Nip in the Bud® Podcast - The children's mental health charity

Nip in the Bud with Dr Bruce Clark: The journey of treating OCD and BDD in children and young people

• Nip in the Bud Children's Mental Charity

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Summary

In this conversation, Dr Bruce Clark, a consultant child and adolescent psychiatrist, shares his extensive experience supporting children and young people experiencing OCD (Obsessive-Compulsive Disorder) and BDD (Body Dysmorphic Disorder). He emphasises the importance of early intervention, the complexities of these conditions, and the need for innovative approaches to care. The discussion also explores how social media influences body image and mental health, highlighting the value of open dialogue in educational settings. Dr Clark reassures listeners that both OCD and BDD are treatable, encouraging parents and educators to seek support early and to foster environments that promote resilience and well-being.

Dr Bruce Clark biography

Dr Bruce Clark joined the National and Specialist OCD, BDD and Related Disorders Clinic at The Maudsley Hospital, London in 2013.  He is a consultant child and adolescent psychiatrist with an interest in treatment resistant Obsessive-Compulsive Disorder and related disorder.  He is also an Honorary Research at the Institute of Psychiatry, Psychology and Neuroscience.

The National and Specialist Team for OCD and related disorders is the only such specialist team in the United Kingdom.  This service has an international reputation for innovation, research and delivery of the highest quality treatment of OCD and other anxiety disorders.

Dr Clark has a broad range of child and adolescent mental health experience. He previously worked in one of the Maudsley Hospital general community based clinics. Whilst working in that setting he became Lead Clinician for the service.  He has considerable expertise in the assessment and management of Autism Spectrum Disorders, OCD, ADHD, Depression, Anxiety Disorder, as well as behavioural management issues.

 Dr Clark has considerable experience in the use of medications to support the treatment of mental health issues in children and young people.

Takeaways

OCD is a common and often crippling mental health difficulty.

Early intervention is crucial for effective treatment of OCD and BDD.

Both OCD and BDD are highly treatable conditions.

Social media can impact body image and mental health.

Parents and educators should foster open discussions about mental health.

Compulsions in OCD can be physical or mental acts.

OCD symptoms often worsen without treatment.

The relationship between genetics and OCD is complex.

BDD is characterized by distressing thoughts about appearance.

Support from mental health organisations can be invaluable. 

Keywords

OCD, BDD, mental health, child psychiatry, treatment, early intervention, social media, anxiety, education, research

Reading recommendations

Can I tell you about OCD - Amita Jassi

The 'Can I tell you about series'

Nip in the Bud - Where to get help

https://nipinthebud.org/where-to-get-help/



Alis Rocca (00:00)

Okay, welcome Bruce. Thank you so much for your time and for joining us at Nippon Abad. My first question just really could you tell us a little bit about your journey and what you currently do?

Bruce Clark (00:11)

So, I'm a consultant child and adolescent psychiatrist. So I've gone on a long journey, I guess, from medical school. So I'll hone in, if you like, on my current work with people with OCD, BDD and related disorders. So yeah, I'm a consultant child and adolescent psychiatrist. I work in the National Specialist Team for Children and Young People at the Maudsley Hospital. It's a team for ⁓ children, young people with OCD, BDD and related disorders. And I've worked in that team ⁓ as my only clinical role since 2012. So ⁓ I've got a lot of experience at working and supporting people with obsessive compulsive difficulties.

It so happens I'm also the clinical director for all of our child and adolescent mental health services, which is 1200 staff. It's a big department. And also one of the exciting things I've been involved with is something called the Kings Maudsley Partnership, where we're drawing together the Maudsley Hospital clinical side of staff and the Institute of Psychiatry, Psychology and Neuroscience side to come together and work much more closely to accelerate that pipeline from research into clinical practice. And hopefully later this year, we start to move into one facet of that, which is a new 90 million pound purpose built clinical research facility for children and young people that will include OCD services. So that's really exciting. It's going to be the biggest clinical research facility for children. On the Morsley campus site, there was a little plot of land the middle and we're now the tallest tower which is great for children and young people and yeah hopefully we'll be moving in there very shortly.

In short, what I want to do is kind of really find the key pieces of discovery science that are going to translate into practice that will make a difference on a national and international level. The truth is whilst we talk about and I'm sure we will be thinking about things such as know treatments for OCD as they currently exist

The truth is if you look internationally, the majority of the world's population will have no access to any of those things. And so I think there are so many fundamental things that we can do if you just take AI as a single example of an area where that could hold the prospect for people in developing countries, part of our global majority communities, to have access to evidence-based treatments if we can get things that work right and in the right way. And it's only really by partnering those clinicians and scientists together to have the capacity to build, you know, the evidence base. It just isn't there yet. And I kind of feel passionately that we won't solve mental health issues at large scale by just replicating the same model. It's not going to be solved by having just more and more people like me doing things.

We need to do things differently. And so I'm hopeful and it's been my passion that we do that partnership between us, you know, we have some of the most cited researchers in mental health working alongside us at the moment in the IOPPN and the Morsley Hospital. We have the largest set of highly specialist mental health services nationally. Drawing those two things together is going to be unique and we're going to have a new clinical research facility built into that, which again is a unique proposition, an environment where people aren't patients, they're coming along as, you know, to help us with research, having the facilities to do that properly, having the kinds of equipment and imaging that allow us to start to ask questions. You know, I've got all sorts of exciting ideas. In my head, if you're someone who's suffering with BDD, how do you look at yourself in the mirror? How does your brain think about things that differs from someone who looks at themself in the mirror and doesn't have BDD? And we're going to have really exciting child-friendly sort of research facilities where they're not invasive, you can walk around with them on. The technology's advanced so much, we'll have things like portable MRI equipment that we can roll around to gather quick brain scans and things. So things will hopefully take a step change in the not too distant future.

Alis Rocca (05:02)

That's really exciting to hear. I think from my perspective as an educator, seeing this huge wave of mental health issues and conditions in schools, to hear that that is happening, but also that it's happening in a way that will become accessible to so many people is really exciting.

Bruce Clark (05:22)

I agree. It won't be accessible with just doing more of the same. We won't be able to afford that model with the scale of the issues. Yes. And it's often then stuck at the severe end of difficulties by necessity. ⁓ But actually what you want to do is sort of turn the tide and nip things in the bud.

Alis Rocca (05:31)

…too slow to get to the chalk face.

Bruce Clark (05:41)

Absolutely, that's exactly what we're all about is just that early intervention and that making a difference. Okay, thank you for that. We're going to dig a little bit deeper into two things that you talked about there. So OCD and BDD. Let's start with OCD. So I think what would be really good and useful is if you would just explain what OCD is, just give a layman's definition of.

So first of all, OCD is a common, sadly often crippling mental health difficulty with a very, very high level of suffering for people who have OCD. It's deeply, deeply unpleasant to have. And what it's characterized by is people who have obsessions and obsessions are, we can all have an obsessional thought.

But if we imagine those and ramp them up to the extreme, obsessions are intrusive ideas, images or impulses that pop into our head. And obsessions are, as they pop into your head, sort of instantly distressing or anxiety provoking. And we don't understand why people have those pop into their head in some instances so much more frequently.

And it's such a distressing experience for them. But what happens in OCD is where you have those obsessions that are the ideas, images or impulses that are distressing. People manage that by carrying out compulsions. And so that's the link. A compulsion is a repetitive physical act. So for instance, an obsession could be about contamination and the physical act could be excessive and repeated washing. But importantly, and often people forget about this, compulsions can be mental acts. So you may not be able to watch someone's OCD, if you like. They may be engaged in ⁓ mental compulsions that in turn help them manage the distressing obsessions. But sadly, that relief that they get from the physical or the mental compulsions is only temporary and short-lived. And the next obsession and the next and the next and it becomes a whirlwind that takes over. And it gets to a level where if you like, you've got obsessions, you've got compulsions, but then the D, the disorder, that's the important bit for someone like myself, a psychiatrist, you have to think about those things because we can all have an obsessive thought, we can all do a bit of a ritual. But when is it becoming, if you like, disordering? And that's a key ⁓ clinical judgment as to this has clearly reached a point where it's impacting on your social, educational or working life. And sadly, the natural history of OCD, if you look at people who start with the earliest symptoms of OCD, and you measure it objectively that clinicians such as myself can do, it's only very typically in the early stages of someone's life with OCD that it measures as mild or it sometimes measures as mild in people we've done some treatment for. OCD very typically ramps up to moderate and severe levels of suffering and impairment. That's a well understood aspect of its trajectory.

That sounds really sad and it is sad, but the truth is, and that's why I really enjoy working with OCD, I find it fascinating and I really value trying to help people with this, but what I so often say to people who have OCD or indeed BDD is that this is highly treatable.

The treatments that we have are really efficacious. For the majority of people, they make a massive difference, if not helping people get rid of OCD. And that's the case for the majority of people. And of course, not everyone is that lucky. There's not really many health conditions where it is effective for absolutely everybody. And that's where the research and the cutting edge is. So how do you help maybe the 20 % who can't get that treatment resolution or the people who relapse. So that's why I think doubling back to that research angle is we have good quality treatments, really encouraging people to come in. They work so much better than in many areas of mental health. But I'm also interested from a research perspective on what next.

Alis Rocca (10:38)

Can I take you back to the beginning of OCD? What would trigger it? Is there something that triggers it? Is it genetic? Is it familial? Why does it happen?

Bruce Clark (10:50)

There's a simple answer to that, and the simple answer would be we don't fully know, but it's more nuanced than that. We are clear that genetics are an important influence. So the genes that we get from our parents, if you like, help predispose us to OCD. And we think that 40, maybe 50 percent of the causality is inherited. And that's very clear to say that we don't necessarily think there's like a single gene that's broken like you can find in some health conditions like sickle cell, for instance. It's quite clearly understood the genetic mechanism. It's much more likely that you're inheriting a sort of risky profile of genes that if you like predisposes you to it. And then it gets a little bit murkier. OK, so it's not all genetic. So environmental factors must be important and people have looked at environmental factors that are causative. You know, like what might have happened in your life that's made you then get OCD. And truthfully, people have looked at so many different things. You know, is it separations, birth traumas, the experiences of abuse, all sorts of factors have been looked at and nothing has been nailed.

There's some early signals and interest in certain facets around BDD, but it's still very, very, very early research. So we haven't found something that causes it environmentally. There are environmental factors that if you've started your journey of having OCD aren't necessarily great. know, if people ⁓ doing more or less accommodation for OCD, that can have an influence on how much it comes to the fore, but actually the causation, it just isn't understood and it's much more likely to be really intimate interpersonal facets. No one thing just the way, if you like, your inherited personalities interacted with stressors. What we do know and I know very much from clinical life and practice is that OCD often comes out in a person's life when they're under stress, sitting some exams, a divorce, those sort of things are often a ripe environment for your health to deteriorate. But I'm often at pains to tell parents who come to see me who've often carried for many years a sense of guilt that we used to argue when we were getting divorced and if the kids saw that, did we cause them to have OCD? And I do sort of say there's nothing to suggest that that's the case. And you know what OCD came out in stressful times, but if that stressful time hadn't been now, there's always stress around the corner. It was coming down the tracks, if you like.

Alis Rocca (13:50)

You talked about the symptoms or the signs and in the beginning they're mild. What might a parent or an educator look for so that we can respond early on before it gets into moderate and beyond?

Bruce Clark (14:06)

It's really interesting and it's one of those scenarios, to be fair, when someone's got proper OCD and you look back, say, ⁓ I can see it. But it can be quite tricky to spot from the normal distribution of life in the moment back in time. But you can spot sometimes people getting drawn into time consuming rituals. So a teacher, for instance, might spot things like contamination based OCD. It's still the largest group of obsessions. That's the most common type of obsession to have contamination based obsessions. It might be triggering if you start to see that a child is sort of carrying out longer, almost ritualized, ⁓ cleaning really scared to walk into anxiety, getting caught up into things repetitively. But I'm saying that knowing that it's actually quite common for kids around three, four of toddler age to get a bit ritualized. And often if it's very, very early in life like that, it's good to just take a slightly watchful waiting approach, clock it, wait and see. I've been interested to read some early data coming out from a research group in Scandinavia who've been really sort of piloting how you can intervene in very early life, early experiences of OCD and what they've been doing could be helpful for kids with a huge range of anxiety disorder. So if a child is seeming quite anxious and reticent, helping people do two things seemed to be really promising, not accommodating lots, not just doing what the child wants, helping them see that, you know, it's not going to be the best thing to do that and also helping in the earliest phases of anxiety coming out, having a dialogue that anxiety is a normal experience, we all have anxiety, that you need to try and walk into it to some extent and sit with it rather than just early on adopting a pattern of always escaping from anxiety. That seems to be a promising area. So I would sort of, guess, in core encourage teachers and people spotting early signs to do those things not getting drawn into early aspects of accommodation wherever possible It's super hard as a parent because you love your kids and you're gonna want to do you know things to help them not be stressed So just being measured and mindful of that and also helping those early conversations with children young people that life is gonna bring some anxieties and at times you're going to need to walk in and I can be there to support you walking in and sitting with some of that anxiety.


Alis Rocca (16:58)

And I think in some aspects that sort of goes against what you want to do as a parent. You want to protect. I want life to be as possible. yeah, but to actually say, and for teachers to actually be teaching, anxiety is something that we all feel. And it's okay to feel anxious at times, but to do that anxiety together.


Bruce Clark  (17:08)

Yeah, yeah, you know, I come here and I get interviewed. It's not normal. You feel a bit anxious about it, don't you? But you do things like that over and over and you do quickly realize that you get more confident, get stronger. And actually teachers can share lovely personal examples of that, I'm sure, to say, look, you used to make me quite anxious teaching the class and standing up in front of you, but I've done it so often now I enjoy it.

Alis Rocca (17:48)

Yeah. And what about when those symptoms become more intrusive? much do you give them the soap and allow them the time to go and wash their hands repeatedly? Or how much do you step in and say no, but aware that that might build their anxiety beyond a level that feels safe or right?


Bruce Clark  (18:11)

I'm going to answer that two ways, because first of all, I'll continue what I've just said in that if you're starting to recognise a pattern of unusual requests for soap, for instance, I would be actively encouraging people in those early days not to get drawn into it. That is the time to say, no, the limit of soap is one press. We're going to stick with that. No. And try and write it out early. The other way to answer that, and I often have to say this clinical life where people are being referred to us. Sadly, we have NHS waiting lists and they are really, know, OCD has become crippling. And there are times when sometimes parents, families, loved ones are going to have to accommodate for a bit in a reasonable way until more concerted professional support and guidance to unpick all of that can come into place.

And so in those circumstances, because I work in a national team, I'm often meeting people who've been quite poorly for quite some time. You have to be honest with folks and say, you're not going to be able to go cold turkey and just stop accommodating everything tonight. It won't be effective. It'll be utterly overwhelming. And what I sometimes say at that end of the spectrum, if you like, is try and just do some of simpler stuff. OCD has a habit of moving around from one thing to another. If you're seeing something come in early and it feels not dominant, try and resist that. Maybe you'll get some success at knocking that back and we can build upon that success in the future when we start to unpick it with kind of professionally led psychological therapy.

Alis Rocca (19:58)

Can you explain that a little bit more? It tends to move around. What do you mean by that?

Bruce Clark (20:03)

So OCD, I mentioned contamination-based obsessions as an illustrative example before. Roughly 40 % of people who have OCD will have a concern around contamination. So you can see by me saying that, 60 % don't. So that's often a common myth, OCD is all about contamination worries. It's often not. But the truth is the vast majority of people with OCD will have several or multiple obsessions. So an obsession about one, you know, contamination, obsessional ideas about harm coming to themselves or families, obsessional ideas about things they may have done or really unpleasant images. So multiple obsessions, those ideas, images and impulses, multiple of them happening for an individual with OCD kind of all at once, if you like. So you don't get people who have an obsession and a set of associated compulsions. You can, but it's actually a small minority and unusual circumstances. The majority of people have multiple obsessions and their compulsions will match those. And so your question was, well, what happens over time? It's very typically the case that over time, OCD might loosen its grip on one particular obsession and associated compulsions and latch it onto something else. So that's something that you quite commonly see that it just migrates gradually in form. ⁓ You can have certain key things often that will stay for many years. you know, obsessions about, you know, worries and harm coming to their family might be a common theme that stayed for years.

But OCD very often migrates. And if you think about other anxiety disorders, people who worry, they can often worry about something in particular, say spiders, just to pick an example, and that's been a common theme, but often anxious people will start to worry about other things. They're more likely to worry about, you know, maybe exams or other things can come in and just like that.

OCD just doesn't stay static over time, it changes. But an important facet of that and why I feel so passionately about people getting treatment is really sadly if you look at the natural history of OCD, if you don't do anything, if you don't have treatment, it doesn't go away on its own. By comparison, if you take people who develop depression, another very common mental health difficulty,

If you take lots and lots of people who developed their first episode of depression and simply did nothing in two years time, a lot of those people won't be depressed again. There is a natural end. Now that's a cruel thing to do. But I'm just illustrating that some mental health disorders do have a habit of fading away. If you look at the typical person with OCD and we think BDD as well and you just do nothing, it's going to stick around.

It needs treatment. If you do nothing. Well, I sort of said earlier that most people with OCD tend to migrate up into the moderately severely impaired by it anyway. The level of morbidity isn't great for people with OCD. It's not a mild mental health condition for most people. So where do you go? It's yeah, it  gets tough early on, really.

Alis Rocca (23:52)

Is it neurodevelopmental? it a mental health condition? How is it described? What are the differences between those?

Bruce Clark  (24:01)

So there's several ways to answer that. And people define what's a neurodevelopmental disorder and what's a psychiatric disorder and what's a mental health difficulty. There's some sort of softness of that language. But if I take a sort of strict diagnostic manual kind of approach, so the World Health Organization create one manual and there's another manual that comes largely from North America that are really, really great guidance. And they do have a set of neurodevelopmental disorders. So they include things such as, but not limited to, autism spectrum disorder, Tourette syndrome. They don't include OCD in that. OCD belongs in a category of obsessive-compulsive disorders. And one of the key distinctions is that neurodevelopmental disorders are very typically something that starts very, very early in your life. So they're sort of built into you. And if, you know, I think already what I'm about to say is question when you think about ADHD, because you can grow out of ADHD. A lot of people don't. But neurodevelopmental disorders are typically things that are there from very, very early life and are considered to be things that are really related to the way that your brain has developed.

In contrast, OCD is very much, it comes on later, is treatable, you can get rid of it for many people, and that is quite different to a neurodevelopmental disorder. But if you dig into that, these are not perfect distinctions. So saying that something neurodevelopmental is hardwired into the way you are, you and I were talking minutes ago about how

Genetics are important in the development of OCD. That's hardwired into the way you are. And it's just, so for me, there's still some slightly artificialness, but I do certainly think about something as autism spectrum disorder. I don't approach autism spectrum disorders. I'm going to treat that and we're going to get rid of it. I do like to meet patients with OCD and BDD and think together. I'm viewing this as treatable and I want you to get rid of it. I want to put it behind you. And that can happen for the majority of people. So that's one of the key distinctions.

Alis Rocca (26:38)

Is that being able to get rid of it, is there a dependence on age? So is it easier the younger you start working with a child or does it not matter?

Bruce Clark  (26:49)

There's not great data on that. There's literally studies that have shown both things. Having OCD, OCD is typically onset, it's said to be what we call bimodal. So you typically are in a group of people who get your OCD in adolescence or 10 to 12. So there's a group there. It's slightly enriched for males over females in that earlier group, only very slightly. If you're not in that first bump, you're in the second bump of the bimodal onset. And you then typically get your OCD in your 20s. That's a lot of the people with OCD. There's some rare stuff after births and after brain injuries, but they're bimodal. And so we know that having OCD early on in life in some ways is not a great sign. You're perhaps more likely to have a pattern where it can relapse and it can come back. But even that's not been brilliantly followed up. But we know actually that you can get brilliant outcomes, really, really get rid of OCD whenever you start treatment. I used to work very closely with colleague Professor Matash Coles, now works at the Karolinska Institute. And when I was new in this job, I always remember him telling me that he decided to go into work with ⁓ OCD when he was much younger in his career and worked on an older adults ward and found somebody, I'm guessing he was a junior psychologist at the time, with OCD that had been part of their life for pretty much their whole life and they'd never had treatment. And he did standard treatment with that person and they got rid of it. And that I thought was kind of, it inspired him and I found that story inspiring. So whilst we don't fully understand the proper longitudinal trajectories of OCD, those studies just haven't been done. It's enormously expensive to do research studies where you follow people up over decades. You know, you just can't imagine the cost and infrastructure needed to do that. So I generally like to have the message for people that you can always get treatment for OCD. And sometimes I meet young people, of course I meet young people where we haven't managed to get them better. And sometimes maturity, a different point in your life different circumstances, different motivations, it's always worth coming back to. It's a treatable disorder and I never ever want people to lose that hope.

Alis Rocca (29:47)

I think that's a really good message that I hope people listening to this will take away is that it is treatable. Believing that, what would you advise a parent to do to get to the point where they get that treatment for their child?

Bruce Clark  (30:03)

If your child, if you really got to the point where, look, rituals are taking up like an hour a day is often used. It's like an hour a day. That's starting to have an impact. I would definitely go and seek some support, some signposting. School staff can often give you advice, go to your GP, get referred in. There's quite a good literature supporting the fact of reading about OCD, getting some of those ideas early on about not accommodating, sitting with some anxiety, doing some of that work, reading and learning. It can be really helpful early on. I'd encourage people to do that. There are brilliant OCD and BDD charities, places like OCD Action, OCD UK, the BDD Foundation. They can all do a fabulous job at supporting your learning, signposting, introducing you to a community of other people who've had experience can share their own practical examples. Really worthwhile. But it is then worth going into getting referred on. I absolutely understand the state of waiting lists and can services. I don't have a good answer for that. I'd love them not to be there. But that's not a reason not to start that journey and think about it.

There are mental health support teams that are increasingly being rolled out in schools. The government has just recently recommitted to trying to push up the number of schools, where there's going to be more expertise sitting within schools, supporting kids with mental health. All of those things are opportunities to start to address things. So I just actively encourage people to, if they're listening - know that OCD is treatable and the sooner you can get cracking the better.


Alis Rocca (32:00)

Really good advice, thank you. You were involved or you made a film. Tell me about the film because we're talking about signposting and educating parents. Why did you make the film? it for that reason, to raise the profile?

Bruce Clark  (32:15)

We've done a few films. I've done a film for Nip in the Bud in the past, which will be on the Nip in the Bud website. But we also made a film and I think the one you're referring to, I love the fact that you're calling it a film. It's a six, I think a six and a half minute clip, but it is it. It's called OCD is not me. And so I think you can get to it through OCD is not me dot com or you can just go on YouTube and type in OCD is not me and have a look. You'll see younger version of myself in it and some of my colleagues. And we made that through the support and generosity of a philanthropist, someone who came to our team and the young person that families life had crippling, crippling severe OCD and did brilliantly and, ⁓ you know, has recently graduated university and OCD isn't part of her life and that family remembered our assessment and felt a bit despondent. You we were giving a message of hope and it's so hard when you're sitting with OCD, particularly of that severity, to think that you can break free of that. And having done so, that family wanted to then make a film, which includes a number of young people, to, if you like, give a message back to the folks sitting on our sofa they made it for us to use in our clinic.

And a number of people have said it has been quite inspiring because those are real stories, real young people who literally, it was made with the impetus of, tell the folks at the beginning of their assessment journey, go for it, do it. It doesn't have to be part of your life.


Alis Rocca (34:02)

Thank you. So the other thing you keep mentioning is BDD, so body dysmorphic disorder. you tell us again, like you did with OCD, just in layman's terms, what is that? What does it mean?


Bruce Clark  (34:16)

So, I've been at pains when I've talked about OCD to explain that OCD is in fact just one of a wide family of obsessive-compulsive difficulties. So another obsessive-compulsive difficulty is a condition called body dysmorphic disorder. There are others, things like olfactory reference disorder. Not many people have heard of that one. You see those in specialist clinics or maybe hoarding disorder, trichotillomania, these are other things people might have heard of and they're examples of what are now categorized as obsessive compulsive disorders. So back to BDD, it's an obsessive compulsive disorder where those intrusive ideas, images, impulses, it's normally images and ideas center around appearance. And so a sense, if you like, of being unattractive and being profoundly distressed by those ideas about appearance. Importantly, just like every other obsessive compulsive disorder, there has to be ritualized compulsions which you are using in part to manage your sense of distress. So this isn't just looking in the mirror and think I don't like that particular aspect of my personality, my appearance. We all have those experiences, much like anyone can have anxiety. These are people who are having really profoundly distressing appearance related anxieties. They are usually multiple, just like I was saying about other obsessions. And people are doing something ritualized in order to manage that anxiety. And it then becomes disordering. It's interfering with your ordinary life. You're not going out. You're not going to school. You're often late for school and you're doing things compulsively. So that could be extensive hours of mirror checking, mirror avoidance at all costs, avoiding reflective surfaces, putting things out onto social media very purposefully in order to seek compulsive validation. It can include repeated washing, makeup applications and people do lots of other things compulsively to alter their appearance. So you've got those obsessions which are image related and compulsions which are used to manage those anxieties. Again, it's profoundly distressing. An important qualifier in the diagnostic manuals that I use is to check out with a person describing those things to you.

Whether they believe that all of their concerns regarding appearance would be sorted out by altering their weight or shape. If they say yes, I think my weight and shape are at the root of every single one of these images. You're probably dealing with someone who has an eating disorder rather than BDD. BDD isn't a worry about weight and shape. Right. It's other aspects of appearance. Now, that I'm simplifying in the sense that it's much more common in people who've had eating disorders to also have BDD, if you like, as an additional item, much like mental health disorders often exist together. Often people have depression and OCD. And so people with eating disorders are more likely to have experiences of BDD, but they are considered separate disorders and the treatment approach is different.


Alis Rocca (38:11)

How might it look in younger children, so primary aged? So I asked because a lot of what you just said was talking about putting things out on social media, application of make-up. How does it look in a primary?


Bruce Clark  (38:27)

We sort of don't know. And the easiest answer is you probably won't see it in the primary age class. It's really a phenomenon of peri and post puberty. But there is research interest in that, much like if you'd met me 15 years ago and we were talking about anorexia nervosa, it was quite rare to see that in pre pubertal people. We carried out the largest epidemiological survey.


Certainly in the UK, possibly the world is carried out nationally in the UK. And for the first time ever, the Office of National Statistics who lead on this included measures of body dysmorphic disorder, which is very illuminating in helping us understand how common this is. And essentially it's exceptionally rare at primary age. It is more of a phenomenon of perian post pubertal life.

And interestingly, when I was talking about OCD, I was talking about the early onset group of OCD patients have slightly more males than females. But by the time everyone's got OCD and you're into adult life, it's pretty even. BDD does look like it's much more prevalent in females and particularly worrying the group of late teens, early twenties females is very, very enriched, you know, upwards of three and a half percent of that age group later teenage early twenties life have BDD and that's it makes clinical sense to me from what I see in clinic but it's worrying and the reason that it's worrying is that BDD is a very what I say morbid condition it's a real torturous really deeply unpleasant personal experience and we know 60, possibly 80 percent of people with BDD will have sort of suicidal thoughts at any given time because they feel so dreadful about their appearance and the rates of attempts on suicide are very, very high. There's ⁓ Professor Phillips, who's a leading international researcher in BDD, and she often makes the point that, you know, the mortality, the the issues with suicide is possibly the highest in BDD of any mental health condition. Now, I'm not talking about a race to the bottom, I'm just trying to highlight that BDD is associated with really worrying, distressing, suicidal thoughts. And the other thing that I feel passionately about in my career is when I'm teaching and training clinicians coming up in the earliest parts of their career is it's well described in the literature that patients with BDD very typically have a tremendous sense of shame. They are not going to tell you unless you ask about their BDD symptoms. That's not the case for the majority of people with OCD. It's much more easy and they will share their experiences, but it's well described. there are many reasons that contribute to this, that if you don't ask, you're not going to be told that sitting behind my low mood, my self harm, my suicide attempts is an experience of feeling ugly, if you like to put it in simple terms. And so I'm always tutoring our staff who are, you know, on the front line in accident emergencies. Please just ask a few simple questions about appearance related anxiety when you're assessing someone who's at a dark spot in their mental health journey, because if you don't ask, you won't know. And this is a common disorder.


Alis Rocca (42:20)

How would you suggest educators or parents ask? So not at medical level, but how would you have that conversation without, so I'm imagining not wanting to give them any ideas or to say that you should be worried about your, I'm asking this because I'm worried about the way you look.


Bruce Clark  (42:40)

Risk in the way if you were to ask it in the wrong way, someone who has BDD who will assume that every so typically will assume that everyone finds them unattractive.


You know, if you're opening up a conversation about someone's experiences, their low mood, their distress, you can open up a conversation by saying, you know, introducing a few other things and discussing what might be contributing. And I might choose language such as it's really common for young people to have worries about appearance. you know, often people don't talk about that. Is that something that's been distressing for you? That seems like a neutral, balanced way, and I think that's the sort of neutral question that perhaps a teacher might feel comfortable asking about.


Alis Rocca (43:32)

And I like the way you made it seem like it's not going to be just you that's feeling this, that actually this is something that can be.


Alis (43:41)

It is very common. can all think back to teenage life where we've all, everyone has worries about their appearance. So you can reflect that, but it can be a segue into telling that, ⁓ you know, that's actually a big problem for me. And I often think, as I've learned and come on a journey of understanding BDD over the course of my career, and I think back, to my experiences in school and secondary school where everyone would worry about aspects of their appearance at times. But I also recall friends who wouldn't go out, wouldn't go to a party or something else because of an aspect of their appearance. I was fortunate that I wasn't like that. I do think back.

You know, I wish some of those people had had an opportunity just to talk about that. might have been nothing, but this is a common disorder. If you're thinking roughly three and a half percent of your sort of late teens, early twenties females, you're going to find people around the class who are really getting to the point of it's disordering for them and that support would be helpful in getting that out in the open because they won't tell you otherwise. another colleague who inspires me, Professor David Veale. Often I do the children's side of work at the Maudsley Hospital and David's ⁓ a really, really senior researcher and clinician working with adults and he actively encourages his peers who are working in adult mental health, always think about this when you're working with folks who you've considered to have social anxiety, people using substances and that's been a long-term problem.

People with BDD fears have often, not always of course, but have often turned to using substances or alcohol to manage the way they feel. And also people with years and years of depression that just hasn't responded to treatment. That can be a thing, but also just please ask about is body image sitting as the core fear that you just won't talk about.


Alis Rocca (45:57)

Can it be cured in the same way as OCD?


Alis (46:00)

That's where I smile. Yes, absolutely it can. And I often tell people that when I was a junior doctor sitting my postgraduate exams, I remember having to write an essay or some long piece about a set of conditions that were sort of considered untreatable, if you like, and describing those. And it included body dysmorphic disorder in another name at the time. So

I started my career writing, if you like, about a condition that was considered untreatable and I'm proud to have been part of a team and working with brilliant researchers much brighter than me who've designed and delivered iterative programs of research that we've rolled out through our team and services and really checked out and developing the psychological therapies in particular to the point now where the outcomes are looking as promising as they do for OCD. And I'll remind you that I've said that that's amongst the most treatable mental health disorders. So I guess the point that I will reflect on when I come to my own retirement is that for me is going to have been a really exciting thing to have been part of taking a condition that's very common, understanding how common it is trying to tell the story differently. This isn't something niche and importantly, it's not something that's untreatable. It's highly treatable and we're still ramping that up. So that feels exciting.


Alis Rocca (47:35)

And I suppose again, it's getting that message out to parents and educators that if you notice, have that conversation, try and bring it to the surface, but also to understand that it is treatable. So would your, the same advice be as for OCD, try and get referred, try and get help early on.


Bruce Clark  (47:54)

Teachers are so well placed. I meet people who are really suffering with their mental health. Teachers are experts in supporting young people and knowing the full range of experiences. I spend a life working with people with a quite extreme set of mental health problems. Teachers are really in a perfect position to have the ordinary and everyday conversations so that young people who have everyday appearances anxieties can have a helpful and fruitful conversation about that. I think there can be a lot of really positive whole class discussions about what appearance means for young people in society, what does social media have as an impact on that. I think that that must be a healthy and thoughtful topic to discuss in a PHSE curriculum for instance.


Alis Rocca (48:50)

without necessarily waiting to see a student who's suffering but actually preempting it by having that conversation.


Bruce Clark  (48:58)

And I know, you know, you were a teacher and you'd be more expert in this than me, but I've given so many lectures over the years about BDD and OCD where I'm talking in terms like this, of course, in sort of general and generic terms. And then someone will bend my ear after a lecture and say, you know, listening to you, I've realized.


And I think those opportunities are important and teachers are really great at knowing that and having a great sense of what to do with that and how to explore and help people guide. So I'm just thinking, and you will be more expert than me, that if you're having that sort of everyday conversation about, know, teenage life can be tough, it can make you worry about your appearance. What does that mean? What does social media do to that? And then having a sense if there's someone who's standing out or saying something different. You know, I think that would be something that would be really helpful.


Alis Rocca (49:58)

You've mentioned social media a couple of times. you feel, because there's obviously been such a rise in social media use, and we hear all the time about the impact of social media on people's mental health, on their wellbeing, on the way they see themselves in the world. Do you think as a result there's been a link to a rise in BDD?


Bruce Clark  (50:20)

That's a very clever question and it's not an easy one to answer. It's probably the most common question I get asked, rightly so. And it has tremendous face validity, doesn't it? It's striking that that's important. Honestly, it's a tremendously difficult question to know because we don't have accurate data about how common was BDD before social media. I do have a tremendous clinical sense that when I'm working with patients with BDD, social media and abnormal use of social media, we definitely have to help people think about how they're using social media in a healthier way. But that's not to say that social media as such has caused people to have BDD. I think it's a really important question to examine.


And we also have to examine it with an open mind and heart. Sometimes people ask me that question. And I wonder, you think or are you hoping we'll just turn social media off? It's here to stay. And so the question really is, how do we understand our interactions with social media and what do we do to make that healthier? We're not going to turn off social media. And it's also important to remind ourselves that social media can do lots of things, positive and negative. Where do we all go now when we're worried about our health? The web. And so where there are concerning aspects potentially that we need to understand and use healthily, it's part of life. It also brings positives. These great, you know, support charities and stuff. All of their information is also out there very helpfully in social media. It's complicated.


Alis Rocca (52:17)

It is complicated and I think that's part of the role of parents and educators is about how we teach our children and young people to use it in a considered way rather than just consuming but actually be using it in a way that they're considering how they're getting the information, whether it's misinformation, whether it's the right information. Thank you, you've given us so much to think about whether we're adults who are caring for children or adults in school, parents,


Is there anything I've not asked you that you think would be helpful that we haven't covered?


Bruce Clark  (52:55)

I think that I mentioned earlier that if you're worried about things early on, know, where'd you go? The web. So places like OCD Action, ⁓ OCD UK, the BDD Foundation, there's support systems for Tourette's Syndrome, hoarding, there's all sorts of really positive, go to good, reliable sources. I also think sometimes buying a book, I like a book as well. Having a read, there's a book on the adult side, Fiona Chalicune published a book called Break Free from OCD. A colleague in my own team some years back working together, it's kind of published our approach to treatment, breaking free from OCD. We published a book called Appearance Anxiety that's aimed at young people with lots of chapters about BDD and, you know, it won an award nationally is considered good quality mental health reading such that it's been put into every library in the UK. So I think reading and, you know, just flagging good quality literature, we're not making profits from those books. I just mentioned them because obviously those titles are in my head, but high quality material. And I honestly think those third sector organizations and other parents you can hear where sensible opinions are coming from. And I'd encourage people to use those aspects of social media. I think we didn't necessarily touch upon those.


Alis Rocca (54:31)

Yeah. And key takeaways, if you could sum up our conversation from a parent's perspective, what would you hope that they take away from it today?


Bruce Clark  (54:42)

And that's a good question and keeping it succinct. I think I just want to share again my passion and commitment to encouraging people to seek the right supports. I, course, hear the journeys where people haven't had good treatment, but it is the case that OCD and now shortly following behind BDD, they are responsive to certain types of medication and certainly psychological therapies.


Mental health conditions in many instances are treatable and these are amongst the most treatable, so don't give up the fight.


Alis Rocca (55:20)

that. Thank you. You've mentioned a few titles there. We are compiling a book list on our website. Is there anything else, any other books that you would suggest people would read that we can put in our show notes? You've already mentioned a few which we'll add to the show notes.


Bruce Clark  (55:37)

Yeah, there's a whole series about Can I Tell You About? My colleague Amita Jassy wrote, she's one of our consultant psychologists, very experienced called Can I Tell You About OCD? The Can I Tell You About series is, I guess, really pertinent for Nip in the Bud because it covers a huge range of different mental health disorders, know, different work to that that I do. And I think that Can I Tell You About? And the thing that I like about that, I work with children and young people, they're short reads. And I often recommend that particularly for younger people. And sometimes OCD and BDD very typically have a habit of taking over families' lives. It affects everyone. Everyone gets drawn in with accommodation and the impact. And so I often recommend those shorter books like, Can I Tell You About OCD maybe even to give to a sibling. It's a short read and it might help you understand what's going on and you know I think I think that can be important so I'm guessing that would be the other book that's come to mind.


Alis Rocca (56:48)

Thank you. Thank you for your time today.


Bruce Clark  (56:50)

Pleasure.