Module 1: Understanding Body Dysmorphic Disorder. Building Body Acceptance. Introduction. Are you a person who finds that you spend a great deal of time
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Page 1 Psychotherapy Research Training C C I entre for linical nterventions Module 1: Understanding Body Dysmorphic Disorder Building Body Acceptance Building Body Acceptance Module 1 Understanding Body Dysmorphic Disorder Introduction 2 What is Body Image? 2 What is Body Dysmorphic Disorder ? 3 Could I have BDD? 5 My Negative Body Image 5 Negative Impacts of BDD 7 How does BDD develop? 8 The Good News 9 What You Can Expect from this Information Package? 10 Module Summary About the Modules 11 12 Building Body Acceptance This information provided in this document is for information purposes only. Please refer to the full disclaimer and copyright statements available at www.cci.health.gov.au regarding the information on this website before making use of such information.
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Page 2 Psychotherapy Research Training C C I entre for linical nterventions Module 1: Understanding Body Dysmorphic Disorder Building Body Acceptance Introduction Are you a person who finds that you spend a great deal of time focussed on a particular aspect of your appearance? Do you view a particular part of your body as seriously flawed in some way? Have you noticed that your effort s to improve or hide the area of concern from others is becoming time consuming and affecting your life in a negative way? Do you have trouble believing others when they tell you that you look fine? If you answered yes to a ny of these questions , you may be experiencing a problem called Body Dysmorphic Disorder and you may want to keep reading these fiBuilding Body Acceptance fl Modules. The aim of this current module is to provide you with some general information about body image and Body Dysmorphic Disorder, to consider how this problem might develop, and to discuss some of its negative consequences . In later modules, we will discuss how you can overcome this problem. What Is Body Image ? From time to time, most people will feel somewhat dissatisfied with particular aspects of their appearance, perhaps thinking that their thighs are too big, skin is too blotchy, or that they are not tall enough. Furthermore, most people will engage in some level of personal grooming, will check the mirror to see how they look, and may use make -up or other treatments to enhance their physical appearance. However, there is a difference between momentary dissatisfaction with your appearance, which we all have f rom time to time, and a body image problem. Before we get started, it is important for us to think about what we mean by body image . Of note, the term body image does not refer to how you actually look. An image of something usually refers to a representation of the original thing. For example, a memory is a mental representation of a past event, and a photograph is a visual representation of the thing in the photograph . We say it is a representation because it often does not have the same qual ities as the original thing. For example, an A4 sized photograph of a giraffe does not mean that giraffes are actually A4 sized. Body image therefore refers to a representation that you have of your physical appearance . All of us have a view of how we lo ok and may evaluate this in a positive, negative, or even neutral way. However, individuals with a body image problem may have a particularly negative and sometimes biased view of one or more aspects of their appearance. This negative view can lead to a pr eoccupation with the area in question, and to high levels of worry and distress. Before we go further , take a few moments to describe your appearance , and how you feel about your appearance .
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Page 3 Psychotherapy Research Training C C I entre for linical nterventions Module 1: Understanding Body Dysmorphic Disorder Building Body Acceptance Now notice how you described your appearance. What did you focus on? Did you consider your overall appearance or did you focus on one particular aspect? What kind of language did you use to describe your appearance? Were you able to describe things you lik e or only those things you do not like about yourself? Chances are that rather than describing your actual appearance , which would mean you use d non -judgemental and factual wording (e.g., 163cm tall, light skin) , you have just described your body image . That is, you have likely used evaluative words (e.g., short, pale ) to describe both how you see yourself and how you believe others see you . This will be an important distinction throughout these modules. Most people who have a serious body image problem want to change their appearance , in the hope that this will make them feel better about the way they look. This can include seeking out expensive beauty treatments and even cosmetic surgeries to change the way the y look. Unfortunately, while such treatments and procedures may change a person™s appearance , they can often fail to address the underlying body image problem that led the person to seek these change s in the first place. As a result, o ften people are dissat isfied with the outcome of their treatments, or a new concern about one™s appearance arise s to replace the old one, and the desire to change one™s appearance continue s on. Rather than suggesting ways to change your appearance, t hese modules will therefore explore ways to improve your body image, and to reduce the impact of a negative body image on your day -to-day life. What Is B ody Dysmorphic Disorder ? Many people can have a poor body image , seeing their general physical appearance in a negative light (e.g., fi I hat e my bodyfl ). However, t he term Body Dysmorphic Disorder, or BDD, is used to describe a particular more specific type of body image problem . BDD is marked by an intense preoccupation with a perceived flaw in one™s physical appearance. Individu als with BDD often spend significant periods of time worrying about and evaluating a particular aspect of their appearance . Large amounts of time may be spent checking their appearance in the mirror, comparing their appearance with others, and engaging in behaviours designed to try to hide or conceal the area of concern. While the preoccupation may be with any body part, and can change over time, the m ost common areas that people with BDD report as being problemati c include: Skin including acne , wrinkles or complexion Thinning or excessive h air on the head or body Nose size or shape Eyes or eyebrows Lips, smile, teeth or mouth Cheeks, c hin or jaw Ears Overall face shape Legs, thighs or calves Genitals Breasts Buttocks Stomach Arms Neck Scars Height Muscles / build Individuals with BDD are often concerned that the body part is too big or too small, not the right shape, asymmetrical, or out of proportion to the rest of their body. In BDD, u sually the actual flaw a person is worrying about is so slight that others do not really notice or consider it important. In some cases, the flaw may be imperceptible to others . However, even if this is pointed out to a person with BDD, they will continue to worry about that area of their body and often believe that others are thinking negatively of them because of it . It is important to recognise that BDD is not simple vanity or dissatisfaction with appearance. BDD is a distressing condition which is often associated with depression, social anxiety and feelings of shame. BDD often creates significant interference with day -to-day activities, as it can limit one™s desire to leave the house, socialise, and participate in activities such as work or study.
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Page 4 Psychotherapy Research Training C C I entre for linical nterventions Module 1: Understanding Body Dysmorphic Disorder Building Body Acceptance BDD is thought to affect approximately 1 -2% of the population, and affects men and women equally. It often arises during adolescence, however most people who are diagnosed with this problem do not receive a diagnosis until 10 to 15 years after their symptoms began . It is thought that this may be due to the secrecy and shame often associated with the problem, which prevents people from seeking help. While BDD may present in many different way s, t ake a moment to consider the following two case examples: Jane is a 36 year old woman who attended her GP complaining of depressed mood. Upon further questioning it was found that over the past few years Jane ha s slowly withdrawn from her friends, and often refuse s to leave the house due to what she describes as her fihideousfl looks . Jane f eels that the lines around her eyes ma ke her look much older than she is , and she worries that others will notice this and be repulsed by her advanced ageing . Jane fre quently checks her lines in the mirror, and applies eye cream approximately once per hour. She will not go to the shops to buy groceries unless she has carefully applied make -up and styled her hair forward to conceal the lines around her eyes as much as po ssible. Jane has been spending what little money she has on trips to the beauty salon and expensive creams. She says that the main reason she is depressed is because she cannot afford the plastic surgery that she knows would fix this problem. When Jane™s G P told her that her lines were very faint , barely noticeable and more than appropriate for her age , Jane said she knew he was just being kind and asked if he knew of any new treatments that could help her with this problem. Bill is a 28 year old man who attended his GP complaining of high anxiety. Bill described feeling very anxious being around other people, such as at work, going on dates , catching up with his mates, and even attending family gatherings. Generally Bill avoids these sorts of situations as much as possible , and he is considering quitting his job. Bill™s fear of social situations seems to have started in recent years, since becoming preoccupied with the idea that he is balding. Bill worries that his hair is prematurely thinning, that this is very noticeable to others, and that people will ridicule and mock him. He has begun spending money on expensive hair replacement treatments. Bill feels better in situations where he can wear a cap to cover up his hair, but becomes highly anxious in situations where this sort of attire is inappropriate ( e.g. , at the office ). When the GP told Bill that his thinning was hardly noticeable , Bill felt he wasn™t being taken seriously. In summary, Jane and Bill™s stor ies are consistent with a diagnosis of BDD because they meet the three criteria used to diagnose BDD by experts around the world. 1.Jane and Bill are experiencing a preoccup ation with a slight defect in their appearance 2.The preoccupation and associated behaviours are significantly affecting their ability to function in some way (e.g., socialising , leaving the house , working ) and are causing the msignificant distress (e.g., depression , anxiety )3.Their symptoms are not due to another mental health problem , such as an eating disorder* So at the heart of BDD is a fairly specific negative body image that one tries to manage via various behaviours that are intended to improve things, but often backfire and make things worse. From now on we will use the term ‚negative body image™ to refer to the perceived flaws in your appearance that seem to preoccupy you the most . We have settled on this term, because it is likely at this early stage you believe that the body image you hold is very much accurate and in tune with how you really look. But, whilst at the moment you might see this image as an accurate one, hopefully you can also acknowledge that the image is a negative one, and that you would like to feel be tter about how you see yourself . We will also use the terms ‚flaw™ or ‚defect™ to describe what you perceive as a flaw or a defect, even if others wouldn™t necessarily agree. What matters most is the distress your appearance causes you. *While BDD and eating disorders are often both thought of as being body image problems, they require different treatment approaches. If your preoccupation is mainly with your weight/shape and you have changed your eating patterns because of this, we recommend that you instead review the fiOvercoming Disorder Eating Modulesfl available at www.cci.health.wa.gov.au . Due to the associated medical risks, we recommend that you contact your medical practitioner if you are engaging in extreme food restriction, vomiting, laxative use or excessive exercise .
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Page 5 Psychotherapy Research Training C C I entre for linical nterventions Module 1: Understanding Body Dysmorphic Disorder Building Body Acceptance Could I have BDD? If you are reading these modules, it is possible that you have already been wondering whether you need to work on your body image. Alternatively , these modules may have been suggested to you by a friend, colleague or health professional. Either way, i f you are uncertain about whether these modules are right for you, we suggest that you complete the following quiz to see if BDD might be a current problem . If you have answered most of the above questions with Often or Very Often, then BDD might be some thing you want to work on. BDD can be experienced from mild to severe levels , so e ven if you have only answered Often or Very Often for a few of the above statements, you may still want to stay with us as you might learn some skills that could be useful in the future. My Negative Body Image At this stage, we recommend that you identify more clearly your negative body image . You might do this by closing your eyes and bringing an image of yourself to mind. Note how you see yourself in your ‚mind ™s eye™. Be aware of the details of the picture you see. Be aware of any other felt impressions or sensations that might go with this picture (e.g., a burning, tingling or raw sensation to represent acne, or a sensation of heaviness in a body part that you see as being too large, etc). Open your eyes and use the information you gathered in that image to record the following: The particular body part or aspect of my appearance that I am highly dissatisfied with is: My main concerns about this body area or aspect of my appearance is : Never Occasionally Often Very Often I feel very dissatisfied with one or more aspects of my appearance I have difficulty concentrating on things other than how I look I use words like ugly, defective, unattractive , or horrible to describe my appearance I check my appearance in the mirror or other reflective surfaces or I avoid mirrors or reflective surfaces because of the way I look I use cosmetics, clothing or other means to camouflage aspects of my appearance I hold my body in certain positions to hide aspects of my appearance I ask others whether I look okay or I try to convince them how bad I look I have trouble believing people when they say I look fine I compare myself to others and think that I look worse than them I spend time researching ways to fix my appearance I spend time trying to improve the look of the body part I dislike (e.g., by picking my skin, getting cosmetic treatments, grooming) I contemplate cosmetic surgery I avoid socialising because of how I look I avoid intimate relationships because of how I look The way I feel about my appearance prevents me from doing things I would like to do
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Page 6 Psychotherapy Research Training C C I entre for linical nterventions Module 1: Understanding Body Dysmorphic Disorder Building Body Acceptance The picture I see of myself looks like: The other sensations that go with this picture are: See if you can summari se all this information into one sentence that captures your negative body image (e.g. fiI have terrible disgusting acnefl, fimy nose is horrible and hugefl, etc) My Negative Body Image is– ______________________________________________________ If you feel comf ortable to do so, it can also be interesting to take the time to draw a portrait of yourself. Some times we can better capture how we think and feel about something using pictures rather than words. You don™t have to be a brilliant artist to be able to do this, using stick figures or any other visual representation is f ine. The main thing is that it captures in some way how you see you. At the end of these modules we will ask you to do a self -portrait again, so you can see if there have been any chan ges in your impression of yourself. MY SELF PORTRAIT
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Page 8 Psychotherapy Research Training C C I entre for linical nterventions Module 1: Understanding Body Dysmorphic Disorder Building Body Acceptance How Does BDD Develop? So far we have discussed what we mean by the terms body image and Body Dysmorphic Disorder , have considered whether this may be a problem for you, and have explored some of the negative aspects of experiencing such a problem. However, something that many people who experience this problem will ask is, fiwhy do I have this problem?fl The exact cause of BDD is not known . While there is some evidence that BDD , like most disorders, may in part be inherited or have a biological base, it is generally accepted that several other important factors can increase the likelihood of you developing the problem. For example, people with BDD often report the following prior experiences: Having others around you experience a body image or anxiety problem Especially during your childhood and adolescence, your experiences can strongly influence how you view yoursel f. If you witness someone such as a parent or friend worrying excessively about their own appearance and going to large efforts to try to improve or conceal a perceived flaw, it may increase the chances of you also worrying about and trying to amend an aspect of your appearance . If you have been exposed to others who set strict standards regarding appearance , or who are anxious about their appearance being negatively judged by others , it can als o increase the likelihood that you too will set strict standards about your appearance and hold concerns about your looks being judged by others . Acne or other physical changes during adolescence Adolescence is not only a time of rapid physical change, but also a time when being accepted and fifitting infl with others is particularly important. The onset of acne, hair growth , weight gain, growth spurts, and breast enlargement are some common changes that occur during puberty. If you were concerned that you were developing too quickly, too slowly, or that a previously acceptable or even attractive feature (e.g., smooth skin) has changed unfavourably, this can increase your chances of becoming focussed on and wanting to cover up that feature. Experiencing a change in your appearance Outside of adolescence, a change to a previously acceptable or attractive feature can also be judged negatively and increase your concern regarding that particular feature. The development of fine lines around you r eyes or mouth , weight gain, scarring, the loss of hair with age, and the changes women experience to their bodie s post pregnancy , are common examples of changes that can increase the amount of concern one has regarding their appearance. Having experienced negative comments, bullying or teasing While not everyone who is teased or bullied about their appearance will go on to develop BDD, many people with BDD report specific memories of this , especially during their adolescence. Regrettably, bullies will often focus on something that you may already be feeling insecure about. Hurtful name calling such as fipizzafl or fifreckle facefl , and negative labelling suc h as fiuglyfl are unfortunately common in the school yard. Even seemingly playful nicknames, such as fistretchfl for someone who is taller than average, can leave you believing that others simply cannot see past that aspect of your appearance, and are evaluati ng you solely based on how you look . In some cases, even witnessing such events happening to another person can increase your belief that others judge and accept their peers based primarily on appearance. Social and cultural pressures Throughout history and even in different current cultural groups, perceptions of beauty have varied greatly. For example, contrary to current western ideals, being well above average weight in some cultures is viewed as a sign of wealth and prosperity. Unf ortunately, particular industries such as those concerned with cosmetic products and procedures, dietary supplements, and fashion, have a vested interest in making us feel like we are not quite good enough and that we could do more to improve our appearanc e. The use of methods such as soft lighting and airbrushing of magazine photographs can also lead to the normalising of somewhat unrealistic and unattainable appearance standards.
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Page 9 Psychotherapy Research Training C C I entre for linical nterventions Module 1: Understanding Body Dysmorphic Disorder Building Body Acceptance Take a moment to write down any experiences you have had that may have increased your concern and focus on your appearance . ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ As mentioned, these are simply some of the common experiences that people with BDD have reported. It certainly does not cover all possible contributing factors. Don™t worry if you are not able to identify any particular factors that may have contributed to the problem starting in the first place . You can still work on changing the problem even if you d on™t know where it came from. The Good News Given that your susceptibility to developing BDD may have been influence by biological factors or even experiences from the past, it may at first seem a little discouraging . After all, there is little we can do to change our biological make -up, and we certainly can™t go back and change our past. But the good news is that it doesn™t necessarily matter how you came to develop BDD , when it comes to taking steps forward to change it. It is really important to read on, because as you will see in the next module, there are things that we do in the ‚here a nd now™ that keep our BDD going–and t hese are the things we can do something about to overcome this problem.
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Page 10 Psychotherapy Research Training C C I entre for linical nterventions Module 1: Understanding Body Dysmorphic Disorder Building Body Acceptance What You Can Expect From This Information Package This information package is designed to help you begin to reduce any preoccupation you may have with an aspect of your appearance, and to address any unhelpful behaviours you may be engaging in due to concerns about your appearance . We have begun with a discussion about what BDD is, what impact it can have on one™s life , and how it may develop . In the next module, we will explore and discuss what keeps BDD going. The modules after these will focus on what you can do to overcome BDD . The fo llowing are the modules that make up this information package: Module 1: Understanding Body Dysmorphic Disorder Module 2: What keeps BDD Going? Module 3: Reducing Appearance Preoccupation Module 4: Reducing Checking & Reassurance Seeking Module 5: Overco ming Negative Predictions , Avoidance & Safety Behaviours Module 6: Adjusting Appearance Assumptions Module 7: Self -Management Planning When using self -help materials, some people might skip sections or complete things in a different order. The modules in this information package have been designed to be completed in the order they appear. We recommend that you work through the modules in sequence, finishing each module before moving on to the next one in the series. We believe that by doing this, you will maximise the benefits you might receive from working through this information package. We believe that this information package will be beneficial for people with BDD, as well as anyone who would like to address difficulties they might have with their body image . We encourage you to take the journey through these modules and hope that you will come away with a more balanced and healthy image of your body , feel more accepting of yourself, and hence get back to living the life you want . You might find that it gets a little tough at times, but we encourage you to stay with it and keep on working through these modules until you reach the end. See you at the next module!
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Page 11 Psychotherapy Research Training C C I entre for linical nterventions Module 1: Understanding Body Dysmorphic Disorder Building Body Acceptance Module Summary fiBody imagefl refers to the mental representation that you have of the way you look .A body image problem does not necessarily mean that there is a problem with your appearance, but rather that you are perceiving and evaluating your physical appearance in a negative way .Body Dysmorphic Disorder, or BDD, refers to a speci fic body image problem marked by an intense preoccupation with a perceived flaw in your physical appearance .BDD is not simple vanity or dissatisfaction with appearance. BDD is a distressing condition which is often associated with depression, social anxiety and feelings of shame .People with BDD can spend significant amounts of time evaluating their appearance in the mirror, comparing their appearance with others, and engaging in behaviours designed to try to hide or conceal the area of concern .BDD o ften creates significant interference with relationships and with day -to-day activities . It can limit your desire to leave the house, socialise, and participate in activities such as work or study. Itcan also negatively affect your finances if you pursue costly cosmetic or dermatological procedures. While biological factors and experiences from the past may increase the chances of develop in gBDD, by focussing on the things that keep it going in the here and now, you can work towards overcoming this problem .Coming up next – In the next module, we will explore and discuss what keeps BDD going.
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