B (3:18)

Yes. So BDD also, same for body dysmorphic disorder. That's when an individual has a preoccupation, a hyper fixation and strong disgust feelings around sometimes a specific body part. So the more classical showing of BDD might be, you know, they've always been hyper fixated on their nose or it may be body part parts. So they may have a few different body parts that they're hyper fixated on. And there's a general disgust and also a unsatis. It's putting it lightly and unsatisfactory about that appearance part. That body part we say sometimes typically neck up, but it can affect the whole body. Now with that, the second part to the DSM diagnosis definition is at least an hour a day they are spending on compulsive behaviors. These may be mental or physical things such as mirror checking or camouflaging. And then obviously, you know, because it's in the dsm, there has to be a disordered element. So this means that the person is struggling to enact in work, school, dating, general life functioning. And typically the other qualifier in DSM diagnosis of BDD is there's very low insight. So often they feel that there's actually a problem with their appearance and it's not a mental health condition.

A (4:33)

So how might you tell the difference between someone who has actual diagnosis of BDD versus body image issues? I think about myself, you know, having had two babies and it changes your body. And luckily I've had a lot of treatment in eating disorder, so I knew how to adjust. But I know a lot of people who, let's say they're maybe you're going through puberty is another time where a lot of body image issues show up. What would be the Difference between someone with body image issues per se and bdd?

B (5:08)

Absolutely. I want to definitely start off by saying if somebody is feeling like they're having body image concerns, or I think society has kind of started to call it body dysmorphia. Sometimes those two terms can even be different. It does not mean that that's not hard and not difficult. So I never want people to think that I'm dismissing it. The reason, though, it is very important to separate that from BDD is BDD is chronic. It's an everyday experience. It does not change because somebody feels better or it's not a short period of time like they're at the beach in a swimsuit. BDD is consistent. Generally, body image concerns is where someone's not too happy with parts of their appearance. Maybe as they're getting older, they. They're noticing a little bit of sagging or some lines or like you said, you know, for. For a lot of people after they have a child, they might think that certain parts of their body stretch, but it's not as consistent and it's also not as disordered. So what I mean by that is, typically someone with body image concerns is still going to work. They're still happy in their marriage. They may cover up a little bit in a bathing suit, but they're still going to the beach. Pretty much their life is the same. They may start to explore, like looking at plastic surgery, or they may, you know, want to cover up, but it is not the primary focus of their day. It is one of many things that they're struggling with, and it may not come around all the time. They might be fine, etc. And maybe they have to go to a beach party and then they think about it. So that's the big difference is it's not as chronic, as repetitive, as urgent, and it isn't preventing people from living their life. There's not that disordered element. Somebody with bdd, rather, is having that experience. I would also say BDD is always going to be more severe. So this person is really struggling for basic daily function where somebody with body image concerns, it's not dominating the discourse of their life.

A (6:59)

Yeah, I just come to mind a client and I'm kind of changing some of the symptoms for their privacy. But they had one area of their body where they had very distinct BDD symptoms. Like, they could also say, yeah, there are other parts of my body that I don't love. I don't. And there I could be better. I wish they were thinner or more sculpted. But for Them, they could even within their own body, they had areas that had body image concerns. And then there was that one body part where they had bdd. So I want to also share to folks listening, you could have both for different areas and that's why there is often a lot of overlap. Anything you want to say about that? Overlap?

B (7:42)

Yeah, I want to make a quick point. It was funny. I was down in San Diego with my family and my sister just had twins about a year ago and one of my twin nephews was acting up and my sister was like, you better not treat me that way. I still have this stomach from carrying you. Right. Jokes about it. You know, I know my sister is trying to lose the weight and it's really hard after having twins, but it's not like she still shows up, she wears a dress, she had a good time. Right. Whereas bdd people don't want to make jokes about it because it's so hurtful and they don't want people to look. But going back to what you're saying, individuals with BDD typically have an overall disappointment and dissatisfactory with body image. Rarely do I have a client that's like, I have BDD on this, but I love my rocking body and my eyes and my teeth. You know, they may have things that they're more neutral about or don't hate. So people can have both. And in fact, when we go through all these differentials, we a lot of people have multiple ones. That's why we're doing this though, is because each of these conditions may have a slightly different or a majorly different treatment and we just want to start to lock down like what is causing what. But absolutely, people can have BDD about one feature where they are not willing to let it go. They hate it. That's all they think about. And they may have some dissatisfaction about other areas, but once again, it's not as predominant and it's not causing them to not leave the house because of their legs they don't like. It's the nose that's really keeping them inside.

A (9:05)

Right. So Chris, can you share what might be the difference for someone with BDD versus body focused OCD or an OCD that's targeted somebody's body process or experience of their body.

B (9:22)

Yeah. So there's kind of two ways that I see OCD sometimes get confused with bdd. The second one definitely more so. The first one is some people have hyper fixation on the way that their body functions, like you were saying. So it could be like the swallowing of Their throat, it could be their breathing, it could be the way that they're chewing. And because of that, they have a hyper fixation on that body part. But it's for a different reason. So typically what I hear from clients is they're like, I will not be able to do well in school today because all I'm going to notice is my blinking. And it is really hard to focus on my work and focus on the professor because I'm focusing on my blinking. Or they might have a fear, core fear that if I don't take over my blinking, my, my eyes are going to dry out and I'm going to have some really soreness in my eyes. Or if I stop controlling my breathing, my breathing will get to a point where I'll, I'll take, you know, strained breaths. Or now that I'm focused on these things, I can't focus on anything else. So they are obsessing and focusing on a body part, but it's not a dissatisfaction about the appearance to other people. It's noticing and fixating on something that's typically, you know, autonomic. Your body's taking care of it yourself. And sure, I mean, yes, we can take over our own blinking and breathing or. But typically that's sort of done for us. And so you're getting focused on these things that are automatic and sometimes a core fear of trying to take it over and doing it right. So that would be the first way that OCD can be misdiagnosed because people come in and say, I can't stop thinking about this. My jaw. Well, a lot of people with BDD are focused on their jaw, but for this client, when they chew, it's the way that their jaw clicks and they, they, you know, can't focus on anything else. But I would say the second part where people get really, really confused is some clients of perfectionist at gocd that perfectionism goes beyond maybe like their reports at work or how they do at school. It's how even their part is in their hair. It's making sure that their teeth are white. It's making sure that their clothes are properly pressed and everything looks good together. They get a stain on the shirt. It's not perfect. They want to go back home. Their grooming rituals are very compulsive. So I totally get that subtype and why it's, it's confusing. So I want to have absolute empathy for clinicians listening to this. No judgment. The difference, once again, is that's why an assessment is so important, is why are you bothered by this. So a classic example of a client I had was younger than most people working in his field at his office. And in his mind, if he could look the part, his. His beard was perfect, his mustache was perfect, his hair was properly cut and combed, his outfit was properly pressed and matched. He could give off this aura of like, I have it together. I may be young, but I'm really good at my job. Right. And he had no complaints about the way he looked. He didn't care how he looked. It just needed to be perfect. So there's not this idea that they have a flaw or there's something inherently wrong with appearance. They just want to groom and look presentable. So those are the two subtypes of OCD that can typically can get misunderstood and then just in general. Right. Like, people with OCD have a hyper fixation on something and they do compulsive behaviors. We see something similar in bdd, but the big difference is it's about their appearance and the dissatisfaction with how it looks to themselves and to others. Whereas when we just talk about ocd, there isn't that component at all. The motive is different.

A (12:42)

Yeah. And I actually just did supervision with some of my staff recently with a client who. They were brought to us for bdd, but we. When we sort of did an assessment, they sounded like it was more like a symmetry obsession. Like they didn't care. They weren't disgusted by the way their eyebrows looked. It bothered them that there actually was some ace. We all have asymmetry, and that feeling just gnawed at them and that they would do these compulsions to try and even them out. And another one is sort of the just right feeling, too. Yeah, yeah, go ahead. You want to share?

B (13:16)

No, no, no. I didn't mean to cut you off, but it was so funny. Like, as you're talking, like, oh, I didn't mention just right.

A (13:21)

Yeah, yeah. I mean, just the feeling that things need to be just right, whether it be hair or body parts and where they sit and are. So do you have other examples of just right?

B (13:33)

Yeah. I worked with a client that was sent to me because they thought it was bdd, and we started working together and we were doing the BDD treatment. And I think that's the great thing is a lot of times when you start to dive into a treatment, people will quickly tell you, like, hey, this doesn't feel like me. And as we were doing the education and also, obviously, as clinicians, we're consistently assessing, even if it's not the first couple sessions. But as we kept going, it was definitely a just right. You know, it's like things had to feel a certain way, be balanced in a certain way. It was supposed to be like this. You know, one of the things that they confused is like, she would take almost an hour to make a ponytail. And look, I have bdd. It used to take me hours to do my hair. The difference was I was like, it's so, you know, it needs to look like this. I need to have this. People are going to notice this and that about it. For her, it was like, my ponytail has to feel just right. So she would just keep putting the hair in the ponytail. And as you know, with just right, it was. Some people, it is symmetry or like, okay, it looks a certain way. For her, it was just like the absence of anxiety. And it's like, oh, okay, OCD is giving me the green light. What's next? So that's why it's so important is some of these subtypes of ocd, like, just right can absolutely have clients doing things that people with BDD do, but for a whole different reason.

A (14:47)

Yeah, just go back because I want to make sure, as we continue, we're really clear and you talked about this. Is it is about understanding what the actual function of the behaviors are. Would you agree with that, or do you have a better way of saying it in terms of as a clinician or if you're a loved one or someone who is suffering, how might you figure this out? What is the questions you might ask?

B (15:13)

I always say, what's the driving force? What's the why? What are you hoping that this change in behavior or thought pattern is going to achieve for you? And so with this client, with the hair, it was like, if I could just get my hair in the ponytail without with it being just right, I can stop worrying about it. Or with the somatic obsessions, if I can just stop thinking about my blinking, I could finally be able to pay attention in class when I'm talking about the functioning of behavior for a client. You know, I notice that your family's getting frustrated that you're always wearing a hat in pictures. What's the function of the behavior?

A (15:47)

Yeah.

B (15:47)

Oh, it's because it covers what I perceive as a bald spot. Or here would be a good difference between OCD just right and somebody with bdd. I've had clients with BDD spend an hour to put on a hat because they're doing it strategically to look like it's covering up parts of their hairline. They don't like, but they don't want it to be too obvious. Whereas the other client was like, I can't stop putting on the hat until it feels right. And I have a good thought. So these are two different reasons, but on the outside, both of these people are doing the same thing. So it's the why. It's. What is the function of this behavior, the motive behind it, and what are you hoping to achieve that guides you as a clinician or a person with BDD as to why you're doing that behavior compared to something else?

A (16:29)

Yeah, I always love Lisa Coyne says, what the funk? Which. Which is what the function. That's your. Like, I always laugh when I think of supervising my staff. We were always saying, what the funk? Meaning, like, well, what's the function of this?

B (16:42)

I finally met her at the conference this year. I love her. She was so cool. She came up to me and was like, I'm so excited to meet. I'm like, no, I'm excited to meet you, but I love that. I'm gonna. Well, I'm not gonna steal it, but I'm gonna. I'm gonna give it to her. But I love that. What the funk?

A (16:54)

What the funk.

B (16:55)

Oh, that's so cool.

A (16:56)

Yeah. So what the funk? Regarding eating disorders, Chris, what is what. How might we just differentiate between BDD and eating disorders?

B (17:06)

I'm gonna be biased in the sense to say this is probably the one people ask the most and is the hardest because people do have BDD about their body parts. And so I think it's so much more obvious if the BDD is around, like, feeling like their eyes are too close together or feeling like their hairline isn't even. That's gonna. Nobody's gonna confuse that with an eating disorder. But, you know, I had a client that did eating disorder treatment for. I was, like, on and off for two years. What she didn't like is when she smiled, she felt like her face was too wide. And so her thought was, if I just, you know, eat less, lose weight in my face, when I smile, my face will look normal. So once again, it's the what the funk, Right? So somebody with the eating disorder is trying to manipulate their weight or their BMI or some focus about their appearance. Maybe the way clothes fits and they're using food in, like, a maladaptive way. So this could be restriction of caloric intake. This could be binging, but then purging. It could be purging. So somebody with an eating disorder, there's a relationship with Food, Food, sometimes even with exercise, as you know, and they're trying to, typically it's to get their weight down, to have a number on a scale. Sometimes it's more on how they see themselves in clothing, how certain things fit. And so the whole relationship. Food is a big part of that. Either, you know, not eating at all or what they eat. We, you know, I know you've done stuff on orthorexia. I experienced it when I worked at a gym. So sometimes it's that if I eat all healthy foods, I'll shed, you know, certain weight and stuff. People with bdd, if they're going to use food or exercise compulsively, typically exercise, we see that in the only qualifier in bdd. Another disorder under the BDD umbrella in the dsm, which is muscle dysmorphia. This is where a person thinks that they are not muscular enough. Typically we see that in gym culture where people start to experiment with steroids, trend like all these different kind of things that they're taking to try to get more muscular and yet despite the amount of muscle they have, it's never good enough. But that person may compulsively have a relationship with food in the sense of overeating, but it's very focused, like a lot of protein. Cutting certain foods to try to look bigger. Right. But in the case of an eating disorder, the person's relationship with food. When I've worked with clients that have both BDD and an eating disorder, I had a client that we had to, unfortunately she had to go back to treatment because she was only eating a bagel a day and the goal was to just lose weight. So once again, going back to the function, people with BDD sometimes do, you know, have a different relationship with food, but it's because like they think they look very unproportionate. So if they look thinner, they think they look better, they can cover up better. Sometimes it's you know, somebody who like a guy doesn't think his jawline is masculine enough. So if he eats less, his jaw will now be more emphasized which will make him look more masculine to women. So if there is a component of food bdd, it's because the body part that they're specifically hyper focused on. They think that the change in the relationship with their caloric intake will cause that body part to look better. If it's more about all over weight or like BMI or fitting into certain clothing size because of food, then we're going to diagnose that as an eating disorder. And like we were talking earlier, people absolutely do have both at the conference. The number is that they were talking about about 30%. So if somebody is trying to overall lose weight through reduction in eating and they're hyper fixated on a certain body part and trying to do something for that, you can have both.

A (20:42)

Absolutely, yeah. And I'll add here, as someone who had an eating disorder is I had an eating disorder but I did not meet criteria for bdd. It was more about wanting to control my food, to feel powerful, to feel in control of my emotions. I didn't like my body, but I also didn't hate it. It was more around perfectionism and so forth. However, I have met so many people and talk to so many people who will say that maybe it started with bdd. There was a part of their body like you've mentioned that they hated and they thought if I could just lose some weight then that part would look better. But then once they started restricting and they all, they started purging or they started using laxatives, something clicked in that and that became an additional component and then that's where the eating disorder, this need for over all over body thinness and the need to restrict can sort of spread. So I think what we can identify here is it could be both, it could be one leading to the other so that it's sort of like a chain reaction. It again, it depends on the, what the funk, what's going on underneath, what's the fueling that behavior. So I love that. And again, I think it's also, also important just for the sake of really being thorough here is there are folks who have an eating disorder who are in larger bodies.

B (22:10)

Yeah.

A (22:10)

And absolutely. And so I think then if they do have bdd, people dismiss them as having bdd saying you can't because you're in this larger body. Like you're. Maybe they binge and purge. It depends. So I, I think that is again where a thorough, thorough assessment is required to differentiate between these conditions.

B (22:34)

Yeah, I think about in my own journey, I don't always talk as much about it, but I mean when I went through a breakup, my first relationship, I fell into a horrible depression. I actually was 60 pounds lighter than I am right now. I got down to like 150 or so, which is not healthy for I'm, I'm almost 6:1 and I could not eat. I was eating only about, honestly I was only eating Raisin Bran in the morning. For some reason that was all I could eat. And I remember everybody thinking I had an Eating disorder. I didn't have an eating disorder. I was so depressed, I was so unhappy. You know, the relationship wasn't healthy, but it was my first and there's just a lot of stuff going on, so I just couldn't eat. I didn't have an appetite. It wasn't like I was liking how I looked. And in fact, I could tell I was looking sickly. If I would have gone to eating disorder treatment, it wouldn't have helped. I wasn't trying to lose weight, et cetera. When I got into orthorexia when I was running a gym, to me, it was less about how I looked and there was just such a culture of health. And in a, in a gym to a level that is not healthy, I could definitely recognize it now. So it was like almost frowned upon to eat a donut. Once again, not about weight gain, but it was like, why would I eat a donut? I'm living a healthy lifestyle. I need deep greens, I need to eat dark chocolates and almonds and avocados, skim milk, you know, it's just such a focus. And then BDD didn't even feel like the same category as those two experiences. So people can experience different things at different times. And that's why I really tell clinicians, like, nobody loves the assessment phase, both the client or the clinician. But I love it for the fact that a lot of these things can appear the same. You really want to make sure you're doing the right treatment for the client.

A (24:09)

Yeah, yeah, Amazing. All right, so let's talk about, as we talked about at the beginning, muscle dysmorphia and bigorexia.

B (24:19)

Yeah. So the idea behind muscle dysmorphia is one of the things that I'm seeing more and more now is there's such a gym culture. We call it gym talk on, you know, not me personally, but that's what it's called on, on TikTok. A lot of influencers now are gym influencers. People like David Laid is like worshiped. He's this guy, you know, that's in great shape. There's a lot of belief around. If I look a certain way, I'll get the respect at the gym. I'll get women and stuff. So the problem that's happening is now these 15, 14, 13 year old boys that could never get the same body as a 28 year old are striving to get that and sometimes putting themselves in unhealthy situations where they're overworking out and they could potentially, you know, tear A muscle, it can impact growth. And now people, too, are experimenting with different things. Some things like steroids, but there's a lot of other things on the market that don't fit into the category of steroids. And I saw that running gyms, I mean, I would see people taking things. A lot of different supplements aren't even, you know, flagged by the fda, and people can get them from. You know, I worked with a client with muscle dysmorphia who's getting all of his stuff from Russia sent over. So the idea behind muscle dysmorphia is when, like we were saying is somebody feels. Feels like they have to go to great lengths. A lot of times, to them, it doesn't feel like great lengths, but they go to great lengths to try to get bigger, more muscular. That's the problem, too, is because of the gym culture, they don't think they're doing anything wrong. And often what's so unhealthy sometimes about gym culture is they see everybody else who's not involving themselves in the same level of exercise is just like basic people. Like, your mom doesn't get it. You know, I've had clients that won't, you know, like, miss a workout. I mean, they'll be on a trip and they'll have a workout and not go. They're in Greece and they won't go see the Parthenon because they're in their hotel room doing a workout. I had a client once with muscle dysmorphia that canceled their trip early because the hotel gym was being remodeled and they didn't have a gym and wanted the gym. So muscle dysmorphia is where you're going out of kind of those normal bounds, that normal range of. Of of behavior because you want to get bigger sometimes. Bigorexia, that. That was a term that, you know, people used to use for muscle dysmorphia. But muscle dysmorphia is the actual clinical term. But bigorexia is where people want to be bigger. They think they're too small and they're trying to get larger and more muscular.

A (26:37)

Yeah, I've seen folks with muscle dysmorphia where I think they look lean and healthy. But what they see, that perception piece is they see this strangly string bean little guy. And even if someone, a medical professional or clinical professional or their loved one says, like, no, you're. You're within a lean, healthy body, their visual, their way of viewing themselves is as if they are just emaciated almost. And that's again, I think, again, where we kind of have to look at, like, is it both? Is there a component here of both? And I think that's something that we can continually assess for or seek consultation for.

B (27:24)

Yeah, I think what's so hard about muscle dysmorphia specifically, too, is like the, like, just like with orthorexia, right, we're telling people to eat well, get exercise, get movement, and it's getting reinforced. I mean, you, like you were saying, working at a gym, it's like when I worked there, you know, I ran gyms for. I won't say the name of the gym because didn't want to give him free promo. It wasn't my funnest. My funnest years, but I think it was. It was almost three years of running gyms for them. And it was like the, the atmosphere, sure, for a lot of people, the atmosphere was healthy. Like, you know, people are coming in to do racquetball, and there's a lot of people with injuries, swimming. But the people, especially the people that were there during the daytime and they're, you know, working out and lifting weights and bodybuilding, I mean, there was like, it was never enough. And in fact, what happens with people with muscle dysmorphia is they get a compliment. It's not like, oh, people think, I'm big, great, I can now be okay. It's like, it feeds that. So, you know, with muscle dysmorphia, it's really getting a client to recognize, like, hey, you're starting to put yourself in situations that are rigid and sometimes you're pushing yourself. I have a client I'm working with right now who had an injury, and the doctor, he had an injury, and the doctor was like, you can't work out. You know, for four weeks he went and worked out the next day. And I was like, look, we gotta do this. You could permanently damage yourself. But that urgency to not lose any of his gains overrode the doctor's advice. So that's what we've been kind of struggling and battling with is how can we find a balance if you're not going to completely give it up? Is there some activity you can do that won't make the body part that's injured worse? So, yeah, those are, some of those. Those specific features. So it's not necessarily different than BDD because it is a qualifier. And people with muscle dysmorphia can also have bdd, but it's different in the sense that the focus is all about not being Built. Built enough and big enough and muscular enough versus, like, a body part. I will say, though, sometimes the way I see the blend a lot is when somebody with muscle dysmorphia is starting to, like, do shows, starting to do bodybuilding competitions, starting to put themselves on social media, then they start to say, like, ooh, okay, I don't like the symmetry of my body. I wish my body was more symmetrical. Or, you know, I really like my body. It's starting to get big, but my face doesn't look right. My face has too much baby fat. I wish it was more muscular. Things like that. Or going back. We were talking in the last podcast about body parts and private parts. Sometimes my clients will say, okay, I really like that I'm getting bigger. But my private area doesn't grow from the gym, so now it looks like too small compared to my body. So all of that starts to kind of blend. But you want to make sure that you're recognizing what's the function of the behavior.

A (30:03)

Yeah, yeah. And I think it's really hard for all of these conditions, especially BDD and muscle dysmorphia is. They've been clearly told by doctors that the surgery that they're going to have could have severe repercussions or very bad recovery options. But they're so distressed that they're still willing to go through and take that risk. And I think, again, it's not a vanity metric that they're going for. Often they're just desperate to try whatever it will be to get them to not have to suffer with this disgust or embarrassment that they feel. So I just wanted to mention that just to kind again, bring it to the reality of they know the risk. They know that the surgery might be incredibly painful. But, you know, I've had clients who were one step away from getting leg lengthening surgery, which I hear is probably the most painful surgery you can have. But they were. If it meant that they wouldn't have to have this emotional agony, that they would do it very, very painful.

B (31:08)

No, I mean, you hit the nail on the head. Is. Is most doctors, as always, right when you go to get any procedure, they're very clear on the wrists. And people with BDD tune that out because all they hear is that there can be an improvement in looks. The leg lengthening one is very dangerous. It's very painful. But people think, hey, if I don't get it, no woman would ever want to date me. People won't take me seriously. It's that rigid black or white thinking, I need to get it, to get all my dreams met. And if I don't get it, my world is going to fall apart. So people will get chin surgery, which people don't realize. Like it's a whole movement. I mean it'. It's a lot of these surgeries aren't, you know, these little nips and tucks. It's pretty major. So unfortunately, the rational part that recognizes the danger gets nullified because the BDD is so dominant in the conversation.

A (31:54)

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B (33:25)

Yes, this is another what the funk, because this is something that a lot of the ways that people with gender dysphoria may outwardly do, you know, behaviors can absolutely be misread as, as BDD. So when we look at what the DSM 5 says about gender dysphoria, so this is that incongruence between the gender expression the person is experiencing, what they're feeling, and the gender they were assigned at birth. So that distress and you know, of that incongruence causes the impairment, causes the discomfort, and that could be a desire to want to change some of those primary or their secondary sexual characteristics because they have a strong desire to be treated as a different gender, the gender they feel that they are versus the one that they were assigned at birth. I always kind of note that not everybody who's transgender or gender diverse is going to experience gender dysphoria. I think that's something sometimes like CIS people or heterosexual people kind of misunderstand. Is that everybody has gender dysphoria, but no. So when I've worked with clients with gender dysphoria, they may be covering up, but they're not covering up because they have a body part that they are perceiving as a flaw. I have a client that's gender non conforming rather. But there's certain features on their body that they think makes them look more feminine. And so when they get misgendered or when they look in a mirror and see themselves at certain features as being too feminine, which they don't associate or identify as, that's where the dysphoria comes in. There's that incongruence from what they were assigned at birth to the gender expression that they hold. And so that is a very different reason behind why somebody may be covering up, getting a certain hairstyle, appearing a certain way versus bdd. With bdd, there's a disgust about that body part because they think there's something inherently wrong with it and that it's flawed. Whereas in gender dysphoria someone is saying, hey, this feature is not making me look androgynous or I identify as female, yet this feature people are, are saying makes me look masculine and misidentifying me. So that's the real difference. Now, the reason that this one is so important to understand the function is when we look at the research about what works in gender dysphoria, it's gender affirming care. When people get that gender affirming care are able to, you know, express their gender properly. Unfortunately, there's a lot of families out there that don't always let their under, you know, their children express their gender properly and are forcing them to wear a dress or a skirt or get a haircut a certain way. But when they do have that understanding, that love from the family, that gender affirming care, their mental health is better point blank. Right? But in BDD it's very different. If you were to allow the person with BDD doing everything they want to do to change their appearance, they're actually going to feel worse. The research is very clear about altering your appearance to getting surgeries, to getting certain haircuts, to getting your eyebrows redone, redone, redone. So that's why that one is so important to be able to tell the difference between these two is because if you were to do BDD treatment on gender dysphoria, the mental health will be worse. Right. If you were to affirm the person's concerns with their appearance and bdd, it'll Be worse. So that's why this one's important, is making sure that somebody gets proper care.

A (36:36)

Yeah. I had a client once who had breasts and they did not feel that they were. They were. They were born in a female body, but they did not feel a relationship with that. It didn't align with the way they. They saw themselves. And so they wanted to have their breasts removed. And their family had brought them in for BDD treatment. And they said, it's not that I have a problem with my breasts, I just. I don't identify with that being my gender. And I think that was very helpful for the family to understand because they had misunderst their wishes. And so that would be just another example of what that might look like. And in making sure we assess it correctly.

B (37:15)

Absolutely. And like we talked about earlier, individuals can have both. I've worked with plenty of clients that have both. I was working with a client who got sent to me for BDD treatment. But I could quickly tell we built a close relationship. They use they, them pronouns and they identified certain parts of their features, like you said, that are very feminine features and made them feel very feminine. That's not how they felt. And so they didn't have a relationship with that. So some of the camouflaging and the way that they were talking in the way that they were dressing was to feel more aligned with their gender. And they really, really didn't like their nose. And that had nothing to do with the nose makes me look masculine or feminine or makes people, you know, perceive me in a specific gender. It was simply just like they were of a certain ethnicity. They felt like that ethnicity. The noses were different than here in America. They didn't like it. They wanted a nose job. So we. What I always tell clients that is sometimes confusing when they have both is why, as a clinician, am I supportive in one aspect but not supportive in the other? And as I explained, I'm like, you identify as non binary. That's who you are. I want to champion that and be supportive of that. And that's going to make you feel validated and loved. But nobody says anything about your nose. I don't see what you see. Your family doesn't see what you see. We have in this room right now a different, you know, impression of what we see in the mirror. I see the nose as not having any distinct features that you are identifying. It's almost like we're looking at two different noses. And when I see something completely different than the client, that is a ding, ding, ding. It's bdd. So having to have that conversation with a client that, hey, this is why we're treating this differently. And usually they understand that and are supportive of that.

A (39:01)

Yeah. One thing we didn't talk about, but I'll just tell a story because you just reminded me, is I used to have my grandmother, we called her granny. And she was an amazing seamstress. And when I was about 12, I developed much quicker than my friends and I was very big busted, comparatively. And she made me these bras. She sewed them that would push them so far up against me, so tight, but she designed them and she would make them for me so that no one would notice. Now, I wasn't doing that because I had bdd. I was doing it because I was. Had social anxiety about it. I'd been. Boys had called me out for having bigger breasts and. And it was very, very humiliating. And I also wanted to sort of bring in that. I think social anxiety plays a role here too. Some people are so afraid of being judged for their body, especially if your body is different to the average, that they may is manipulate their body parts for that reason. Again, it's not bdd. It was more from a function of social, you know, distress and social anxiety.

B (40:13)

Absolutely. That's another one that gets confused. A lot of times when I have younger female clients that were misdiagnosed with bdd, it's because what you said, they developed a lot earlier than their counterparts in school, their peers. They're getting a lot more attention sometimes, unfortunately, from older men. I'm just this. It's not always fits in this exact category, but this is what I typically see clinically. And then they're getting all this attention from men. So now they're covering up, they're embarrassed, they don't like to go to school. Has nothing to do with bdd. They don't think something is deformed or unsightly or different in their appearance than other people. It's just like a lot of times, you know, because of birthdays and cutoffs, sometimes somebody might be in seventh grade who's 13 and some, but he's in seventh grade who's like 11, turning 12. And so they're developing first. And then there's this embarrassment of like, oh, now I'm getting attention I didn't want. I'm standing up in front of the class and there's certain body parts that other people don't have and they're staring and boys are snickering. And so that's why it's so important.

A (41:13)

Yeah.

B (41:13)

Noticing the difference. Right. In bdd, we don't like the appearance. We really think something's wrong with it. In social anxiety, we don't want the attention from people or sometimes has nothing to do with appearance. It might be with, you know, I'm going to say something and people will think I'm weird or strange or different or judge me or I might stutter. So both parties may not like to go out in public and might not like to speak in front of a class, but one of them thinks it's because of a feature on their appearance or features that is disfigured looking, et cetera, whereas the other person doesn't like the attention. They're getting either too much attention for the reasons we talked about or negative judgment. So once again, if we do assessment, and as we've been saying all podcasts long, people can have both. People can absolutely not like their appearance and think that people are going to deem them weird or strange.

A (42:02)

Yeah. And up until now, I think we were safe to say you could have all of what we've talked about.

B (42:08)

Yes.

A (42:08)

Right. Unfortunately, that's a lot to take, but there are folks out there who are managing all of those. We have one more to go. Tell us a little bit about BFRB's body focused repetitive behaviors and what are some common examples of that and how may it differ from BD related behaviors.

B (42:28)

So this is a definitely what is the function? Because people with BDD do have BFRBs, but there is a different reason behind it. I had a bfrb. I was a skin picking, but it wouldn't be considered bfrb. It was considered bdd. I used to take. It's not fun that I used to do this, but I used to take those acne pads because my BDD was focused on acne at the start. And I'd put an acne pad over like parts that I thought were bumpy or pimples. And then I took tweezers and I would scrape, scrape my skin with this acne pad to try to get the acne pads juice down in my skin to get rid of a pimple. If somebody is doing anything around their skin like that. Or sometimes people with BDD think they have too much body hair so they're plucking hairs to try to get rid of body hair. Or they think their eyebrows aren't even enough, so they're picking at their eyebrows to try to even them out. But compulsively, if the motive behind it that function is because they think that it's going to improve or camouflage behavior, we'd consider that bdd. Now somebody is going to have skin picking and hair pulling with a bfrb, but it could also be other things like nail biting, cheek biting, etc. When I work with clients with bfrb, some people do it out of anxiety. I was a cheek biter, so I technically do have a bfrb, but growing up I caused a lot of damage. It's gross because I can still feel where I was a cheek biter because there's dead skin and my dentist told me it's going to be there forever. But I used to do it when I was anxious, but I also used to do it when I was bored. And so a lot of times people with BFRBs, it could be distressing emotions, it could be boredom. I have a lot of clients that pull their hair or pick at their skin and they're just laying on the couch watching tv. They're just not very stimulated. So there isn't sort of this like motive to improve, enhance or cover up an appearance in a bfrb. It has to do with a lot of other stuff, like we said with sometimes anxiety or sometimes boredom. Sometimes it felt good, feels good for clients. I have a client that has a BFRB with his leg hair and he, it feels good to him. He likes that feeling. Right. He doesn't like the outcome of it. That's why he's here in treatment. But he does, he likes the feeling in the moment that is going to be why somebody may be doing a bfrb. Whereas in BDD it's thinking that it's somehow enhancing or improving skin, so they may look alike. I'm sure that when I've talked about my, you know, BDD, people with BFRBs have been like, oh, I've done that too. But they did it for a very different reason. I did it because I thought, you know, I have to clear up my skin. So we want to know in that one it's a lot more about motive behind the behavior.

A (45:01)

Yeah, yeah. And I think a lot of folks would be BFRBs. They may spend a lot of time in the mirror, they may spend a lot of time comparing, they may spend a lot of time engaging in treatments and stuff, which looks a lot like bdd. Right? So I think, again, it's really understanding what is it that you're trying to like. We talked about the funk, I think too, for bfrb, just for those who maybe you're new to that term, a lot of people, when they are doing that bfrb, if they're not doing it from a place of distress. Sometimes they go into a trance like. Like mode in their head where all their emotions and all their problems go away. And they're in completely in a trance by this action and this repetitive behavior. And it's not coming from a place of, like, there's something wrong with my skin and I have to get out of it. And so, again, exploring that piece might be helpful in determin, which is which.

B (45:55)

And I do want to add something. One thing that sometimes happens, which can confuse it even more, is somebody may be wearing pants to cover up their legs, but it's because they have scarring from. From hair pulling from a bfrb. So somebody, a clinician may say, oh, they have bdd. They're covering up their legs, they're hiding it. No, there is a visible condition going on. Right. There is bruising, there is scarring, there is bleeding on their legs. But it's because of the bfrb. So the BFRB wasn't originally designed because they didn't like their leg hair. They didn't like scabs on their legs. Right. It wasn't to enhance, improve, to change or alter their appearance. It was simply because they have a bfrb. But now because of the scarring or the bruising, et cetera, now they're covering their legs up because they're embarrassed or they don't want people to know that they did it. There's a. I don't know her last name off the top of my head, but there's a organization called the Picking Me Foundation. Yes. And Lauren, who is the founder of it, she's been very open about her experience, and she's covered a lot of her parts up. I worked with a woman with a bfrb and she would wear kind of caps and different things because she had parts of her hair missing. She wasn't pulling her hair for a BDD reason, but she was embarrassed about the patches missing. So she would wear wigs or wear things to cover up. So sometimes if that person is coming into treatment for that, that you wouldn't diagnose that as bdd. That's a bfrb, and that's an outcome of the bfrb. And that's. That's some of the shame the person might hold because of the noticeable, you know, hair loss, et cetera. So once again, really understanding the difference between why. And like I said, I've had clients that have a bfrb. They pick their. Their leg hair and they have BDD about their forehead size. So, you know, people can have Both.

A (47:41)

Yeah. Last question before we, we finish up. I'm just thinking about folks who have, let's say alopecia or they have a skin condition or they have had an accident where there has been, maybe they've lost a limb or they have a lot of scarring or so forth, but they're very embarrassed and have a lot of shame about, let's say, their alopecia or whatever it might be. How would you determine to when that person meets criteria for bdd?

B (48:15)

I'm so glad you asked this because this is the one thing I didn't think of when I was brainstorming for our podcast. But this is also one of the top questions I get. So I'm like, oh my God, that's perfect. People would have watched this whole thing and been like, they didn't even answer that question. Yeah. So what do you do? Right? Like what if you do. If somebody has some scarring, they have a facial burn, they're missing a limb, they have alopecia. Like, what if there is something that is noticeable? Right? Because when we look at the textbook, the DSM diagnosis criteria, it has to be a perceived flaw. It's either something that's not even there at all, or it's so minor and minute that only the person can see it. Right? Well, that's not going to be true if somebody has facial scarring or has a big birthmark and they're covering it up and hiding and won't leave the house. So this is my answer. Technically, do they meet criteria for bdd? No, if we're being DSM absolutists. No. The cool thing is, as we remember, BDD is an OCD related disorder. There is a diagnosis code and it's OCD and it's BDD like behaviors with visible flaw. So there is a DSM diagnosis code for that. So if somebody's utilizing insurance and a clinician is very, wants the person to get help, there is a diagnosis in that. I, I don't have that code. I have all the other codes that I use memorized. Like that one's rare. It's not usually, but I have seen some people with it. But it's not usual, but definitely the dsm. You could probably see it behind me on my book code. So there's, I have it bookmarked, but.

A (49:41)

Right.

B (49:41)

So there is that code. Here's the thing. People deserve treatment if they don't have bdd, but it is impacting them and they do have something visible, right? Like they are missing some of their hair or Maybe they do have a larger nose. Right. And kids are making fun of them and they come to you, please, as a clinician, don't say sorry, you don't meet DSM criteria for bdd. Go somewhere else. Right. They are still in pain. The other thing I do as a clinician, I mean I'll never understand what they're going through specifically, but I try to think like, what do I believe? Other people with similar, you know, larger nose or larger bodies or burns and stuff, how do they function? How do they seize the day? If that person has that same D, you know, that disordered component. So they're not living, they're not dating, they're not traveling, they're not living their life, then the cool thing is a lot of the treatment of BDD can be absolutely helpful. I would say the one caveat, anything that I talk about, the dysmorphic part where they are seeing something different than I'm seeing, I just don't include that, you know, and that's so important in people with BDD because they have to know that what they see in the mirror is different than what everybody else sees. But if somebody comes into your office and you do notice it and other people have said something to them and their families and people have made comments, right. Telling them that they have BDD is going to almost be insulting because they're like, everybody tells me I have this. But taking those parts out of treatment, the rest of the treatment will help the cognitive component, it's them seeing themselves differently in pictures and not focusing on that part they don't like in the mirror. The self compassion, the improvement of internal self talk, engaging in exposures. But that would look like getting a job, going out, being with people. So the really cool thing is BDD treatment is so effective that we can use it for, for that if they do have something that people see as like a flaw or is different than what other people have, you just wouldn't use the dysmorphic component.

A (51:36)

Yeah, they still need that response prevention pie of reducing those safety behaviors that they're engaging in around the body part. So thank you for helping me talk about that because I feel like that is a huge question that a lot of people have. Chris, you are amazing.

B (51:54)

Thank you. Well, it's because you're so great at doing this and so it's fun to talk to you. Makes me comfortable.

A (51:59)

Good. I feel like we got through so much. This could have been literally a seven hour course in and of itself. But I'm just so grateful that we got through that I hope that for the people listening you have some clarity now and you feel very validated that it doesn't have to be one or the other, it could be more than one, and that you are validated. If you feel like you've been misdiagnosed or mistreated in the past, tell us where people can hear about you and know more about you. We will put all the details in the show notes as well.

B (52:30)

Yes, real quick, I want to say the only other thing that sometimes gets misdiagnosed is generalizing Dietary disorder and depression, major depressive disorder. I will say, however, most clinicians can see the difference and typically somebody with BDD is experiencing anxiety and depression from the condition. But I think people have enough material in this podcast to really tell the difference. But I mean where they can find me. I'm first and foremost going to be bragging about CBT school. So if you are a clinician wanting to learn more of how to differentiate, we go into more depth in the training. Please head over to CBT school. For those experiencing B to D and especially experiencing multiple co occurring conditions, we're doing a training for people with BDD so that you can get that relief and really understand why it's important as somebody with both OCD and BDD who's experienced eating disorders as well, it's similar but it's important to know them. I call it like different languages, right? Because how you would treat it but also how you would experience it as a person and what treatment you would seek out is so different. I'm on the board of directors for the International OCD foundation and for one of their affiliates, OCD SoCal. I lead the affiliate advisory council for the IOCDF and run some of their special interest groups alongside other great people. So the BDD special interest group, I do it alongside Fugan Nezaroglu and Scott Granite and Katherine Phillips and some amazing people. But you can find me my name, Chris Tronson on all social media. Definitely check me out there. And then in the show notes we'll have the boring things like my email where I currently work and things like that. But definitely reach out to if your clinician needs help with some consultation if you're a person looking for treatment and I always tell people even if I can't see you because sometimes because of state lines and countries and stuff, the BDD treating community is pretty small. So I can try to help you find the care. But I think ultimately going to CBT school there's going to be a lot of really good resources that are going to help you at least get out of the deep, dark places that we get mentally with having bdd.

A (54:27)

Yeah. And hopefully we can train some therapists to get them to be more. More educated.

B (54:33)

That's the goal. That is the goal. I mean, we already struggle to. To get people paired up with an OCD therapist, but at least if we could get as many therapists out there treating BDD as ocd. I think a lot of people, we didn't talk about it, but there's high suicidality rates and suicide. You know, in bdd, there's a lot of isolation, a lot of depression. So if we can get some people linked up with BDD providers who are really going to help people improve their mental health, that's the dream. It's the goal.

A (54:59)

It is. It is. Thank you, Chris. I love you so much.

B (55:02)

Love you more. Thank you for always being open about your own experiences. Super helpful. And thanks for doing all that. You do have an amazing podcast, people. Check out all the different episodes as well.

A (55:13)

Thank you. All right, have a great day, everybody. 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.