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Body dysmorphic disorder

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By Halina Boniszewskateacher and writer

Body dysmorphic disorder (BDD) is a mental health problem related to body image. People with BDD spend an excessive amount of time thinking about one or more imagined or minor defects in their appearance

Sad girl

What is body dysmorphic disorder?

Body dysmorphic disorder (BDD) is a mental health problem related to body image. People with BDD spend an excessive amount of time thinking about one or more imagined or minor defects in their appearance. Their preoccupation causes them great distress and disrupts their everyday life. There is a big disparity between what sufferers believe they look like and how they appear to other people. BDD is often missed by doctors. The reason for this is that it often occurs with obsessive-compulsive disorder (OCD) or generalised anxiety disorder. It may also exist alongside an eating disorder or social phobia. It is regarded as a ‘hidden disorder’ because many sufferers are too ashamed to reveal their problem.

What causes BDD?

The cause of BDD is unclear, but it may be genetic or caused by a chemical imbalance in the brain. Low self-esteem and the way some children judge themselves almost exclusively by their appearance can also cause BDD to develop.

How common is BDD?

Recent studies show that BDD affects between one per cent and four to five per cent of the UK population at any one time.

How does a child with BDD feel?

Most people with BDD feel stressed, anxious or distressed. The severity of BDD varies from person to person, but it can be so severe that the sufferer is unable to think about anything other than their appearance. If left untreated, the condition can be responsible for children dropping out of school altogether. In her book, Understanding Body Dysmorphic Disorder, Dr Katharine A. Phillips writes that in her studies virtually all those children who were in school reported impairment in their ability to do their school work. Children with the disorder may be late for school or not go at all because they don’t want to be seen. Some sufferers find the condition so distressing that they attempt suicide.

Tell-tale signs of BDD

Children with BDD may exhibit any or all of the following compulsive behaviours:
  • checking their appearance in a mirror or reflective surface
  • seeking reassurance about their appearance
  • checking by feeling their skin with their fingers
  • combing their hair to make it ‘just right’
  • picking their skin
  • hiding behind their hair
  • covering their body with loose-fitting clothes
  • wearing hats, gloves or sunglasses indoors

What is the treatment for BDD?

The usual treatment for BDD is cognitive behavioural therapy (CBT) or a type of antidepressant medication called Selective Serotonin Reuptake Inhibitor (SSRI) or a combination of both. CBT is a type of therapy which aims to help sufferers change the way they think and help them develop practical skills to manage their compulsions.

What can the school do to help the child?

If practitioners suspect BDD they should refer the child to Child and Adolescent Health Services (CAMHS) as soon as possible, as the CAMHS waiting list is often very long (see the case study below) and the longer the behaviours are allowed to continue, the more deeply entrenched they become and the longer the course of therapy required.

It is advisable to ask the parent to take the child to the GP, so that the GP can also make a referral to CAMHS and possibly help to speed up the referral time. It would also be advisable to inform the child’s parents that the waiting list at CAMHS may be very long and that they might consider seeking immediate private psychiatric treatment for their child.

Case study: Lauren

At the start of year 4, Lauren was a quiet but popular girl, known for her kindness. Around April time, Lauren’s teacher noticed that Lauren’s behaviour had changed markedly. She had become withdrawn, rarely smiled and made frequent visits to the toilet. She let her hair grow long and wore it so that it covered her face. During PE she always wore tracksuit bottoms, even on warm days.

Lauren’s class teacher became concerned about her behaviour and asked Lauren if she had any problems at home or whether children in the class were bothering her. Lauren denied problems at home and bullying at school. Nevertheless, her teacher contacted Lauren’s mother and explained about Lauren’s frequent visits to the toilet and her change in behaviour. Lauren’s mother said that she too was concerned about Lauren’s behaviour. Her daughter had stopped seeing friends outside school and had also dropped out of swimming and dance classes and now spent most of her time watching TV or lying in bed, often looking at herself with a handheld mirror.

Both teacher and mother were concerned that Lauren might be depressed, so her class teacher contacted the Lead Teacher for SEN at Lauren’s school. The SEN teacher referred Lauren to the Child and Adult Mental Health Services (CAMHS). Unfortunately, as Lauren’s case did not meet CAMHs’s criteria for an emergency referral, Lauren was not assessed by a psychiatrist at CAMHS for another 12 weeks, by which time school had broken up for the summer. The psychiatrist who assessed Lauren diagnosed body dysmorphic disorder. Lauren told her that she hated her own body, particularly her skin, her stick-out ears and her ‘funny knees’. She said she thought about her ‘horrible body all the time; every minute. That’s all I think about.’

The psychiatrist recommended a course of cognitive behaviour therapy (CBT) with a clinical psychologist. This was designed to help Lauren change her patterns of thought. Unfortunately, as Lauren did not meet CAMHS’s criteria for an urgent referral, she was not able to start her course of CBT until the start of November in Year 5, by which time Lauren’s condition had deteriorated. She had started picking obsessively at imaginary spots on her skin and had become so distressed by the resulting inflammation of her skin that she was taking a lot of time off school. When she did eventually start the course of CBT (weekly sessions with a clinical psychologist), she was also given a six-month course of medication, a Selective Serotonin Reuptake Inhibitor (SSRI). Both her mother and Year 5 teacher noticed a difference in Lauren’s behaviour and outlook within a matter of three weeks of the start of her course of treatment. By the April of Year 5, a whole year after Lauren was first referred to CAMHS, she was, according to her mother, ‘nearly back to being her old self again’.

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