a lot of underlying factors, undercurrents in keeping the body factory operating effectively that we can address with nutrition, hydration, alcohol elimination, circadian rhythm regulation, enhancing quality sleep by evaluating sleep hygiene, exploring HPA axis regulation for what I call misattributed anxiety. Sometimes people have anxiety about something like starting a new job, and they misattribute it to anxiety that people are going to see their flaw and reject them. So it's important to explore when you're feeling anxious, be mindful and non judgmental and say, okay, I'm feeling anxious. What is this about? And is it about this one thing or is it about three or four different things? And be ready to identify some of those things. Because? Because a lot of times people with BDD have what Hayes called dirty discomfort. And that means not only are they anxious about something, they also have all these other things that they're anxious about and anger at being anxious and feeling guilty. About being anxious and it's just this whole stew of unpleasant emotions and trigger. We want to explore breathing and distress tolerance activities to help people develop the skills they need to down regulate that HPA axis, that threat response system when there is no actual threat in the current context. Remember, emotions tell us like a fire alarm, hey, there might be a problem, you better get up and take a look. And hey, I'm going to give you some energy to do that. By the way, that's great. You know, that's what anger and anxiety are designed to do. They're designed to help us make sure we are safe and give us the energy to evaluate and if necessary, fight or flee. But sometimes we evaluate and we say false alarm. So we've got to be able to down regulate that HPA axis and let our brain know, hey, there's really no problem right now. So we can go back to that whole rest state thing. Affective and cognitive strategies. We want to explore the functions and origins of the fears. So some examples and there are a lot of other things that may come up, but some kind of off the cuff examples, people who've experienced trauma of abuse or abandonment, that experience may have made them feel unacceptable. They may have projected that onto their appearance. Every time they look into the mirror, they see an unacceptable person. They see a person who is broken in some way and they hone in on that. So their internal feelings of brokenness or unacceptability are projected onto their outer body. Insecure attachments can be justified through cultural influences about acceptability. So if they were rejected or had insecure attachments with their caregivers as a child, they may not have understood why that was. And they may have somehow quote, figured out that their caregivers did not love them and did not want to protect them because they were had this deformity and not saying that that's what was going on. But in a child's mind, children try to understand why is this happening. And that may have been their rationale. Another issue could be that pre existing dysphoria. So if somebody already had anxiety or depression or ptsd, when we're in that state of heightened fight or flee, we feel unsafe in our environment, we feel disempowered. That means that everything in the environment that is threatening becomes more salient, becomes more noticeable. And that also means that if we have something on our person that we perceive as unacceptable or deformed, that is assigned a lot more salience, it's a lot more noticeable. We are more aware of all of the Potential threats and reasons for rejection or harm that might come to us. So pre existing dysphoria can also set a person up to develop body dysmorphic disorder because they can't help but notice the threats and the dangers and the deformities. Another thing that can be helpful is describing the default mode network and evaluate people's default schema. And our default mode network is one of our attentional networks that operates exactly like it sounds on default. I'm not thinking I'm on autopilot. So what are the person's autopilot schema about the world, about themselves, about rejection, about helplessness? So evaluating some of those schema that run through their mind with regularity can be helpful to understanding what is perpetuating the BDD and then replace those unhelpful default schema, those unhelpful autopilot plans through desensitization and response prevention. So helping people when they start getting into a autopilot fight or flee place, encouraging them to and helping them develop the skills to be able to step back and examine the situation and in context, the facts of the situation in context, what they can and cannot control and what the probability is of their fears coming true. Because a lot of times when we're in that fight or flight place, we misattribute possibility to probability. So something that's possible and just about anything's possible. But a lot of times our fears are highly improbable. They could happen, but the probability is pretty small. Examine cognitive distortions like personalization. And that means interpreting other people's thoughts, feelings, behaviors as being caused by or directed toward the person. So that person scowled at me, they must be angry or rejecting of me. Okay, they could. Or you know, what are three other explanations for why that person may have been scowling. Encouraging people to step out of that personalization, which takes us to mind reading. A lot of times we assume we know we see a scowl on somebody's face and and we assume that they are rejecting us or judging us in some way, when in reality they may be, you know, off in their own thoughts somewhere. So mind reading and personalization often go hand in hand. But mind reading is very destructive because we don't know what people are thinking or why they're thinking that way. Catastrophizing, another cognitive distortion or unhelpful thinking style that can plague people with BDD because they go from this person may see this disfigurement and reject me, therefore I am going to be alone forever. So one person rejects You I'm going to be alone forever. That's kind of catastrophizing. So we would want to look at what are the facts in that situation and what is the probability that your belief will actually come to fruition. And all or nothing thinking I have to be perfect all the time. You know, it's hard, especially for people with bdd, as I said, because in our culture, in the American culture, we. We tend to have our face and our hair exposed most of the time. So if we feel like we must have a good hair day every day, we must look perfect every day, then that is going to set us up for devastation. I remember being in high school and getting up one morning and of course this happened a lot, but you get up in the morning and all of a sudden this ginormous pimple is like, right in the middle of your forehead. And the devastation that you would think about going to school. I can't go to school with this. How can I cover it up? How can I hide it? Well, that is just a minor glimpse into what life is like for somebody with bdd. The pimple is going to go away and some people just don't even care about it. But for those who do recognize, they. They know that it's something that's temporary and it's going to go away. For somebody with bdd, it is something that they perceive as unchangeable, and they are having to deal with that every single day. I encourage people to define a rich and meaningful life. You know, what do you want your life to look like? What are your beliefs about how your imperfect appearance prevents you from achieving that rich and meaningful life? And we'll explore those beliefs and explore how their current thoughts, feelings and behaviors, like their compulsive behaviors to hide that flaw or perceived flaw prevents them from achieving their rich and meaningful life. So creating some cognitive dissonance. You want this, but you're engaging in these behaviors that are keeping you stuck, preventing you from achieving that goal, and then processing. And this is one line, but it is a lot of stuff that needs to be covered. Processing feelings of guilt, shame, anger, powerlessness, depression, and grief. This presentation is specific, specifically talking about bdd, not all of the associated issues, but recognizing that there are probably multiple things, both direct and indirect, that the person has lost as a result of their bdd, and they may need to grieve that. So, you know, being sensitive to the fact that there are a lot of issues that, that the person may need to work through environmentally and relationally help the person Figure out how to create safety, including exploring possible reasonable accommodations. So getting their groceries, for example, now that we've got click and pull or whatever it is where you can, you know, order online and go pick it up at the store so you don't have to go into the store. That can be hugely liberating for somebody with BDD because then they only have to encounter that one person who's bringing their groceries out. Working from home, telecommuting, going to, attending classes virtually. There are options out there for people who, you know, they want to have a career, they want to go to college, whatever it is. There are ways that we can help them make that happen. We can empower them to build on those areas of their life while they're working on the bdd. Identify and address areas of disempowerment. So what things in your life make you feel powerless? And which of those do you have any, any control over and over? What can you do to feel more empowered? Enhance effectiveness of interpreting nonverbal cues, especially facial expressions. And you can do this by watching a television program with somebody and pausing the television program periodically and saying, okay, what is that facial expression? How are you interpreting it? You know, so you're doing it without having to go out into public, public with the person right away. Now, one of the interesting things about the pandemic has been that some people with BDD have actually found it liberating because they are able to cover their nose and their mouth if that's the area that they feel that they have a disfigurement. So they have been able to go out and actually engage in more social activities and than they had before. So there are some benefits potentially to helping somebody figure out what can you do so you can feel safe, so you can feel comfortable going out in public. And for some people, it may start out by wearing a mask or wearing a, a scarf or something. But it's important to move from identifying facial expressions on the TV where the person is not emotionally involved in the situation, to moving toward identifying facial expressions in real life and verifying whether with them, whether they were receiving a rejecting look or something else. And that's when you can go with the person into a public place or you can even have hired people if you will come in, whatever makes the person feel safer. Enhance self esteem, Differentiate people from behaviors. And this is part of self esteem that I really like to highlight that we all make mistakes. It doesn't mean that we are a mistake. And differentiating people from behaviors, differentiating people from necessarily their physical appearance. People who've gotten disfigured in a fire or something may feel very self conscious, but many develop the understanding or an awareness that they are not their scar, they are themselves who happens to have a scar now and Enhance Interpersonal skills Since fear of rejection fear of abandonment often goes along with bdd, especially fear of rejection or abandonment because of the perceived disfigurement. Enhancing interpersonal skills is really important so people can accurately interpret what's going on and communicate with other people Compared to other diagnoses. Very little is known about bdd. The high rate of trauma and adverse childhood experiences, frequent comorbidity with mood disorders, OCD and PTSD indicate that there is involvement of the amygdala, the HPA axis and the default mode network schema in the development or perpetuation of bdd. A strengths based trauma informed approach is essential to lay the groundwork for developing safety and empowerment. Remember, the majority of people with BDD have experienced trauma, so the first thing is to help them feel safe in their environment before we can really even help them feel safe in their own skin. Information about differences in cortical processing of visual stimulus as well as altered ability to accurately perceive facial expressions may also provide us some clues for future treatment strategies.