Chasing Perfection: Body Dysmorphic Disorder and Addiction with Dr. Katharine Phillips

Katharine Phillips, MD, is internationally known for her expertise in body dysmorphic disorder (BDD) and related disorders, such as olfactory reference disorder (ORD) and obsessive-compulsive disorder (OCD). For more than 30 years, Dr. Phillips has conducted ground-breaking scientific research on BDD and has provided expert evaluation and treatment with medication and therapy for people with these and other conditions. 

She is currently Professor of Psychiatry, DeWitt Wallace Senior Scholar, and Residency Research Director for the Department of Psychiatry at Weill Cornell Medicine and Attending Psychiatrist at NewYork-Presbyterian Hospital. 

Follow Thriving with Addiction:
www.thrivingwithaddiction.com
www.instagram.com/jonathanaverymd
x.com/jonathanaverymd
www.linkedin.com/in/jonathan-avery-md

Transcript

SPEAKER_01 0:00

Welcome to the Thriving with Addiction Podcast, where we explore how recovery is not just about surviving, but about truly living. Each week we'll dive into the science, stories, and strategies that help people and families heal from addiction and build healthier, more resilient lives. I'm your host, Dr. John Avery. Let's get started. I'm John Avery and welcome back to Thriving with Addiction. Today we're joined by Dr. Catherine Phillips. Dr. Phillips is internationally known for her expertise in body dysmorphic disorder, or BDD, and related disorders such as olfactory reference disorder and obsessive compulsive disorder. For more than 30 years, Dr. Phillips has conducted groundbreaking scientific research on BDD and has provided expert evaluation and treatment with medication and therapy for people with these and other conditions. She is currently professor of psychiatry, DeWitt Wallace Senior Scholar, and Residency Research Director for the Department of Psychiatry at WoW Cornell Medicine, and then attending psychiatrist at New York Presbyterian Hospital. Dr. Phillips, welcome.

SPEAKER_00 1:11

Thank you. Thank you. I'm really delighted to be here.

SPEAKER_01 1:13

And I don't think that intro quite highlights what an expert you are in embodied dysmorphic disorder. You are the expert. You literally wrote the book on it. So it's lovely to have you here to discuss this important topic.

SPEAKER_00 1:24

I appreciate your very kind words. It's really been a lifelong journey, right? To to try to understand this disorder and get the word out to people who are suffering with it that it's it's very treatable. People suffer a lot, but we can do a lot to be helpful. So thank you.

SPEAKER_01 1:40

I know we appreciate your expertise. And tell me how you became, you came to be the expert in this.

SPEAKER_00 1:46

Well, you know, I think it started when I was a resident. I was still doing my psychiatry training, um, and I hadn't heard about BDD. I think really pretty much nobody had uh at the time. Uh you know, I didn't hear about it undergrad, med school, psychiatry residency. It was sort of um, it slipped through the cracks of modern-day psychiatry. It was pretty invisible. But then I saw some patients um who came in for depression, and I talked with them and tried to understand, you know, what was bothering them, what their symptoms were. Um, and I'll never forget one patient who spent about an hour telling me about his concerns and um and we talked about possible treatments. And as he was leaving my office, I remember he had he had his hand on the door handle and he turned around and said to me, Should I tell you the real reason I'm here? And I said, Please do, please, please, can you tell me? And so he sat down and he told me he was really depressed because of his hair. And he thought he was going bald. And meanwhile, he had beautiful head hair, big, beautiful head of hair. But it was, you know, he was making him suicidal, was making him feel life wasn't worth living. Um, he felt uh very socially isolated. He thought he was ugly, and he mistakenly thought that everyone else thought he was ugly, but no one else did. It was his misperception and it was really destroying his life. And I saw other people like that as well. None of them had been diagnosed with BDD because it really wasn't known at the time. Uh, but they too thought they looked terribly ugly, unattractive, deformed in some way. And you couldn't tell by looking at them what why? You know, they looked normal. Some of them were even very attractive. And yet, here, this preoccupation, this worry was was really causing them a lot of suffering. So I decided I need to find out about this, right? And has anyone ever seen it? And we didn't have the internet at the time, so I walked to the library at the hospital where I was training. And turns out there are articles from around the world over the past century written about BDD, but case studies, you know, mostly descriptions of individual patients, but just like the people I was seeing uh from the 1800s and subsequently, but almost no good research studies. So we knew really very little about it. So I decided I have to figure this out. And I first started by just talking with people who had it, spending lots of time with them, just hearing about their experience and their stories and their struggles, trying to identify what are the symptoms, uh, what effects does body dysmorphic disorder have on people's lives? Um, and maybe the most important question is how do we treat this problem, right? We had no treatments at the time. And now we have uh very effective treatments, both medication and therapy.

SPEAKER_01 4:53

Wow, it's incredible how you're able to, you know, bring this into popular awareness. Why do you think it escaped awareness for for so long? Why was it a diagnosis that that we missed?

SPEAKER_00 5:05

I think um part of it is people with body dysmorphic disorder often feel very ashamed. And they feel that people are going to think they're vain. And BDD is not vanity. It's it's really an obsessional disorder that's focused on non-existent or slight defects in one's physical appearance, you know, thinking their nose is misshapen, or their, you know, their eyebrows are crooked, or their jawline isn't, you know, at the right angle. It could be any part of the body. But I just think there's a lot of shame, uh worrying that clinicians won't understand uh that we'll will, you know, label them in some way as a vain or selfish person. Um and also a lot of people with body dysmorphic disorder go to get cosmetic treatment, right? And so, which doesn't work for for uh and so I think it wasn't really recognized um in the mental health professional, uh, you know, among mental health professionals. Uh fortunately that's changed. I think it's still uh under recognized. Um, but a lot of other researchers have gotten involved. And, you know, we've we've the field has advanced by leaps and bounds since I started, you know, back my my early journey back in in around 1990. And now we we know so much more about BED.

SPEAKER_01 6:34

And tell me a little bit more about it, about body dysmorphic disorder, because yeah, I do find myself confused a little bit about when, because we're all obsessed, or we everyone to a degree with how they look. And, you know, I spent my 20s not going bald, for example. You know, it's how do we know when sort of that preoccupation with looks, or you know, especially in the age of social media and everything else that's so focused on looks, how do we know when it progresses from sort of normal preoccupation to more risky preoccupation to, you know, frank body dysmorphic disorder? How do we define it exactly?

SPEAKER_00 7:08

Yeah, it's a great question. There are a couple of guidelines that we use. Um, one is that um first let me just say that body image in people with body dysmorphic disorder, BDD, is distorted. So they misperceive how they look. They they think that you know, we all have a little asymmetry in our faces, for example. That's natural. No one has perfect symmetry of all body parts, but they may think, for example, a little asymmetry of their ears, or maybe a little tiny pimple, you know, that to other people looks very minimal, to them looks huge and and you know, ugly. Uh so there's that distorted body image. Um, and by definition, the perceived appearance flaws in reality are non-existent or only slight in the eyes of other people. So that's one thing. And then two, preoccupation. Uh if you think about these, about perceived defects in your appearance for at least an hour a day in total. Um, and on average, people with BDD obsess about these perceived appearance flaws for three to eight hours a day on average. Well, but if it's more than an hour a day in total, that's a lot to be having negative thoughts and thinking, oh, my chin is the wrong shape, or, you know, oh, you know, I've got a wrinkle at the, you know, at the corner of my eyes, or that's a lot of time. So that's one guideline. Are you preoccupied? Are you obsessed? Are you thinking about a lot during the day? And then very importantly, for body image concerns to be diagnosed as body dysmorphic disorder, the concerns, the preoccupation, has to cause significant emotional distress or significant impairment in day-to-day functioning, right? And usually it's both. So significant emotional distress, things like feeling depressed, anxious, maybe even feeling life's not worth living. That's pretty common among people with BDD. Impairment in daily functioning. Maybe your grades are slipping in school because it's hard to study, because you're worrying about how you look, or you're checking the mirror for five hours a day or three hours a day. And so, you know, it's hard to get your schoolwork done. Uh, maybe you don't socialize as much. Uh, maybe you're not dating or seeing friends because of it. Um, so it's really those the preoccupation and the degree of emotional distress and impairment in functioning. Those are kind of our main guidelines. And I think, you know, for differentiating normal appearance concerns, which most people have, from the disorder, body dysmorphic disorder, which needs good mental health treatment. Um, so I would also mention there's a range of severity. Some people have milder EDD and they may be functioning fairly well, but usually not up to their potential. Um, and if you talk with them, they'll say, well, you know, I really I'm turning down about 25% of all social opportunity uh invitations. Um, but they may be functioning reasonably well at their job, for example, but maybe they didn't go up for promotion because they'd have to be on Zoom calls more and be seen more by other people rather than just staying in their office. So sometimes the impairment is milder, but it's usually there. And if they're not impaired, then they're suffering a lot by definition. They're upset about it. Um, but you know, at the severe end of the spectrum, this BDD is really debilitating. Um, and some people kill themselves because of that. They think they're so ugly that they can't tolerate living anymore. Again, this is all a misperception. Some people, I've seen people who've stayed in there, dropped out of high school because they thought they were so ugly and didn't leave their bedroom for the next 10 years, wouldn't even let their parents see them. So sometimes it really can destroy every aspect of a person's life.

SPEAKER_01 11:03

We'll talk in a minute about how this can lead to substance use, but it can also lead uh because of the severity to depression, anxiety. Yeah, the the incidence of suicide is really high for folks who struggle in this way. Is that right?

SPEAKER_00 11:16

Yeah, we we have very little research data on actual suicide, completed suicide. The numbers that we do have suggest that the rate is high compared to people without BDD. We have we know a lot more about suicidal thinking, suicidal ideation, and suicide attempts. And um uh something called a meta-analysis, a study that pulled together and looked at all the individual research studies on suicidal thinking, suicidal ideation, found that over a a person, a person's lifetime, uh about two-thirds uh have suicidal thinking. I found even more like 80% in my studies. And about one-third, actually a little more than one-third, actually attempt suicide. So that's much higher than in many, many other uh psychiatric disorders.

SPEAKER_01 12:14

And do we have a sense how many people uh have BDD or qualify for that diagnosis?

SPEAKER_00 12:19

Yeah, well, you know, the best studies we have suggest about 2 to 3% of the population currently have BDD. Uh, I suspect it's probably more common than that. The last good study was done more than 10 years ago. And um I wouldn't be surprised if it's becoming more common, I think, in part because of the influence of certain forms of social media and making us all feel uh we don't look good enough and promulgating uh sort of you know, just idealized uh, you know, standards uh for how we should all look. That's not the only cause of BDD, by the way. BDD goes back to the 1800s. And we didn't have social media back then, right? And we know BDD is at least partly genetically determined. So it's not quite that simple. It's not simply social media by any means. But I I wonder if that's just it can be what if it's one risk factor and and might be contributing to an increase in BDD. But that's just something I wonder about. I don't no one really knows for sure. But even two to three per 3% of the population is what the most recent study showed currently. And that's that's a lot of people. Many, many millions in the United States alone. Yeah.

SPEAKER_01 13:34

It's a it's a real lot of people. And does it impact women more than men?

SPEAKER_00 13:39

It's about two, maybe uh two-thirds women and or or maybe 60-40, uh 60 percent uh women and maybe 40 percent men. So I think sometimes it's mis misconstrued as a women's problem, right? Because uh certain eating disorders occur more frequently in in women. But no, BDD affects men also, almost as many men as women.

SPEAKER_01 14:04

And then you mentioned that it carries a risk of having unnecessary cosmetic surgeries or other procedures as well.

SPEAKER_00 14:10

Yes, definitely, yes. You know, we were talking about it's about two to three percent in the general population have people with BDD, but much more common than that um if you look at people who are asking for or receiving cosmetic procedures, like dermatologic treatment, uh any kind of cosmetic surgery. Uh, we know, for example, that about 15% of people who seek cosmetic surgery have BDD. Um and when you look at the converse, how many people with BDD have sought cosmetic treatment or received it? About three-quarters have sought cosmetic treatment and about two-thirds have received it. And that kind of makes sense because they think they really do look bad, even though they really don't. They have that distorted body image. So it makes sense that they would try to fix it, you know, with surgery, with a scalpel, with some kind of dermatologic treatment. I mean, the problem is that the as best we know, these uh cosmetic treatments don't work for BDD. They don't help because they don't they don't change the body image distortion, right? And the tendency to obsess about any little minor or even non-existent imperfection. So, and sometimes cosmetic procedures can make BDD a lot worse. So we really, really advise people to avoid cosmetic treatment. We have much better psychiatric treatments that are much lower risk, very little, if any risk, and they are much more likely to help.

SPEAKER_01 15:40

Right. And that speaks to it not being about the the body part, but about being something that's going on in the brain. You mentioned it's genetically informed, and and then also there are changes in the brain in people that have this. Is that right?

SPEAKER_00 15:53

Yes, yes. You can see on functional MRI, functional magnetic resonance imaging, um, which shows sort of a picture of the brain working, not just the structures inside it, but you can see blood flow and you can see kind of uh the same part of the brain that's overactive in obsessive-compulsive disorder, OCD, is overactive in BDD. And that probably reflects the obsessional thinking over and over again. Oh, I look ugly. Oh, I better get a nose job, oh, that person must be thinking I look ugly. The obsessions that we talked about that occur on average for three to eight hours a day, that's probably what that hyperactivity on brain scans is reflecting. But we also see something else that's really interesting, which is that parts of the brain that are specialized to see the big picture rather than detail, which helps us realize that details are just tiny things, not huge things. That part of the brain in the back of the brain, the occipital lobe, is underactive. So this makes details look huge and prominent to people with BDD. So they look at themselves, they see a tiny little dot on their skin, and they think that looks huge and ugly. It actually looks big and sort of overly prominent to them. Whereas other people would look at it and say, Okay, I don't really even see that. What are you talking about? So it seems that the brain, parts of the brain that are specialized to see detail are working too hard. You can see that on brain on certain brain scans. Parts of the brain that are specialized to see the big picture. So we realize that details are just tiny, not huge, are underactive, not working hard enough. So you get this imbalance in what people are seeing, and little things look really big and out of proportion and abnormal. And that, you know, that's we see that in many different kinds of studies of BDD. We see it, you know, on the brain imaging, brain imaging studies, studies where people look at images on computers, um, et cetera. So, you know, there's this visual distortion that occurs. And it's similar to what occurs in people with anorexia nervosa, the eating disorder, people who are really thin and underweight, but they think they're fat. Similar changes are going on in the brain also, but they're more severe in people with BDD.

unknown 18:19

Right.

SPEAKER_01 18:20

And that's such great information because I think this is the condition that often gets stigmatized and viewed as like a moral failing or, you know, a vanity issue, but it's really a mental health issue that impacts the brain in in dramatic ways.

SPEAKER_00 18:34

Absolutely, absolutely. And, you know, when we s when I started my work, it was many decades ago, it's widely misunderstood as vanity. That probably still happens to some degree, much less so. But we would never call people with anorexia vain. We'd realize, you know, they they must be seeing things differently than other people, you know, do and seeing themselves differently. And it's the same in in body dysmorphic disorder, this visual perceptual aberration, abnormality.

SPEAKER_01 19:06

So it's not surprising, given what a severe condition this can be, that people turn to substances sometimes. What what do we know about BDD and substance use?

SPEAKER_00 19:15

Yeah. Um, so about 30 to 50 percent of people with BDD have a substance use disorder over the course of their lifetime. That's pretty high. Uh, depends on the study. Different studies find different numbers, but um so those are probably the best estimates we have. Um uh most often alcohol, but many have a have a drug use disorder. And I think importantly, about two-thirds of them say that uh BDD is a reason for their substance use. Um uh, you know, about 30% say it's the main reason for their substance use. And about close to 70% say it contributes to at least some degree. And I think this makes sense because BDD is is typically a very, very distressing disorder. People can feel very socially isolated. They often misperceive that people are making fun of them because of how they look. That's not really happening, that's a misperception. Uh, but if someone looks at them, they just kind of assume that the person must be thinking, oh, you look like a freak. Why are you even leaving your house? You know, and of course, the person's not thinking anything like that because the person with BDD looks normal, often quite attractive. Um, but that's often very isolating, uh, it is, you know, very stressful to have this condition, often very poor quality of life, so a lot of suffering. So we often find that people with BDD are self-medicating, uh, their distress. About half of people with BDD will say, you know, specifically that they're drinking or using drugs because they feel uncomfortable about how their body looks. They want to feel more comfortable about how they look when they're around other people. They want to forget, you know, the what their nose is, you know, what their nose looks like, that sort of thing. So they'll they'll use drugs and alcohol to cope. Um, that's the most, you know, when we look at reasons for substance use in BDD, alcohol, and drugs, um, we find that coping motives are are more elevated compared to the general population than other motives, like, I just want to have more positive emotions and, you know, I just want to bond with my friends and have a good time. No, it's really because you're trying to self-medicate uh negative emotions and often BDD symptoms specifically.

SPEAKER_01 21:43

Right. And I've had similar doorknob moments with my patients who are coming for the substance use, which is sometimes a louder symptom than the body dysmorphic disorder. They say, hey, you know, part of the reason I'm doing this is my concern about how I look. And that's always very revealing because it is it does cause so much. To stress as you've highlighted. And then sometimes I imagine they also use addictive substances to um look better, be it steroids or stimulants.

SPEAKER_00 22:11

That's a big problem, yes. I think especially the anabolic steroids. Um there, you know, there's a form of body dysmorphic disorder usually involves the face or the head, perceived defects of the face or head. So skin is number one, anything about the skin, color, tone, you know, blemishes, scars, any per any perceived defects or flaws. Hair is number two, something's wrong with the hair. Nose is number three, usually the face or head. But there is a form of BDD called muscle dysmorphia, which affects mostly uh boys and men uh who think that they're not big and muscular enough, that their bodybuild is really puny and too small. And just by definition, they look normal, right? Otherwise, they wouldn't have a diagnosis of BDD. Uh, there's nothing wrong with how they look. Um, but some of them are actually hugely muscular. And some of them are so muscular that, you know, it's a look that can only be obtained by using anabolic steroids, usually illegally obtained. Um, you can't get that big by working out at the gym or, you know, eating a good diet and those kinds of things. So, yeah, anabolic steroid abuse is a, is a, is a problem. And among people with muscle dysmorphia, it may be the main reason uh that boys and men are using anabolic steroids these days is to become where muscular is a lot of pressure online to bulk up. Um, and of course, there are healthy ways to do that by getting a decent amount of exercise. But the anabolic steroids probably are used by any up to 40% of men with the muscle dysmorphia form of BDD. Um, and the problem is these are potentially very dangerous drugs, as I know you know, very risky, increase the risk of death, increase the risk of heart attacks, can make you infertile, can stunt the growth of adolescence, can, you know, cause a lot of psychiatric symptoms, like most people have probably heard of roid rage, aggressive behavior, depression, you know, when you especially when you're suddenly stopping them. So they're, you know, they're very risky both mentally for your mental and physical health.

SPEAKER_01 24:32

Right. And then similar um in some ways, um, are some of these behavioral addictions like compulsive exercise or compulsive tanning or or some of this other stuff a part of it at times as well.

SPEAKER_00 24:44

Right, right. Yes. I I remember the first patient with BDD I saw who had compulsive tanning. It hadn't been described by anyone ever that I could find in the medical literature. He he was, I mistook his race because he was so deeply tanned. And it turned out that he had very severe BDD, hadn't left his house in about 10 years, um, hadn't been able to work or finished school. And he had actually talked his parents into building a tanning booth in the house. And he pretty much tanned all day, and he had really, really damaged his skin, as you can imagine. And of course, I was worried about his risk for skin cancer because tanning, of course, is a well-known risk. But yes, we find a lot of people compulsively tan, about 25% of people with BDD compulsively tan, specifically because of their body dysmorphic disorder concerns, right? And it's usually because they think their skin is too pale. That's a quite common concern of people with BDD. They think they look like a ghost. Um, you know, some so sometimes it's, you know, they think they're they're going bald, so they'll try to darken their scalp so it doesn't, you know, look as though they are. Again, most people with BDD, really every people with BDD with perceived hair loss, again, by definition, have it's only very slight or it's even non-existent. But yeah, tanning, um, certainly a risky behavior that occurs in BDD. Sometimes we see compulsive exercise. I think, especially among the men with muscle dysmorphia and the boys with muscle dysmorphia, you know, they're trying to, they're they're desperate to build up muscle and may, you know, go to extreme lengths to do that. I I I remember one man I saw many, many decades ago who could only get to my office in a wheelchair. He was maybe about 40, and he had worked out so much, um, including lifting furniture in his basement for hours and hours a day. He had really just kind of ruined his body and had caused all kinds of spinal injuries and back injuries and uh probably irreversible. So um that's you know, that's one of the potential consequences, unfortunately.

SPEAKER_01 27:02

Wow. And you know, substance use is one of the biggest risk factors for suicide. So I imagine when it when it co-occurs with BDD, it outcomes are a lot worse for folks with body dymorphic disorder.

SPEAKER_00 27:13

Yeah, yeah, yeah. People with BDD who also have a substance use disorder have a much higher rate of uh suicide attempts than those without a co-occurring substance use disorder. So the two main risk factors we have found for suicide attempts in BDD, people with BDD are one, substance abuse or dependence, substance use disorder, and more severe BDD. Those are the two main risk factors for suicide attempts in people with BBD. And we also found that if people who use alcohol or drugs, people with BDD who use alcohol or drugs, are using them to cope with negative feelings as opposed to just enjoy the high or have a good time with their friends, but they're kind of what we would call self-medicating their distress, they're also more likely to attempt suicide. So it's really important when you see patients with BDD, and you often have to ask about it because patients are often too embarrassed and ashamed to raise the issue, right? So we it's so I it's really ideal to screen all patients for BDD in cosmetic settings, in psychiatric, mental health settings. But we always, of course, ask about suicidality. Um but I think we also, of course, always want to ask about substance use. And if they have BDD and substance use, ask why they're using substances. And if it's to self-medicate their distress, we have to be very careful, you know, as with all patients with BED, really, and monitor them carefully for suicidal thinking.

SPEAKER_01 28:49

Yeah. Luckily, good treatments exist. Tell me about what we and what we can offer, what we can do if if we are struggling with this.

SPEAKER_00 28:57

We have two great, great treatments. Um, one is certain type of medication, the serotonin reuptake inhibitors, uh, called SRIs or SSRIs. Um, and you know, they're familiar medicines that are very widely prescribed for all kinds of problems and concerns and symptoms. So uh medication like Prozac, and so often Lexapro, these are usually very well tolerated. It's very rare for people to have to stop them because of side effects. Um, there are a lot of myths about them, but they're not addicting. They're not habit-forming, they're not like heroin. They're just most people do great on these medicines and don't become physically dependent on them. And they can really substantially improve the BDD. The obsessive thoughts just don't bombard your mind as often. And when they do come into your head, you do start obsessing about your jawline or your lips or whatever, it's just easier to refocus your attention on something else and let those thoughts just go away. The medication, the serotonin reuptake inhibitors reduce the distress that BDD causes, the depression that so often goes along with it, makes it easier to function, makes it easier to go to school, go out and be around other people. Um, I think one thing to keep in, oh, easier to resist all the compulsive behaviors. I haven't mentioned those yet, because those are often clues that someone has BDD, compulsive mirror checking, skin picking, asking for reassurance. Do I look okay? Can you see this on my face? Those kinds of compulsive ritualistic behaviors just start fading away. It's easier not to do them. You don't get the urge to do them as often. One thing to really emphasize is that people with BDD often need high doses of these medications. And that's fine. It's just like obsessive-compulsive disorder. They need higher doses than we might typically use for depression or anxiety disorders. They don't always need high doses, but I find they're often underdosed. The dosing is often too low. So, as just as an example, my average dose of Prozac that I use for body dysmorphic disorders is about 70 milligrams a day. My average dose of Zoloft is about 200. So with most of the SSRIs, we can go pretty high. Um, there are a few where we don't do that. Um, so it really depends on the individual medication, but um you know, high doses can be much more helpful than than lower doses.

SPEAKER_01 31:32

Right. And and antidepressants are sort of getting a bad name these days in the media and and the political space.

SPEAKER_00 31:40

So much misinformation, right? And and and so many of my patients, you know, worry about weight gain. Well, you know, the SRs really vary in terms of possible side effects, right? And I Prozac, for example, doesn't cause weight gain. I see we a lot of people lose a little weight on it. It's all off Lexapro. Most people don't gain weight on those. Um, but yeah, the worries about addiction and um not being able to stop them. No, it most of them you can stop quite easily, actually. I mean, we usually like to taper, taper over a few weeks. Um, you know, so but it's most people stop them very, very easily. There, you know, they're just a few, few of our commonly used medications out there that you have to, you know, that are more likely to cause what are so-called discontinuation symptoms. But these medications can be so helpful and can really be life-saving. You know, I I think that any patient who's suicidal with BDD needs to be on one of these medications. Um it's it's amazing how much how much they can help. And for some people, the symptoms just disappear. It can take a little while, uh, but it they can be incredibly incredibly helpful. And then sometimes we add other medicines in to uh the serotonin reuptake inhibitor if they're not enough all by themselves. So sometimes abilify, aeropiprazol is a generic term. I like to use buesperone, buesbar, has rarely has side effects. So adding other medicines in can be helpful.

SPEAKER_01 33:13

Okay. And then there's also therapies. Tell me about those.

SPEAKER_00 33:16

Therapy, yes. Uh, we have cognitive behavioral therapy, and I've spent a lot of my life actually doing treatment studies uh of medication and developing and studying cognitive behavioral therapy, and they're both wonderful treatments. We don't know which is better. No good studies have looked at that. I always like to say we have two great choices. And for severe BDD, we always recommend both meds and cognitive behavioral therapy. Now, cognitive behavioral therapy is a boy, it's used for a lot of things. It's used for pain, it's used for insomnia, it's used for depression, it's used for BDD, and it always has to be tailored to the specific issue that's being treated, right? So the cognitive behavioral therapy for BDD is it's a little different from that, quite different from that for depression, for example, and even different from that for OCD. But the main components are we help people learn to look at their thoughts like, oh no, you know, my skin looks terrible. I can't possibly go to the party tonight. Everyone's gonna be laughing at me. And we help people learn about cognitive errors, which we all make from time to time. So, in the example I gave, it's mind reading. Everyone's gonna be thinking I look terrible. Fortune telling, can you really predict what's gonna happen at the party? Um, catastrophizing, and helping people learn to develop more accurate and helpful beliefs. Um we also help people get control over those repetitive behaviors that are triggered by the obsessions, like the checking, checking mirrors and other reflecting surfaces to check the thing you don't like, uh, compulsive grooming, hairstyling, makeup applications, skin picking. These are very toxic behaviors that just keep the obsessive thoughts going. So we teach people to get better control over those behaviors so that they are no longer controlling you. You know, you have control over these repetitive behaviors, which can be really time-consuming on average. Just like the obsessions, they take up about three to eight hours a day for on average. Um, and so getting control over those is really important. Um, and then um we help people uh with something we call exposures, help people gradually feel more comfortable going out into social situations and being around other people. I think there are also misconceptions about CBT, just as there are about medicine. And one is it's gonna be too scary. It's like jumping off of a cliff in the Grand Canyon, you, you know, I can't do this. Therapist is gonna force me to do things I don't want to do. No, a therapist is more like a coach and works with you to help you challenge yourself. But therapists will never ask anyone to do anything that, you know, the patient feels they can't do. So it's it's it's always pushing yourself a bit, challenging yourself to try things that make you a little anxious, but that's that's how you make progress. We also do some mirror retraining, and which is not staring in the mirror. That's a common misconception. But when people with BDD look at themselves in the mirror, they zero in on what they hate, right? They zero in on their hairline or, you know, the little pimple on their on their face. And that's all they, that's all they pretty much see. They just stare at that, right? And don't hardly see the rest of themselves. And that might make their visual perceptual distortions even worse, right? If you stare at something for hours a day, it's probably going to look bigger and bigger and look more distorted. So we help people, because everyone has most people have to look in the mirror at least occasionally, or they run into reflecting surfaces. You're walking down the street, oh, there's a reflecting window. Walk into a restaurant, oh, there are mirrors in here. So we help people learn how to cope with that. So when you need to briefly look in the mirror in the morning to groom yourself, or you happen to run into a mirror in a restaurant or somewhere else, we we help people learn to see all of themselves in a more holistic way. And so this is a brief exercise where they just describe themselves from head to toe, looking at the parts of their body that they usually don't even look at, um, and parts they may like without using any negative words and not zeroing in on what they don't like. So trying to help them see all of themselves to kind of counteract that tendency to zero in on tiny details.

SPEAKER_01 37:43

Right. And then, of course, people with substance use disorder should also get treatment for the substance use disorder. But my experience with people with BDD and and substance use is that you treat the BDD and a lot of the self-medication that you've talked about then then goes away and the and the substance use can can fall off.

SPEAKER_00 38:00

Absolutely. We see that a lot. I think if the substance use is is problematic, then I always recommend treatment for both the BDD and the substance use. Um but yes, I think you're right that treatment of the BDD often, not always, but often will cause the substance use to you know improve.

SPEAKER_01 38:18

And then just to uh underscore it, people do improve. People get better when they get.

SPEAKER_00 38:24

You know, I I always say if you persist and if you get good medication treatment, high enough doses, if you need a higher dose of an SRI, not everybody does, but a lot of people do. If one doesn't work, you can try another. You can add in another medicine, you get good cognitive behavioral therapy that's tailored for BBD specifically. The odds of improving are at least, I would say at least 90%. You know, and sometimes the improvement comes pretty quickly. Sometimes those medicines, SSRIs, work pretty fast, um, although gradually, but sometimes they kick in pretty quickly. Um and sometimes it takes longer, you know, and and you have to to try more things. But um most people, most people do get better. That's that's the really good news.

SPEAKER_01 39:12

And so after decades of studying uh BDD, what do you hope for for in the future? Are there other new treatments to keep an eye on, or what do we expect uh for the course ahead? Yeah.

SPEAKER_00 39:21

Yes, I hope as we get to understand the brain better, the brains of people with BDD. Of course, the brain is the most complex organ in the body, so that's always a that's that's uh that's always a challenge. But as we understand more what's going on in the brain, we can develop even better treatments. And there are little hints of of some approaches that may help, uh, which involve enhancing that ability to see the big picture so that tiny details look tiny, not huge and gigantic. And so a study I was involved in with some vision researchers, we trained people with BDD to enhance their ability to see the big picture, their holistic visual processing with a computerized task, task on a computer. Um, and uh Dr. Jamie Fusner at the University of Toronto, who's done groundbreaking work on visual processing in BDD, um, has published some preliminary data. And both of these studies are pretty early, small samples, preliminary data, but showing that stimulating uh that part of the brain uh that is underactive in people with BDD, the dorsal ventral stream, uh, so I'm sorry, the dorsal visual stream uh with a form of transcranial magnetic stimulation. It was intermittent, uh, it's ITBS. Uh so it's a type of magnetic stimulation that stimulating that part of the brain seemed to enhance holistic visual processing in the brain. And body image concerns did improve to some extent. So we have these kind of early hints of some approaches that may ultimately be shown to work. We need more research studies, of course, and you know, good studies compared to comparing these approaches to something else, placebo or something else, to see a sham treatment to see how well they work. But I think there's a lot of now a lot of good researchers in the field. And, you know, I think research is expanding and growing. So I'm very optimistic that in the coming years we'll know more about BDD, we'll understand the brain processes better, and and we'll have even better treatments.

SPEAKER_01 41:39

Well, I'm optimistic, and I'm thankful for you for being such a pioneer in the space and bringing it to all our attention and developing all these interventions. You're fantastic. I feel very lucky that you're here at Cornell's.

SPEAKER_00 41:49

Oh, thank you. Thank you.

SPEAKER_01 41:50

Thank you for all you do, and and thanks for spending time with us today to discuss body dysmorphic disorder.

SPEAKER_00 41:55

Oh, thank you so much for having me. It's been a real pleasure.

SPEAKER_01 41:58

Thanks for listening to the Thriving with Addiction Podcast. If you found today's episode helpful, please follow and subscribe wherever you listen to your podcast and share it with someone who might benefit. You can also connect with me on Instagram, LinkedIn, and YouTube, or visit thrivingwithaddiction.com to learn more. Stay tuned for next week's episode, and remember, thriving is possible.