452 Body Dysmorphic Disorder: What Actually Helps (and What Makes It Worse) with Chris Trondsen Two Courses: Your BDD Toolkit and The Clinician’s BDD Toolkit

Summary

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Your Anxiety Toolkit Podcast — Episode 452

Body Dysmorphic Disorder: What Actually Helps (and What Makes It Worse)
Host: Kimberley Quinlan, LMFT
Guest: Chris Trondsen
Date: September 24, 2025

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Overview

In this highly informative episode, Kimberley Quinlan is joined by BDD expert Chris Trondsen to explore Body Dysmorphic Disorder (BDD)—what it really is, why it’s so misunderstood, what worsens it, and most importantly, what actually helps. Together, they also discuss their collaborative new courses: "Your BDD Toolkit" (for individuals) and "The Clinician’s BDD Toolkit". The conversation is raw, practical, compassionate, and filled with specific strategies and nuanced clinical insight.

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Key Discussion Points & Insights

1. What is Body Dysmorphic Disorder?

[03:15 – 06:27]

• BDD Defined:

  • Classified as an OCD-related disorder characterized by obsessive preoccupation with a perceived flaw(s) in one’s appearance.
  • The flaw is typically minor or not observable by others. Sufferers may spend at least an hour or more daily on compulsive behaviors like mirror checking, camouflaging, or seeking reassurance.
  • Common fixations: facial features, skin, hair, but can focus on any body part.

• Why It’s Misunderstood:

  • Family and friends often mistake BDD for ordinary body image concerns or vanity, but it’s profoundly painful and leads to social isolation.

• Notable Quote:
  “They feel like they’re unsightly, they feel like they’re deformed… they spend at least an hour a day or more through mental and behavioral compulsions, sometimes camouflaging, trying to hide the features.”
  — Chris Trondsen [03:50]

2. BDD vs. Vanity & Public Perception

[06:27 – 09:18]

• Misconceptions:

  • BDD is often interpreted as narcissism or self-obsession, when in truth it stems from deep pain, isolation, and shame.
  • Behavior isn’t about striving for beauty but desperate attempts to feel “acceptable”.

• Personal Experience:

  • Chris shares his own high school struggles with BDD and hiding his self-imposed skincare routines, underlining the suffering, not vanity.

• Notable Quote:
  “People with BDD actually think very low of themselves, have low self-esteem, and really just want to be accepted.”
  — Chris Trondsen [07:45]

3. Pain, Shame, and Disgust: The Core of BDD

[09:18 – 14:42]

• The Emotional Toll:

  • Intense disgust and shame set BDD apart, distinguished by a “core belief” of being unworthy of love or acceptance.
  • Unlike OCD (ego-dystonic), BDD thoughts/behaviors are often ego-syntonic: sufferers believe their fears about appearance are justified.

• Notable Quotes:
  “There’s not a lot more painful than to feel disgust towards yourself… shame and humiliation, embarrassment. It’s so, so painful for them.”
  — Kimberley Quinlan [12:18]

  “BDD is much more egosyntonic. People believe the thoughts.”
  — Chris Trondsen [13:14]

4. What Makes BDD Worse?

[15:24 – 36:19]

• Common Traps:

  • Reassurance seeking (asking loved ones for validation about appearance)
  • Excessive research (deep-diving online for products, procedures, or standards)
  • Camouflaging (makeup, clothes, strategic masking)
  • Escalation to cosmetic procedures (fillers, surgeries)
  • Plastic surgery rarely provides relief; often worsens distress

• Isolation:

  • Avoidance of social contact, employment in appearance-focused industries, and misuse of things like masks or clothing to hide perceived flaws can entrench the disorder.

• Distorted Perception:

  • People with BDD focus on minute details, zoom in on “flaws” physically and mentally, and misread neutral faces as negative or judgmental.

• Cultural Complications:

  • Social media, aesthetic professions, and access to drugs like Ozempic can all be triggers or reinforcers.

• Notable Quotes:
  “Everything you’re doing, if you’re listening to this with BDD, is your natural response. But unfortunately, it just reinforces the condition.”
  — Chris Trondsen [15:26]

  “Plastic surgery… when somebody with BDD seeks out that plastic surgery, they’re almost never happy with it. In fact, a lot of times it makes them less pleased with that body part.”
  — Chris Trondsen [18:00]

  “BDD is trying to convince you that you’re not even worthy of human connection.”
  — Chris Trondsen [29:25]

5. Understanding Perceptual Distortion

[23:36 – 28:18]

• BDD and Perception:

  • Sufferers perceive their appearance differently due to how their brains process details (left hemisphere dominance for “zooming in”).
  • Compulsive mirror checking or focusing on small parts fuels the misperception.

• Notable Quotes:
  "If you notice your clients when they look in the mirror, people with BDD, they go straight to the part that they don’t like."
  — Chris Trondsen [45:23]

6. Treatment: What Actually Helps

[36:19 – 51:22]

• Evidence-Based Interventions:

  • CBT (Cognitive Behavioral Therapy) and ACT (Acceptance & Commitment Therapy): Education on BDD, cognitive restructuring, addressing shame, self-compassion, and possibly trauma.
  • ERP (Exposure and Response Prevention):
    • Modified for BDD—focuses less on “exposing” to flaws and more on planning and practicing life re-engagement (social activities, going into public spaces).
    • Contrasts with OCD ERP (e.g., not having clients repeat “I am ugly” or using distortion filters, which can reinforce negative beliefs).
  • Perceptual Retraining:
    • Teaching clients to view themselves holistically and from a realistic vantage point (arm’s length in the mirror, focusing on objective, brief descriptions rather than fixating).

• Medication:

  • SSRIs may be more necessary (often at higher doses than for depression/anxiety).
  • Medication can enhance insight and improve ability to engage with therapy but comes with client-specific complexities, especially fears about side effects that impact appearance.

• Integrated Approach:

  • Holistic care, addressing co-occurring issues (trauma, bullying), and involving family/partners when appropriate.

• Notable Quotes:
  “With treatment, it’s a much more CBT treatment… Perceptual retraining, which is something you don’t even do with OCD, is a whole element of treatment that doesn’t even get done in OCD.”
  — Chris Trondsen [39:44]

  “We’re reteaching somebody with BDD how to see themselves in the mirror or pictures or videos the same way that other people see them.”
  — Chris Trondsen [45:00]

  “If you are experiencing a moderate to severe case of BDD, especially if it’s to the point that you’re struggling to do daily functioning, having a conversation with a psychiatrist about medication is pretty important.”
  — Chris Trondsen [49:43]

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Important Timestamps

• Intro, guest welcome, course background: [00:03 – 02:55]
• What is BDD? Why under OCD-related disorders? [03:15 – 06:27]
• BDD, vanity, and societal misunderstandings: [06:27 – 09:18]
• Pain, shame, and BDD lived experience: [09:18 – 14:42]
• What makes BDD worse: [15:24 – 36:19]
• Plastic surgery and perception: [19:44 – 24:16], [24:16 – 28:18]
• Isolation and social implications: [28:18 – 34:42]
• BDD in other body areas: [34:42 – 36:19]
• What actually helps – evidence base, treatment structure: [36:19 – 44:12]
• Perceptual retraining: what it looks like: [44:56 – 48:52]
• Role of medication: [48:52 – 51:22]
• Wrap-up, course info, future episode tease: [51:22 – End]

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Memorable Moments & Quotes

• “The last D in the disorder stands for disorder. And disorder means a real loss of quality of life…”
  — Chris Trondsen [09:19]

• “It’s not a joyful preoccupation with your body... it’s incredibly painful.”
  — Kimberley Quinlan [08:59]

• “Let’s look at the motive of behavior… All it’s doing is reinforcing something’s wrong. And when they feel relief by covering up... the only way I can feel any sense of comfort is if people can’t see the flaws.”
  — Chris Trondsen [34:00]

• “If you're treating BDD like OCD about appearance, your client will not only not get better, but may be harmed.”
  — Chris Trondsen [39:21]

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The Clinician’s and Sufferer’s Course

[Info at cbtschool.com — Your BDD Toolkit and The Clinician's BDD Toolkit]

For clinicians and individuals seeking practical skills and step-by-step tools, Chris and Kimberley’s courses offer in-depth guidance and video demonstrations, including perceptual retraining and case conceptualization.

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Closing Notes

Chris and Kimberley will dive deeper into differentiating BDD from other disorders like eating disorders and general body image issues in a follow-up episode. For now, individuals and clinicians are encouraged to seek specialized support and evidence-based interventions—recovery is possible, and help exists!

Additional Resources:

• Check show notes for links to Chris Trondsen, courses, and CEU opportunities.

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A beautiful life is possible—help and hope are available.

Transcript

[A]

All right, well, I am so excited for this episode. This is an episode we have been planning for months. So let me give you guys a just a little background because you're getting the hot scoop here on your Anxiety Toolkit podcast. About a year ago, my amazing friend Chris Trondsen and I had a conversation about how I would love for him to join us at Circumstances DBT School to train our clinicians and people who are suffering with bdd body dysmorphic disorder. Chris I consider to be an expert, probably the best clinician, I would say, in the world in this area. An amazing advocate for folks with bdd. And he said yes. So for those of you who don't know, I have Chris here with me. Thank you so much, Chris, for being here.

[B]

Yes, thank you so much. That was the sweetest intro, by the way. Thank you so much. I was just gonna say I didn't wanna interrupt you, but no, I was so honored. This is your baby. Like CBT school is like Kimberly Quinlan, right? It's your baby. You've trained so many clinicians, so many people with the disorders have gotten help. So when you asked me, I was extremely honored and beyond excited.

[A]

Yes, I was too. And so we are here to talk about bdd, but we're also here to share that a few months ago, Chris and I sat down in a hotel room and with all the cameras and all the lights and with a raging festival going on next door and recorded for like what felt like days and days, like 12 hour days, we did not stop and we did get those courses created. Now we're still finishing up the suffering course, so you will be able to get that. But the clinicians, BDD Toolkit is out. You are welcome to take check it out if you're a clinician. And for those who are sufferers, you can also access Chris teaching you exactly the steps that he takes his clients through in treating bdd. So it is gold. You can go over to CBT school to check it out. But today we have Chris wanting to really get you familiar with the topic and get really excited. We're talking about what body dysmorphic disorder is, what actually helps and what makes it worse. So thank you, Chris, for being here. It's an honor.

[B]

Oh, well, thank you so much for having me. I'm beyond excited, obviously, to be on the podcast, but more so just to share this. I know clinicians all the time are asking me questions about it, wanting to consult with me, and BDD is a widely misunderstood disorder. So I'm just excited as Somebody who has bdd. Just that more and more clinicians are going to be accessing the course and being able to start treating people. There's a lot of people with BDD and not enough clinicians that know how to treat it. So I'm really excited about this course.

[A]

Yeah. And I think what's so exciting too is, and we're going to talk about this in future episodes too, but I think that people often treat BDD as if it's just body image issues. And I want to talk to you about that. So first of all, tell me off the bat, what is bdd?

[B]

Yeah. So bdd, which stands for body dysmorphic disorder, it's classified currently under an OCD related disorder. So we have the disorders like obviously like trichotillomania excoriation disorder, known as skin picking, you have hoarding disorder and then you have body dysmorphic disorder. Now, body dysmorphic disorder is a mental health condition where an individual becomes very fixated on a flaw or flaws on their appearance. They feel like they're unsightly, they feel like they're deformed. And when they look in the mirror, they feel like absolutely ugly. But also, even more than that, they feel like they have this feature. It could be the nose, the eyes, the ears. You know, typically it's neck up. But they have a fixation on a perceived flaw. And because of that flaw, they spend at least an hour a day or more through mental and behavioral compulsions, sometimes camouflaging, trying to hide the features. It could be through makeup, wearing a hat, if they feel like they're losing their hair, through covering with clothing, or sometimes more drastic measures like self plastic surgery, which is very scary, or plastic surgery. And so this, the reason we highlight that word perceived is I think the most difficult part about having this condition is that friends, family and everyone looking at the person doesn't see that flaw. They can go to doctors, they can get reassurance from other people and continuously getting told, no, your skin looks fine or your nose isn't big, but this person sees it differently. And so that's really kind of the component of the disorder, this difference in what they view, this problem with perception.

[A]

Yeah, absolutely. And what I want you to share about here is why is BDD under the category of an obsessive compulsive related condition? What is it about them? And I know we will talk about this in a future episode, but I just wanted to clarify, why is it under that umbrella?

[B]

Yeah, there's two real reasons. The first reason is because of Dr. Catherine Phillips, someone who I admire a lot, who wrote the Broken Mirror, the first real book on bdd. She saw a lot of similarities in the research as obsessive compulsive disorder and also found that there was a high co occurring rate of people with OCD and people with bdd. She also strategically knew that if it was under the OCD related categories that it would get more research, more attention for people suffering. But there's similar components we see in the brain. But mainly people with BDD also have that very obsessive nature. They get fixated on park. They can spend hours, sometimes eight hours a day till their legs hurt, looking in mirrors, looking at pictures, recording themselves, watching it back. So they have that obsessive nature and then the compulsions come in. So similar to people with OCD who feel the need to drive back around the block or pray, somebody with BDD is feeling like they need to continue to camouflage or research different procedures or skin products or ways to cover it up. We see the same things as reassurance seeking, the same loss of quality of life. So there's so many similarities, there's some differences, but there's a lot of similarities with the two conditions and a high co occurring rate. Often, you know, if somebody has bdd, they're more likely to have OCD than any other condition.

[A]

Right? Often when I have a new client with bdd, sometimes their family members may perceive the person with BDD as being too self focused or, you know, overly concerned with their looks, as if it's sort of like a, a personality trait per se, or, or a weakness on their behalf. What are your, what are your thoughts on, what do you tell clients and loved ones of people with BDD about that?

[B]

Well, I think that's sadly one of the most misunderstood elements of the condition. A lot of people think that people with BDD are vain, are very self focused, and that's not it at all. Some people's presentation of BDD is actually a lot of isolation and hiding. But some people's presentation with BDD is sharing a lot of pictures, dating a lot, getting into a lot of intimate relationships because they want that reassurance that people see them as equal. So typically people with body dysmorphic disorder find themselves to be unsightly, unattractive and almost like outsiders in our society. And they just desperately want some kind of relief from the fixation on the body part, but also some reassurance from others that they belong, that they're good looking enough and they're going to have access to the same things most people have, like friendships, love, family, children. So people with BDD actually think very low of themselves, have low self esteem, and really just want to be accepted. Unfortunately, because of the compulsive nature of it and the fixation on that appearance, multiple dermatologist appointments, multiple plastic surgery assessments. Others on the outside who don't understand the condition assume it's because they want to look great, they want to be the hottest in the world, and that they're focused on their looks. But it's so far from vanity.

[A]

Yeah, it's funny. We always kind of make jokes or roll our eyes at when people misunderstand ocd. You know, just the other day I was talking to someone in my office suite and they were saying, you know, everyone has OCD at this point. Like, and I did my best to educate them and they kind of blew it off. Right. But I think what I said was people with OCD are seriously suffering. They don't just want order. And I think that what I want to. The reason I tell that story is I think we sometimes think people with BDD are looking in the mirror, just trying to look better and trying to, you know, because culture is constantly telling us to be taller, shorter, have, you know, be different, be whatever. It's constantly telling us to change and be something else. But BDD is incredibly painful. It's not a joyful preoccupation with your body. And I wonder if you could maybe share your own experience or the experience experience of a client. What you have noticed about folks with bdd?

[B]

Yeah, I mean, you hit the head, the nail on the head. And one thing I always try to remind people is the last D in the disorder stands for disorder. And disorder means a real loss of quality of life, whether that's general happiness, social relationships, work relationships. And so people with BDD are really suffering. And I want everyone to think that the way we look is always elevated in every culture. There's a whole billion dollar industry and improvement in looks. And so this is the first. There's research that people who look better might make more money at work and get jobs. So the first reaction people get is your appearance. That's the first impression. If somebody has BDD and their brain is telling them that they are so hideous, they don't even deserve respect and love. That person doesn't want to go out in the open. And so I know for myself you're asking about my personal, and then I'll share just general what I see in clients. But I remember in high School, I was on a sports team and we spent the night before a tournament, and I had created my own self kind of skin routine of acne products because I thought I had horrible acne, even though every dermatologist was like, you have a few pimples, that's it, Right? But I'd kind of done research online. I created my whole kind of self routine. And I remember waking up before the other boys, sneaking into the bathroom to do my whole skincare routine, which made me feel human enough to leave the house. And I remember crying while doing it because I'm like, everybody else just woke up. I mean, they're teenage boys. I don't even know if half of them brush their teeth, but they just kind of like got up, threw on maybe some Axe body spray, and we're done. And we went to the tournament. But I had this, like, our routine, this struggle. I was so nervous people were going to get up and catch me and all that. And to me, it was just like I felt like a monster, an outsider who just wanted to be accepted. Especially during that time when we're trying to get approval from our peers and from people that we're attracted to. And so that's what I hear from my clients now. That was the early signs of my bdd. When I talk to clients who may not get to my office until after they've tried so many different surgeries or camouflaging or research, people are in pain. A lot of them aren't working because being around the public is too difficult. They feel that others are staring them, noticing their flaws and judging it. They're often not in a relationship. A lot of them are living at home. They're going to different, you know, dermatological appointments, cosmetic dentists, just trying to get relief because 247 in their brain, even sometimes in their dreams, everything is, you look unsightly, people are judging, you look like a monster. You'll never be loved, you'll never be accepted. You're worthless. So I just think that people experiencing BDD are just getting a constant dose of just, you know, their brain attacking everything about them. It goes a little deeper than appearance. Over time, they start to have that core belief that they're not even worthy of love, affection or attention.

[A]

Yeah, the word that comes to mind for me and I, Broken Mirror was the first book I'd ever written on bdd. I was assigned it when I became an intern working with folks with bdd. The word that just keeps coming up for me is just the feeling of disgust about themselves. And you know, I think there's not a lot more painful than to feel disgust towards yourself. Like, that's a horrible, painful, shame filled experience that folks with BDD are navigating. So I think it is really important that we acknowledge that they're coming to us with that feeling. Shame and humiliation, embarrassment. It's so, so painful for them. And that's why I love in the course you really get to the bottom of that and acknowledge that that's where we're meeting the people when for sufferers as well.

[B]

Yeah, I mean, you hit it on the head. A lot of times people ask me as they navigate from, you know, treating maybe solely OCD and wanting to start treating clients with BDD or they're getting clients coming to their practice and I tell them all the time is there's a little bit of a difference. I think the biggest. Sorry, a big difference, you know, is that for most people with ocd, OCD is ego dystonic. They have a very clear understanding that these thoughts and these feelings are not that of their own, especially after they get a diagnosis and have some education on the disorder. And so there's a lot of like, I want this thing to stop attacking me. How do I make it go away? BDD is much more ego syntonic. Like people believe the thoughts. They want to engage in these compulsive behaviors out of desperation just to be able to feel like they belong. But one thing that you nailed is that it's a lot more than anxiety for bdd, which is a huge difference for most of. There's a lot of shame, just feeling horrible about self. There's a lot of guilt. There's a lot of like, onus and blame on certain aspects of their appearance. And sometimes in severe cases, people almost feel an obligation to the public to not even leave their home because they're like, I don't want to force people to feel sorry for my appearance or, you know, look down on me or, or you know, make other people feel discomfort, but having to look at my disgusting appearance. So I mean, just to think that you don't even belong running into a store. So many clients are ordering things delivered to the home and just to spare others from seeing them. So that disgust, that shame, that guilt and that just overall unworthiness that we see in this condition makes it so, so detrimental and disordered.

[A]

Yeah. So painful. So painful. So let's start with what makes it worse and then we'll move on to what makes it better. What are some things that people with BDD do that make it worse? And then maybe we can talk about some treatments that can make it worse as well. So would you share like. And when we talk about this, I just want everyone to know, in no way are we saying you're at fault or you're doing anything wrong. It's a natural response to engage in these sort of traps of the condition. It does trick us into doing behaviors maybe that take up a lot of time. So what are some of the things that people do that can make it more difficult or make the disorder stronger?

[B]

Yeah, and I'm glad that you put that caveat at the beginning. I want everyone to hear this. Everything you're doing, if you're listening to this with bdd, is your natural response. But unfortunately, it just reinforces the condition. So I'd start with a lot of reassurance seeking. So sometimes it might be with a trusted family member or a loved one. It may also be with your romantic partner. Do my teeth look too big for my face? Does my neck and my jaw not look masculine? Do I have too much body hair? Are my breasts not symmetrical? So, asking a lot of questions, and typically that's what I hear from partners, is that their loved one that they're in the, you know, romantic relationship with is just constantly asking for reassurance about looks. And the reason it doesn't work is people with BDD don't believe it. They often dismiss it and think that the person is just pitting them and saying nice things to make them feel better. I would say the second thing is research. You can go on a deep dive. I mean, I know people love Reddit, but I think I just have such a bad taste in my mouth because of everything myself and clients have done on that website to look for stuff for relief. But there's a lot of people posting different things. This makes you look hotter. You know, online they have these things called the golden ratio. And people are looking like your eyes have to be this down on your face. And people are, you know, using all these apps to look how symmetrical their face is. And so this just feeds the beast. And so people with BDD are picking up their phones, and all the people they're following are. Are. Have something to do with a skincare brand or plastic surgery. Speaking of that, what definitely doesn't make it worse is camouflaging, which soon becomes sort of like a little bit lighter cosmetic work and then heavier cosmetic work. And so what I see in my younger clients, who obviously aren't of age of doing any kind of plastic Surgery or fillers or Botox is they mainly start with camouflage so you know, saying they're cold so they're wearing a shirt at the pool or they might cover some like skin imperfections they see that no one else sees with makeup. And then typically over time that might become fillers and Botox and Sculptra and all these different, you know, chemical peels, bleaching teeth compulsively. And then eventually with people that go untreated with bdd, it typically ends with plastic surgery. And so as you read in the broken mirror and the research is very clear about this, when somebody with BDD seeks out that plastic surgery, they're almost never happy with it. And in fact a lot of times it makes them less pleased with that body part. In those rare, rare instances where someone does like the plastic surgery, it's typically short lived. They are either going to start seeking more plastic surgery for relief or they don't like the balance of their face now after the plastic surgery or, or they were expecting to be super happy because their appearance was fixed and then they're not and fall into a depression. So that's why we always say whether it's plastic surgery or dermatological interventions or even just camouflaging, it's actually going to make you feel worse in the long term.

[C]

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[A]

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[C]

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[A]

I'd like to just pause on that and dig a little deeper because it's a conversation I often have with clients in terms of to have surgery or not. And I think what's really difficult is folks with BDD maybe see someone on social media. I know I'm thinking of One person in particular right now who they say, I just didn't like my nose. And I knew when I turned 18 I would have surgery and my nose, they reduced the size or they did whatever, they took the bridge down or whatever they did. And then I was happy. And so they've seen that and they have the, this person with BDD has the idea that that's what it's going to take. So does it mean that everyone who's had surgery has bdd or what is different about the surgery of the person who has beat, has not got bdd and it just goes well and they go on to live their life and they don't even really think about their nose ever again compared to someone with bdd.

[B]

Yeah. I think the difficult thing is we are in a culture where plastic surgery can be celebrated. People will post their afters and the comments will say, wow, you look so much better. So I think the hard thing is just like somebody who may have, you know, a substance use addiction, they'll go to a bar and think how come everybody else my age gets to go to a bar and drink, but when I drink I have a problem with it. Right. So we know that there's something different. It's similar to bdd. There are of course times where people will go and get certain fillers or Botox or enhancements and feel better. The problem with somebody with BDD is they do not see the same thing that everybody else sees, including their surgeon. So what happens is you have two people trying to fix something, but they have two different versions of it. So the person with BDD is going to see this exaggerated. Let's, you know, talk about a nose. Let's somebody goes in for a rhinoplasty for a nose job, they walk into the office and they see the nose as big, they see it as wide, they see the bump as over exaggerated in their head. Cause there's a problem with perception and the way that the brain works with individuals with bdd. Well, the surgeon doesn't have bdd. So the surgeon is looking at it and thinking, you know, one thing clients who have gotten surgery will tell me is that they almost had an argument with their surgeon. Because a surgeon is like, I think you're wanting to go too far. But it's cause two individuals see way different things. And so how can two people come to a conclusion on a body part when people are seeing it look differently? Now, just like you mentioned, sometimes clients with BDD were bullied or were, you know, did have a feature, you know, I had a client with BDD who wanted to get his ears pinned back and did before he saw me. And he had gotten called Dumbo growing up and his ears stuck out. And, you know, his parents always made a comment. I'm like, people can have BDD and also have body parts or features that maybe other people agree, like, hey, yeah, when you're 18, if you want to get your ears pinned back. But what I explained to him is nobody has ever said anything else about the other features. And in fact, in his case, when he went to talk to the surgeons about getting these things fixed, they kind of turned him away, which is astounding for plastic surgeons. They're typically known for wanting to make money, but they were just like, hey, man, like, we. We feel like that's going to be overboard, like, you're going to start to look a little bit odd. So what I told him is, like, sometimes people with BDD are more sensitive to appearance, features, want to get things fixed, but that doesn't mean you're going to have that same result and that same feeling around everything else you're doing. So you really have to. What I always tell clients is do the treatment first, if you can, for at least three months with me. So if you do decide to move on with plastic surgery, I can't follow you home and force you not to do something. But my hope is that the treatment helps with some clarity and whatever decision you make won't be as drastic as it would have been without treatment.

[A]

Yeah. In the courses we walk through the steps that you take with clients, and it was so cool to watch you talk, because it's like, it's very, very similar to what we do, is we do a lot of education at the front end, because sometimes folks with BDD don't know that their perception may be off, you know, and that's, I think, very helpful for folks for BDD to understand because they believe what they see is real. Can you explain what's going on for them and why their perception is off and how that shows up for folks with bdd?

[B]

Absolutely. And you made a good point. I mean, the education, for the clinicians, listening education is done much more than any of the categories in the related disorders, including OCD itself. Because I think what's unique about this condition is that people are coming in and you're not their first stop. Typically it's a family member or a partner or somebody who's intervened and said, you need to get help, or the person is like, I don't think I Have bdd. I just am very stressed about my appearance and want someone to talk to. So the beginning stages are so important, that education phase, to get the client to at least be open. Like, hey, maybe it doesn't have anything to do with my appearance. It's that preoccupation that is really causing the distress. So unfortunately, in individuals with, with bdd, just like all mental health conditions, we know there's something going on in the brain. You know, mentor of mine, Dr. Fugan Ezraglu, we were doing a talk together and she said it really well, we're the only people that are never gonna see what we really look like. I mean, we'll see a reflection of what we look like, but none of us can go outside of ourselves and see ourselves. So the first problem and the reason why people with BDD see themselves so differently is, is in the manner of how they see themselves. So one absolutely trademark aspect of BDD is people are looking in mirrors or taking pictures of themselves or videos in a manner that other people don't. So they're getting very close to these mirrors. They're getting zoomed in on these pictures and they're getting so fixated on these small details. So if somebody, for instance, has a little bit of acne and that's what their BDD is really focusing on, they're looking at themselves in a mirror and they're only seeing the acne. That's what they're focusing on. They're getting extremely close into the mirror. They're only noticing that. And it may only be 2 to 3% of their face, but to them it's a hundred percent because they're not looking at their nose or their eyes, they're not seeing the whole picture. They're just getting very isolated on the part of their face that they don't like, and in this case the acne. But additionally, there's stuff going on in the brain. So when people are looking at themselves with BDD or what we found is the part of the brain, the left hemisphere, that usually is utilized for high focus details and very fine information that is only sort of tapped in for the average person when they're doing something that needs that. If they're hammering wood and they're getting really close on the nail, if they're an artist and they're looking at fine details to paint, their left hemisphere is lit up. But in normal conversation, like I'm having with you, the right hemisphere is lit up and they're also looking holistically, although I'm making eye Contact with you. I can see the, you know, outside where it looks pretty and there's grass. I could see that. I think it's a shirt or a blanket that's hung up. Like, I can see everything. Right. That's not how people with BDD are found through research to be looking at themselves. They're getting very zoomed in on fine details. They're getting very interested in the little lines of their face or the fact that this side of the jaw isn't as even, or the fact that they have a little bit of acne right here. And then coupled now with that getting close in the mirror, staring for hours, all of that comes together. And now the person is focusing on 3% of their appearance and absolutely negating the other 97%. And in their head, they're just a set of acne or a set of, like, big calves or too small of a waist for a man. I mean, just whatever the fixation is. And so that has to be understood by the client, because if not, they're going to push back and say, I see it in pictures, I see it in the mirror. Don't tell me I'm crazy. I see what I see. It's helping explain through actions, through what's going on in the brain and other factors. We know people with BDD see themselves and perceive themselves differently than the average person does when they talk to them.

[A]

That is so helpful, I think, for folks to hear. And I know again, I have. It's been so helpful for my clients to understand. Are there any other things that make it worse?

[B]

Absolutely. I mean, one thing that they found in the research as well is that people with BDD misread faces. Oh, okay. I see what you're saying, like, what people do to make it worse. So one of the things that makes the disorder worse and that people do to make it worse is that people misread faces in BDD research. So what that means is when they were shown a set of faces that were neutral, people with BDD perceive them as, like, angry, confused, disgusted. So let's think about that for a second. If I have BDD and I'm going out and I'm misreading everyone's faces, I. I'm going to see them as being judgmental or disgusted. And then because of my confirmation bias, I'm going to say, oh, see, I just got confirmation that I look terrible. Let me get back in the house. And then that's what they do. So another thing that makes it worse is that isolation, because BDD is trying to convince you that you're not even worthy of human connection. So if because of your fear of going out, because of misreading faces or assuming people are whispering or taking special notice, which people with BDD do personification, this belief that people are taking special notice, that isolation occurs and then it reinforces, well, Chris, you don't have a partner. Chris, you don't have friends. Chris, you don't have a job. It's because you look terrible. The disorder never gets blamed, of course. Like, hey, because of bdd, I don't leave the house. So one thing I'm talking to clients all about is that the goal of treatment is to get connection. We gotta get you back into school or work or dating or friends or volunteering or at family events. Because people with BDD tend to isolate themselves, which makes it worse because now they're just alone with their thoughts. And if BDD is dominating those thoughts, that becomes the problem.

[A]

Right. And as they have more and more experiences meeting with people, they get to learn and experience that connection and feeling seen and accepted, which can help them go in the better direction, which it can always. It's hard to do, but it's doable. Are there any other things that make it worse?

[B]

Yeah, I mean, I would say that some things that I see clients with BDD do is they actually end up getting a job at a place that they can get sort of like free Botox and free teeth bleaching or whatever it is. Right. So they end up getting a job in the, the field because BDD is so drawn to that. So I've had clients that have worked for modeling agencies or I've worked for med spas. And that whole culture unfortunately is looks, looks, looks 247 and they have access to, to things. They're, you know, watching models, not eating and starving themselves and then getting ideas about that or they're watching people get now on. I think a big problem that's that I'm starting to see in the field is a lot of clients are getting on things like Ozempic when they don't need it. So they're taking it. It's not a health related factor, but they're doing it because in BDD it may not be always about weight loss, but a lot of people think their face shape is too big for their body. So if I lose weight drastically, my face will finally look decent or, you know, my, my. It's more emphasized that my body's not even when I'm heavier. So if I lose weight, it'll look More up and down, which people notice that it's not symmetrical. So that's what I think. You know, the drugs that are coming out and helping people with diabetes. Clients with BDD are unfortunately using it when they don't need it because there's not a lot of regulation and that's making it worse. So I always tell my clients if they're working at a dermatology office, a med spa in a field that has an aspect of superficiality, I'm not going to tell you what to do, but you have to be mentally strong working there because you're going to get a lot of messaging that's just going to feed the disorder.

[A]

Oh, for sure. I remember in my eating disorder I worked in a gym which is 360 degrees of mirrors. And I knew I would not recover staying in that environment. A big part of the reason I became a therapist was because I knew I could no longer continue the work that I was doing in an environment that was going to have reflective surfaces all around. I think it's true too, of a lot, since I was just thinking. A lot of clients really loved Covid because they got to wear a mask. And they still are wearing masks in some cases under the lens of, you know, some of. I've even had clients admit that they, they lie and tell people they're immunocompromised so that they can continue to wear masks to school, to, to work, social events, on airplanes. And it's okay if you want to wear a mask. I'm not saying that's wrong, but. But they then identified that was them actually masking their perceived flaw.

[B]

Absolutely. I always tell clients, let's look at the motive of behavior. There's some people that are still wearing masks for health reasons and through their doctor's orders. And there's clients that wear masks because it gets to cover the lower half of their face that they may not like. So I'm always asking clients, you know, I'll have CL say, oh, I love wearing hoodies. I'm like, it's 95 degrees out there. I love a good hoodie. I probably own more hoodies than I. People always see me in suits on these things. I'm like, I don't wear this on a Tuesday, right? I have hoodies. I love my Vans hoodies. They're comfortable. I grew up wearing hoodies. But you're not going to wear a hoodie in a 95 degree weather. But people will wear it to cover up because they don't think their breasts are even or for men, they might think that their chest is uneven or they feel too small, you know, some muscle dysmorphia. So they wear this baggy sweater to look larger. So a lot of it is about motive behind it. Why are you doing the behavior? Because all it's doing is reinforcing something's wrong. And when they feel relief by covering up, let's say wearing a mask or a baggy hoodie, the messaging that they're learning is, the only way I can feel any sense of comfort is if people can't see the flaws that I can see when I'm not camouflaging or covering up.

[A]

Yeah, and you bring up a good point. And I want you. I know you had mentioned before that it's often from the neck up, but I want to also say I've had a significant amount of clients who have BDD about their private areas. The size of their penis, their labia. Like, it can attack any part of your body. And it doesn't have to be like, oh, I don't like my entire body. It could. It often will just pick one very annoying part, and they focus on that so much. So I just wanted to sort of normalize that for folks. If you are a. Again, it adds a layer of shame if you have this preoccupation with, you know, again, a sexual part of your body or a part that you wouldn't usually show somebody.

[B]

Yeah. I think the reason we always say neck up is not because that's, you know, the only part of the body that gets affected. I think just sometimes because the eating disorders and BDD get confused.

[A]

Yes, but.

[B]

But like you said, BDD absolutely attacks parts of the body from the neck down, including sexual parts. Like you said, you know, a lot of men, you know, feel like, do I have breasts? Right. Do I have gyno? The size and shape of nipples is a big one. Evenness of breasts, evenness of chest. Sexual body parts. Right. Like, I think it looks too big or too wide or too small, My butt is too flabby, it kind of goes down. So that, I mean, I think what's hard is BDD is already difficult to talk about. A lot of people don't want to open up to someone because naturally, if somebody's saying, I think this thing is odd looking, our eyes go straight to it. So they're like, great. They're gonna confirm what I feared this whole time. But how do you talk to somebody about your private parts? And then, like I said, clients will ask their partners. Their partners, of course, gonna Say they like it, that's why they're in a relationship with them. One of the reasons they think they're just lying. And then unfortunately I've had because people kind of notice that as a weak spot. I've had some clients where their exes, after they break up and it's a nasty breakup, the ex will text, it was gross looking or it was disgusting and I held my, you know, my nose the whole time we were in it and just ignore it. I mean, it's just horrible what happened. So I've noticed that clients, it takes them a while to be comfortable enough with a BDD specialist to open up and share that their sexual or body parts are the things that they're focused on.

[A]

Yeah, yeah. So what can make it better? Let's go there and we can maybe as we go. You cannot think of other things. But what, where are we going from here? Like, is there hope? Is there things to make it? What does that look like? Do you want to share?

[B]

Yeah, absolutely. I mean, one thing that I'm really happy about is that there is absolutely frontline evidence based treatment for body dysmorphic disorder. And it works. And I love presenting with people like Kathryn Phillips and Sabine Wilhelm because they do a lot of research. There's also. I gotta butcher his name, so I won't even pretend to say it, but there's a researcher out in Sweden who's done a lot of research on people getting better. So people do get better. And in fact sometimes, you know, it's impressive the numbers of people that get help. So what makes it better is finding somebody that absolutely understands the disorder and the treatment and getting a proper diagnosis. So that's really important because there are a lot of disorders that can appear the same. I know we're doing a podcast on that, so I won't spend any time on that for this conversation. But you want to make sure that the person who's providing the treatment understands the condition so they can really make sure that you're getting the right treatment for the condition. With that said, I mean when you get a really good dose of education, cognitive behavioral therapy, acceptance and commitment therapy, exposure response prevention, you're addressing shame through things like self compassion and you're looking if there is any trauma, is there any history of bullying, are there these kind of things that have really, really created sort of a bruise on self esteem and affected, you know, somebody's ability to accept affection and their attachment. So when you get a full kind of quote unquote dose like we talk about in this training that we did together of BDD treatment, people do get better. And so that's what I always tell people is you have to find the right diagnosis and the right treatment.

[A]

One of the things I loved as I sat across from you and you recorded like, like a, oh my gosh, like a machine, was how I have consulted with clinicians who, because BDD is under this umbrella of obsessive compulsive related disorder, they've come to me in a consultation and will say I, you know, they, I know they had a fear that their nose was big or long or whatever, so I just expose them to it by making it longer or writing scripts. And I used all of the ERP that I would usually use with OCD and you know, it didn't hit the spot. And I loved, as you were doing the, the training is you're. We're incorporating CBT and erp, but you also include things like perceptual retraining and we use the ACT work and we talked about motivation and, and that's why I love the way that you present this. So can you share with us what the erp, how it may look different for folks with bdd?

[B]

Yeah. To take a quick step back, you know, when we were talking about what makes it worse on the clinician side, if you treat BDD like OCD about appearance, your client will not only not get better but may be harmed. And I think one of the things that breaks my heart and it's like, I don't know how many times I can say it without seeing seeming obsessive and following people on the Internet, but I do see people that are claiming to know, be it body dysmorphic disorder and to be pretending to be leaders in the field. And we have great leaders. Actually. It was funny, I was thinking about it the other day. Outside of Scott Granite and Jamie Fuser, most of the leaders are women. I was like, go Power. They're doing incredible work for us. I love Fugin, Kathy and Sabine and Robin Stern. But when we take OCD treatment and just change it to BDD and just change a few words, it's not only an incomplete treatment, but it's not going to be helpful. So some of the things that I unfortunately have seen clinicians do when they treat it through ERP like OCD is they've had a client sit there and write, I'm ugly, I'm ugly, I'm ugly. I need to accept that I'm ugly. I've had clinicians kind of have them use filters that make their nose look even bigger and stare at that. I've had clinicians have somebody, you know, go out and kind of accentuate certain flaws that they think they have. And the reason that doesn't work is because the person already thinks that about themselves. So you're almost kind of reinforcing this distortive thinking and this distortion in appearance. So if they're already seeing themselves incorrectly, why would we then distort the appearance even more when what we're trying to do is the opposite, and pull them back in and let them see themselves correctly through perceptual retraining, which is something you don't even do with ocd. So it's a whole element of treatment that doesn't even get done in ocd. And so acceptance of being ugly or unworthy and, you know, people are already. It's that egosyntonic component. They already think of themselves like that. It would be the same if you're working with a client with depression and you're having them write out, I am worthless and nobody cares about my existence 100 times. It's the opposite of what we need. So with treatment, it is a highly. Much more CBT treatment. First of all, because you're trying to get the client to start to see, how did I get here? How is my distorted thinking influencing the way that I function? But when you ask about the erp, the way that I look at ERP for BDD is we're trying to get the client back to. Into their life. So their quote unquote exposures might look something like, hey, I normally order everything through doordash. I'm going to start going into the place and order and maybe take the food to go.

[A]

Yes.

[B]

And I'm going to work up to ordering and then staying in. Because part of what the treatment is showing them is, look, if you really do look as disfigured and deformed as you think, how come you go into Chipotle? You're getting treated with respect to, well, maybe Chipotle is a good. I'm like, are you sponsored by Chipotle? I don't want to ruin your sponsorship, but every time I go into Chipotle, I look like I'm bothering them. They're like, ah. And I'm like, you don't close for another two hours. Calm down, sir. Right. You know, please, just. Just help me with my burrito. But in all seriousness, right, like, how come the workers are treating me with respect? How come they seem very unbothered or unconvinced? To even look up at me. How come when I'm walking out, no kids that are very blunt are shouting something like, mommy, he looks weird. So it starts to sort of pull apart BDD's argument.

[A]

Yes.

[B]

And as people make connections, even if it's just through getting to know the barista at their local coffee shop, it starts to send a new signal to them. And I think of the. The treatment as a teaching tool. It starts to teach them, wait a second. I do belong in society. I do belong in this way. Also, we're doing a lot of response prevention. So I sit with clients. Let's look at who you're following on social media. Eek. Everything you're following is a plastic surgeon, models, et cetera. Who would you follow if BDD wasn't even part of your life? Let's get back to that. So the treatment for me, how I think of erp, is once the client's really understood the disorder is perceiving themselves and not comparison. That's a big part of treatment too. But they're perceiving themselves better. They're not comparing. And then they have the cognitive stronghold that they're starting to really be able to perceive their situations different mentally. Then once they go into the outside world, it's not about, like, exposing them to things they hate. They've already been doing that to themselves before seeing you. It's getting them reconnected in life, and it's addressing any of those things, like I said, the bullying or the shame or the, you know, any kind of trauma and stuff that they have, just making them a whole person. So it's a very more complicated, it's much more extensive, and it's very different than ocd. So that's the biggest thing and why I was excited for you to ask me to do this training is I just want clinicians to know that you have some foundations that will be helpful to treat bdd, but you gotta make some drastic difference and see the disorder in a different way than ocd.

[A]

Yeah. And that's why I loved learning from you as well, is because it is a very holistic approach. You're looking at more than just the safety behaviors or compulsions that they're doing. What you're talking about, the way you talk to yourself, the way you think about things, the perceptual training retraining was amazing. So in the course, you actually, because we rented a hotel and we were doing it, recorded, you took me into the bathroom and walked me through exactly what that would look like. Like how you would do it. And do you want to share quickly what that looks like and a little more about that? Because I think that's an area that a lot of clinicians don't even know exists.

[B]

Well, what I loved about what we did is so many. I would. I'm not even kidding, Kim. The number one thing I ask, people ask me all the time is like, is there a video of people doing perceptual retraining? I'm like, there is now. And Kim is my. Kim is my, you know, my. My test dummy in it. My. My client. The idea behind perceptual retraining is if you're treating bdd, ask your clients how they see themselves, right? So some people go to another extreme and don't even look at themselves. But typically people do, and it's. So they do it in a way that's compulsive. So the idea behind perceptual training is we're reteaching somebody with BDD how to see themselves in the mirror or pictures or videos the same way that other people see them. So let's say I'm going to start with mirror retraining. What I'm going to ask the client to do is, hey, we're going to stand in a mirror and we're going to do it a little bit differently. So instead of getting really, really close up or using a magnifying mirro, we're going to use a traditional mirror. I want you to be an arm's length away, because most of the time, unless you're, you know, on a crowded subway, most people are at least an arm's length away from you, like a comfortable distance. What I want you to do is practice when you see your reflection going straight to comfortable eye contact. There's almost like a triangle where our eyes and our upper nose is. And that's typically where we look when we're speaking to somebody else. I want that to be the first place you go when you look in a mirror. Why? Because if you notice your clients when they look in the mirror, people with bdd, they go straight to the part that they don't like. So they'll stand up, they'll look in a mirror, and they'll go straight to their thighs if it's that, they'll go straight to their neck if they think that it's their neck, forehead if it's their hairline. So they're gonna practice making that comfortable eye contact, and then they're gonna practice seeing their whole self. I call it like zooming out. Because the research shows they zoom in, we gotta zoom out. Then what I'm wanting them to do, which is entirely different than they normally do, is to describe to me, the clinician. I want describe yourself, the client, in the mirror, in an objective way. So this has to be something that if we had 100 people in the room, they would agree to your observations. So I typically say, hey, think of it as almost like if you've ever seen Law and Order, they ask the people when they're doing the police sketch, you know, they're not saying like, ooh, she was voluptuous and I loved her upper lips, right? They're just giving you generic. Like, she had red hair. It was, you know, down to her shoulders. So the client starts to describe themselves objectively while, you know, from top to bottom, but they're only briefly staying on a body part. We're not teaching them to spend a lot of time in the mirror or to fixate. They're already doing that. Right. So what they're learning from this perceptual retraining is how to be objective versus judgmental and subjective, how to be an arm's length in a mirror, how to start with their, their eye contact instead of fixating on the part of their body they don't like. And then lastly, how to see themselves holistically. They practice that if they see videos of themselves, especially younger clients that are tiktoking everything also in pictures, not zooming in on pictures, but seeing the whole self, and especially in pictures, I'm like, tell me what's going on in the picture. You know, half the time the client doesn't even notice the other things in the picture because they're so focused on how they look. So perceptual training is teaching the client to start to see themselves the same way everybody else sees them and the same way everybody else sees themselves. So it's a very effective tool and it's become even more advanced. Fuga Nezoroglu released a book, and there's also really good some worksheets out of Australia to really start to teach clients, even attention retraining. So we're noticing that clients throughout school. I'm working with a young client right now, and she's like, at school, all I do is sit there and think about my appearance. So it's being able to start to focus outward, become mindful, use meditation, be able to think of other things. So not only is somebody looking at themselves perceptually different, but they're thinking about other things instead of their Appearance. So that appearance isn't the only conversation. They're head all day, all, you know, long.

[A]

Yeah, Amazing. Now there's one thing that I want to make sure we don't forget to talk about. So these are all like treatments that are really effective. What role does medication play in treatment as well? Because I know in the courses and in the work you do and in the books that you've mentioned, we're talking a lot about these like modalities and therapeutic techniques. Do people with BDD need to be on medication as well or what is the research on that?

[B]

I would say with body dysmorphic disorder, yes, it is more needed than even an ocd. And I always remind clients I'm not a psychiatrist. I'm also not a meds pusher. I'm not anti meds. I took medication for BDD and it really helped my treatment. But I think it's an individual case. However, if you are experiencing a moderate to severe case of bdd, especially if it's to the point that you're, you're struggling to do daily functioning, having a conversation with a psychiatrist about medication is pretty important. We've been talking about Dr. Kathryn Phillips. We've been talking about the Broken Mirror. She's a psychiatrist, she writes a lot about the dosaging. But medication can really help with insight. And I think that's one of the things that people with BDD often have is low insight about the disorder. So medication can have them having better insight. Just like OCD, SSRIs are frontline. So these are things like Prozac and Luvox and Lexapro and others. And we need a higher dose than somebody who's going in for depression and anxiety. So what I tell everybody is I understand. And I think what's a unique challenge, Kim, that I don't think a lot of OCD therapists recognize in BDD is a lot of times the reason that people are afraid to get on medication, they're afraid it's going to affect their appearance. I didn't want to get on medication because I thought it was going to make me break out. I had no reason to think that, but I was just in a hyper vigilant state of fear of having acne. But clients a lot of times are afraid of weight gain or weight loss because they think it will affect their appearance. Breaking out, yellowing of teeth, what if it hair loss? What if it makes me look different? So what I always tell people is find a prescriber you trust, go in with questions, ask those questions. Let's not get reassurance, but let's ask those general questions and learn how medication can help. Because I will say for a lot of clients with bdd, they do need medication that helps with insight. Does not mean that people can't get better without it, but it may be a very advantageous tool in your recovery.

[A]

Amazing. I agree. Thank you so much for that. Okay, the good news is you and I are going to do a backup follow following episode talking about how to differentiate between BDD and body, body image issues and eating disorders and OCD so that people if they're having still questions about which is which, you can follow up with that episode. For right now, for those of you listening, do go head over to CBT school. You can go to cbtschool.com treatbdd that is the course for clinicians and you can go to cbtschool dot com forward slash your BDD toolkit if you are someone who has BDD and you're wanting to learn exactly how Chris and myself would treat the condition if you were our client. So thank you Chris for being here. Your knowledge is so, so impressive. Thank you so much for your time.

[B]

Well, thanks for having me. Like I said, I'm excited what you're doing for clinicians, giving them access to evidence based treatment. And thank you for having this podcast. I always hope that more and more people learn about BDD because so many people are struggling and so many clinicians have their best interest but just need to understand how to how to treat them. So thank you for everything you're doing for our community. Really appreciate it.

[A]

And if you want to get in touch with Chris, do check the show notes and we will have links to where you can work with Chris and everything there. Also, one thing I forgot to say is we are CAU approved by NBCC and so our clinician courses can. You can get your continuing education units by taking this course as well. Thank you Chris.

[B]

Thank you so much for having me. It's always an honor.

[A]

Please note that this podcast or any other resources from CBTSchool.com should not replace professional mental health care. If you feel you would benefit, please reach out to a provider in your area. Have a wonderful day and thank you for supporting CBTSchool.com.