On this episode, Dr. Amy and Teri welcome Dr. Katharine Phillips, one of the leading experts on body dysmorphic disorder (BDD), to discuss what it is, how it manifests in terms of symptoms, and how it’s treated. Dr. Phillips explains what “red flags” parents might see, the causes of BDD, and how to talk to your kids or teens if you have concerns. She also shares the difference between anorexia and BDD, two different disorders, and why BDD has nothing to do with vanity. Tune into this podcast to learn who is typically affected by BDD and when it usually sets in, as well as the three most common areas of the body that usually cause concern for those who suffer from BDD. You don’t want to miss this interview with a true subject-matter expert!
ABOUT DR. KATHARINE PHILLIPS
Dr. Phillips is internationally renowned for her clinical expertise and pioneering medical research studies on body dysmorphic disorder. She is a professor of psychiatry at Weill Cornell Medical College, Cornell University, where she has her clinical practice. She has more than 350 scientific publications, has given more than 600 presentations in the U.S. and abroad, and has given more than 500 media interviews, including Newsweek, Time, the BBC, NPR, 20/20 and the Oprah Winfrey Show. She’s published many books on body dysmorphic disorder, including “The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder,” “The Adonis Complex; The Secret Crisis of Male Body Obsession,” and the first edited volume on BDD, “Body Dysmorphic Disorder: Advances in Research and Clinical Practice.”
ABOUT US
Brainy Moms is a parenting podcast hosted by cognitive psychologist Dr. Amy Moore. Dr. Amy and her rotating co-hosts bring listeners conversations with experts on topics in parenting, child development, education, psychology, mental health, and neuroscience. Listeners leave with tips and helpful advice for helping moms and kids thrive in life, learning, and relationships. This episode is co-hosted by Teri Miller, MS PSY.
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On this episode, Dr. Amy and Teri welcome Dr. Katharine Phillips, one of the leading experts on body dysmorphic disorder (BDD), to discuss what it is, how it manifests in terms of symptoms, and how it’s treated. Dr. Phillips explains what “red flags” parents might see, the causes of BDD, and how to talk to your kids or teens if you have concerns. She also shares the difference between anorexia and BDD, two different disorders, and why BDD has nothing to do with vanity. Tune into this podcast to learn who is typically affected by BDD and when it usually sets in, as well as the three most common areas of the body that usually cause concern for those who suffer from BDD. You don’t want to miss this interview with a true subject-matter expert!
ABOUT DR. KATHARINE PHILLIPS
Dr. Phillips is internationally renowned for her clinical expertise and pioneering medical research studies on body dysmorphic disorder. She is a professor of psychiatry at Weill Cornell Medical College, Cornell University, where she has her clinical practice. She has more than 350 scientific publications, has given more than 600 presentations in the U.S. and abroad, and has given more than 500 media interviews, including Newsweek, Time, the BBC, NPR, 20/20 and the Oprah Winfrey Show. She’s published many books on body dysmorphic disorder, including “The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder,” “The Adonis Complex; The Secret Crisis of Male Body Obsession,” and the first edited volume on BDD, “Body Dysmorphic Disorder: Advances in Research and Clinical Practice.”
ABOUT US
Brainy Moms is a parenting podcast hosted by cognitive psychologist Dr. Amy Moore. Dr. Amy and her rotating co-hosts bring listeners conversations with experts on topics in parenting, child development, education, psychology, mental health, and neuroscience. Listeners leave with tips and helpful advice for helping moms and kids thrive in life, learning, and relationships. This episode is co-hosted by Teri Miller, MS PSY.
CONNECT WITH US
Website: www.TheBrainyMoms.com
Email: info@TheBrainyMoms.com
Social Media: @TheBrainyMoms
Dr. Amy's website: www.AmyMoorePhD.com
Sponsor's website: www.LearningRx.com
DR. AMY: Hi, Smart Moms and Dads. We are so excited to welcome you to another episode of the Brainy Moms podcast brought to you today by LearningRx Brain Training Centers. I'm your host, Dr. Amy Moore. I am joined by Teri Miller today as my co-host, and we are coming to you from Colorado Springs, Colorado. Teri and I are really excited to welcome our guest today, Dr. Katherine Phillips. Dr. Phillips is a psychiatrist who is internationally renowned for her clinical expertise and pioneering medical research studies on body dysmorphic disorder. She has more than 350 scientific publications, has given more than 600 presentations in the U.S. and abroad. And has given more than 500 media interviews to outlets, including Newsweek, Time, Dateline NBC, 2020, and the Oprah Winfrey Show. She's also the author of several books on body dysmorphic disorder, including the first book ever written on it. And is here today to talk to us about problems with body image, particularly in teen girls and women. And in fact, we handpicked her specifically for this topic, since she is regarded as the expert on it. Welcome Dr. Phillips.
DR. KATHARINE PHILLIPS: Thank you so much. Thank you for your lovely introduction. I'm really delighted to be here today.
TERI: We are definitely thrilled to have you here. And I told Amy before we started recording, I actually feel pretty nervous about this episode and this is a bit of a teaser, listeners, if you want to just make sure and keep listening, keep tuning in, we're going to get to kind of the personal story behind all this and a little bit, but this is very personal for me. I don't know that I have this official diagnosis and we'll dig into that a little bit more, but it's something that I have struggled with and I have not made it a secret that I've struggled with an eating disorder for years and this kind of issue, body dysmorphia. So I would love for you to tell us, starting off right at the get go, what's the difference between body dysmorphic disorder and just the normal insecurities that we have about our bodies?
DR. KATHARINE PHILLIPS: Great question. So body dysmorphic disorder, which I may refer to as BDD at times, popularly often referred to as “body dysmorphia,” but officially it's body dysmorphic disorder, is on a continuum with normal appearance concerns, but it's more, it's more problematic than that. So it's not your, you know, typical bad hair day or, “Oh, I have a pimple today, I better, you know, cover it up.” People with BDD get preoccupied with flaws that they perceive in their appearance, which in the eyes of others are nonexistent or just minimal. So they have distorted body image. So they think they look ugly, unattractive, sometimes they'll use very extreme terms like, like a “monster, freak,” whereas in the eyes of others they look normal and some are even very attractive. So there's that distorted body image and the preoccupation, usually at least an hour a day, worrying about how you look. And then, importantly, the preoccupation with these perceived defects and appearance must cause significant emotional distress or significant impairment in day-to-day functioning. So that's a very important way to differentiate the disorder, body dysmorphic disorder, which needs treatment from more typical, common, everyday body image concerns, which most people in the general population have. So again, that's significant. It must cause significant distress. So examples of distress could be low mood, anxiety, self-consciousness, sometimes suicidal thinking, and impairment in day-to-day functioning at the milder end of the spectrum. Maybe you lose some time, you know, to studying because you're, you know, obsessing about how your nose looks or how your skin looks, and maybe you can't concentrate as well in class because you're worried that other people are looking at you and thinking you look ugly. And some people actually stop going to school or stop working because—now that would be more severe, but because they think they look so ugly and they don't want to be seen. And some people have such severe body dysmorphic disorder that they don't leave their home. They don't, they just hide away and don't go out to do anything. And some even commit suicide. So there is a spectrum of severity and some, you know, people have milder BDD and then some people have very, very severe BDD. But I would say to differentiate from normal appearance concerns, it's are you thinking about a flaw in your appearance for at least an hour a day? And usually it's more than that. Usually it's in the range of three to eight hours a day on average. And do these worries, do these preoccupations cause you significant emotional distress or interfere in some meaningful way with your day-to-day functioning. And usually it's both, both distress and interference in functioning.
DR. AMY: So, if the flaw is real and there's the same type of preoccupation or social anxiety around not wanting people to stare, that is not BDD, is what I'm hearing you say.
DR. KATHARINE PHILLIPS: Yeah. I mean, if someone, for example, has, you know, is where—hair concerns are very common and especially in men and boys. They can worry they're going bald. If someone's actually bald or has very little hair, we wouldn't diagnose BDD because you're right. You know, the preoccupation, the defect in the eyes of others for BDD has to be nonexistent or fairly minimal. Nothing you'd really notice when you first met. So we'd give a slightly different diagnosis, but we usually treat it the same as BDD. And the treatments, which we'll talk about later, medication and therapy, can be helpful for those concerns too.
DR. AMY: And then what is the difference in this perception about the body between someone with BDD and someone with anorexia, for example.
DR. KATHARINE PHILLIPS: Yeah, so, you know, I think in most cases BDD can be pretty easily differentiated from other disorders, psychiatric mental disorders. It's sometimes, it's often misdiagnosed as something else, like OCD, which it's not. It's a compulsive disorder, it's different from that. But the eating disorder, anorexia, that's probably the most complicated, what we call differential. So sometimes it can be hard to kind of, not so much with anorexia, but with eating disorders that don't quite qualify for anorexia or bulimia where, where people think they're too, you know, they're too fat or the parts of their body are too fat and they have some abnormal eating behaviors but they don't quite, their symptoms don't quite qualify for anorexia or bulimia. Sometimes it's a little hard to say, is this BDD or is this what we would call, it's a big mouthful, but the diagnosis is called “other specified feeding and eating disorder.” So in other words, it's not quite anorexia, it's not quite bulimia, it's not quite another standard eating disorder. Sometimes there's a bit of overlap for some people, who, especially those who are concerned about weight, between BDD and eating disorders. But BDD usually involves the face or the head. But it can involve body weight. And if someone has a full-fledged eating disorder like anorexia nervosa, bulimia nervosa, and their only concern is that they're too fat or that their stomach's too fat or their thighs are too fat, something like that, we would actually diagnose the eating disorder, not body dysmorphic disorder. So the eating disorder diagnosis sort of trumps the BDD diagnosis. Now, someone can have both an eating disorder and BDD. So if they think that, you know, their skin is horribly scarred and it's not, or they think they're not, you know, their nose is horribly crooked and it's not, and they are preoccupied and very distressed and it's interfering with their day to day life, well, they can have BDD and an eating disorder, you know, with the typical eating disorder symptoms. But I think there is a bit of a misconception out among some people that the body image concerns that are symptoms of anorexia or bulimia constitute the disorder BDD, and they don't. So anorexia, they have some things in common, but anorexia is a different disorder than BDD. Bulimia is a different disorder. And that's important because the treatments are somewhat different. We approach the treatments differently. So if someone has a full-fledged eating disorder and thinks they're too, you know, anorexia bulimia thinks they're too fat, or parts of their body are too fat, we would just diagnose that as the eating disorder, not BDD. If that answer wasn't clear enough, because it is complicated. Please ask a follow up question. I'm trying to be as clear as I can.
DR. AMY: So if someone has a preoccupation with their weight, but it's not manifesting as, you know, restrictive eating, you know, or purging, that would be BDD.
DR. KATHARINE PHILLIPS: Yes, if their weight hasn't fallen so low that it's in the anorexia range. And yeah, if they don't have symptoms of bulimia, like bingeing, vomiting, laxative use, all that, you know, and they don't fulfill, their symptoms don't qualify for bulimia, but they have weight concerns that could, that could constitute BDD. So sometimes a little tricky to tell the two apart. What I do with someone with weight concerns, I really try to ascertain, do they really have anorexia? And, you know, go through all the symptoms that are required for the diagnosis. And do, is this really part, is this weight concern really part of bulimia? And go through all those symptoms. And so yeah, and then if the, if they do, then I would sort of attribute the weight concerns to the eating disorder. But they might have other body image concerns, you know, that would qualify for, for BDD. Like they think their chin is the wrong size, or they think their ears are sticking out.
DR. AMY: So is there a social or cultural influence on the development of BDD? I know you've been studying it for a very long time. I wrote my undergrad senior thesis in the early ‘90s on anorexia. And one of those things that I identified was, you know, this standard of beauty that was being perpetuated by television commercials and print ads. This was before social media. So I have to guess that social media has thrown fuel on the fire. Is that happening?
DR. KATHARINE PHILLIPS: I believe that certain forms of social media that focus on images and unrealistic images of people and altered images and, you know, are almost certainly contributing to an increase in the prevalence of BDD. Almost certainly. Now, do we have the studies to back that up? Not really. We know that for more typical body image concerns that are not body dysmorphic disorder because they're not that problematic that, you know, social certain forms of social media what I'll call image-centric social media, which focuses on appearance. And how people look that you know that that social media is probably increasing the prevalence of more typical normal body image concerns. That just makes sense. And for BDD, we don't have good studies, you know, we really don't. But I think it, it must be contributing because if you see unrealistic images, you, you constantly look at what we are supposed to look like, and it was bad enough when we just had the fashion magazines, right? And now, you know, all this exposure to social media at young ages and so much of what you see isn't real because of the filters, and now people can morph themselves, and, you know, we get likes on whether people, you know, how we look in a photo and all that sort of thing. I mean, it's hard to imagine not contributing to an increase in the prevalence of BDD, how common it is, and it's probably one more risk factor for getting BDD. But social media alone doesn't cause BDD because so many people are exposed to social media, right? And most people don't get BDD. So we know that BDD is, like other psychiatric disorders, is partly genetically determined. So maybe 40 to 50 percent of the risk of getting BDD is from, is genetically based.
TERI: Goodness! I feel like that's super insightful for our listeners to hear, because I think, maybe we even hear from the media or I don't know, we, as parents, maybe it's just as parents, as moms, we have this shame and guilt that my kid is showing these symptoms, you know, my daughter is showing these symptoms, you know, I caused it. I created this. And I think what I'm hearing is there may be this genetic component and it's something I've, I've looked at in my family that I, I can see these characteristics in my grandmother, and then I can see them in my mom and my aunts and my cousins and myself. And now things playing out in my daughters. And I've thought of it as, “Oh, well, that was the environment. It was because we have just passed down these, you know, this environment of performance. You have to look a certain way.” And what I'm hearing is there's actually a genetic component.
DR. KATHARINE PHILLIPS: Yes, definitely. We know this from big twin studies that have been done. About for BDD is about 40 to 50 percent genetically determined. So no blame there for anyone. And then, you know, there are multiple other risk factors. We don't fully understand what all those risk factors are. But some studies show suggest that if you've been teased a lot, you know, especially as you were younger, that may increase the risk of getting BDD. Of course, teasing alone isn't going to cause BDD, because most of us got teased about something when we were growing up, and most of us don't have it, right? But, yeah, so the cultural and environmental risk factors, since everything's not genetic, are important, but there's a lot that we don't understand about. But I think it makes sense to think in terms of it's partly genetically based, it's partly perhaps based on life experiences that you've had. And, you know, perhaps especially being teased, bullied, or taught that appearance is the main thing that matters about you as a person. And perhaps our society's emphasis, you know, an overvaluing of physical appearance. Probably all those things contribute. And for each person, the risk factors are probably a little bit different. So, yeah, we can't say there's just one thing that causes BDD. It's not just how you raised your child. It's not just that they start looking at social media at 13. It's, there's no one, no one cause. It's complicated.
DR. AMY: So talk a little bit about the behaviors that parents should be on the lookout for. What are those red flags that suggest maybe their child should be assessed?
DR. KATHARINE PHILLIPS: Yeah, that's a great question. One thing I didn't mention the definition of BDD because I focused on are you preoccupied with some perceived flaw in your appearance for at least an hour a day and does it cause a lot of distress or interfere in some way with day-to-day functioning? That's kind of the core of how we define it. But another important piece of it is these repetitive behaviors that people do, like checking mirrors a lot. Comparing your own appearance to that of other people. Some people with BDD change their clothes a lot because they're trying to find, they put on an outfit and they think, “Oh, this makes me look horrible, um, doesn't cover up my neck, which I think looks really gross, or doesn't cover my thighs well enough, or it makes me look ugly. You know, I've got to find a different one.” Sometimes skin picking is a clue that someone may have BDD because skin is the most common concern. Most people are concerned with more than one body area over the course of their, their disorder. And so skin is most common. Often it's perceived acne, scarring, “My skin's not perfect.” Hair is second most common. It can be anything about your hair. Curly, too straight, it's uneven. And nose is number three. But it can be anything about your face, anything about your body, and because people get so upset by seeing themselves the way they do, they try and check how they look. They try and hide it. They try and fix it. And so that leads to all these behaviors, the mirror checking, taking a lot of selfies and comparing your selfies, you know, one selfie to another. “Have I changed? Is this better? Oh, I look okay in this one. Oh, horrible. And all these others.” So these behaviors can be a clue that someone has BDD. I think other clues are that BDD often leads to a lot of social avoidance. Because if you think you look really bad, you don't want to be around other people because you think they're thinking that you look bad, right? And some people with BDD even think that, mistakenly think that other people are singling them out of the crowd and noticing them even more than they notice other people and thinking, “Oh, she looks so terrible. Look at that hair or look at that. Look at those lips.” And of course, this isn't going on. It is a misperception and because the person with BDD sees themselves that way, they think other people do as well and that they're even being singled out of the crowd and so that can make people not want to go out and be around other people. And sometimes people are just, you know, not going out and doing things because they're spending so much time obsessing and doing those repetitive behaviors, which we also refer to as rituals or compulsions. You know, they're often just stuck in the mirror for hours a day, picking their skin and redoing their makeup and trying to get their hair to look right and things like that. So I think those repetitive behaviors, social avoidance, feeling uncomfortable around others, and in school-age kids, school refusal. You know, school refusal is not a diagnosis. It's a behavior that can be a symptom of multiple diagnoses. And I think often, we don't consider whether it might be BDD, but I think something like more than 20 percent of the people who participated in my research studies, many, many, many hundreds of people dropped out of school because of BDD. It was something like 22 percent dropped out of school, sometimes as early as elementary school. It could be high school, it could be college. They just, again, sometimes were so obsessed they couldn't study, they couldn't do the work, they were stuck in the mirror, or they were just too anxious being around other people 'cause they thought everyone was staring at them and thinking they were ugly even though that wasn't really happening. It’s their misperception. So school dropout or strugglers, sometimes they'll go to school, miss some classes, or really be struggling to get the work done. Because it can be hard to concentrate 'cause you're obsessing about how your skin looks or how your hair looks. So these are some, you know, some of the clues. And if you, you know, I know we'll talk more about what to do, but if you, if you observe any of these clues, you know, it's always good to not ignore them, but, you know, if you have, depending on your relationship with the person is to ask, ask about them and see if you can get the person to open up a little and share with you, you know, what's going on.
DR. AMY: Who is the most affected? Like what age group? What gender? Who do you see this most in?
DR. KATHARINE PHILLIPS: Oh, I see it mostly in adolescents and young adults. I've seen people, children as young as five with classic BDD, a little boy who thought his hair just looked horrible and his teeth were too yellow. And he wouldn't go to school because of it. So he was five. I think he was in kindergarten at the time. Yeah, it was heartbreaking, but he got much better with treatment and he went back to school. I've seen people in their eighties with classic BDD. And some of whom have suffered, you know, for most of their lives. That's very, very sad. They didn't get the right treatment because, you know, we didn't know, we didn't have any treatments. We didn't know, what effective treatments were until quite recently, because BDD has all been understudied. People haven't known about it. We haven't had the treatment studies to really know what worked. But I would say most often, so BDD most often begins at age 12 or 13. Two-thirds of people have onset of full-fledged BDD, two thirds have onset before age 18. So this is a disorder that begins in adolescence and it's often missed. And so people don't come to clinical attention, seek treatment often until much later, and sometimes not for decades, which is really heartbreaking. It can onset, you know, onsets as early as age four or five and, and rarely onsets, almost never onsets after the forties, which is very interesting. So it's usually, it's very common in adolescents, young adults, and that's the age group I most often comes to see me, but it can occur in any age. And it affects slightly more females than males, but I think sometimes it's thought to be, you know, like anorexia or bulimia, a disorder that affects almost all, you know, predominantly female. And that's not the case, about 40 percent of people with BDD are male. So that's important to keep in mind. It occurs around the world, everywhere. And there have been reports, oh, from, from very isolated villages in Africa with no access to social media, television, movie theaters, anything, right? So, and it's pretty well, it might be especially common in countries like, Japan, Korea, we don't know for sure if it's more common there. We know that most of the prevalence studies, the prevalence studies have come from Western Europe and the U. S., the good ones. And it currently affects probably close to 3 percent of the population. So, and, you know, that's a lot of people. And I wonder, since the last really good prevalence study hasn't been done for eight years, I wonder if it's even higher than that because of the likely influence of social media.
DR. AMY: Aren't you dying to do that study now?
DR. KATHARINE PHILLIPS: No, I, yes, it would be great. It would be great. Yeah, it's those studies, you know, you want to do them without bias. You want to, like, sample, get a representative sample of an entire country, you know. That's a good way to do them and they're hard to do, but yes, I hope more good ones come along. Because I suspect the prevalence is going up.
TERI: And I think even the awareness, because I'm thinking about when you said onset 12-13, I think, you know, 20 years ago, 30 years ago, and I'm going to say 40 years ago, you know, people just didn't know we didn't know.
DR. KATHARINE PHILLIPS: No one knew about it. And, you know, you can, you can find really great case descriptions of people with BDD back into the 1800s from around the world. But when I was doing my psychiatry residency training in the late eighties, early nineties, no one knew about it. I think that was because, you know, I had wonderful supervisors. I got great training. It just wasn't on the map and it had fallen through the cracks of modern day psychiatry. The public didn't know about it and mental health professionals didn't know about it. I think that's in part because people with BDD are often very secretive about their concerns because they worry that they will be misperceived. They'll be considered vain or a superficial person, although BDD is definitely not vanity. And so I think there's a lot of shame associated with it. I think fortunately, these days, people are a little bit more willing to speak out about it, which I think has really improved its recognition. I think the other reason we didn't know much, we didn't know and no one knew about it, even in 1990, was because we had virtually no research studies. And so we didn't even know what all of its, what all of the symptoms were. We had no treatments at all. We didn't know what to do. We didn't recognize it. So people were getting misdiagnosed with things like schizophrenia. Don't get the right treatment for BDD if you're diagnosed with schizophrenia. Those are very different treatments. There's misdiagnosis, obsessive compulsive disorder, just, just depression, things like that, social anxiety disorder. So fortunately, you know, I started my work on this in the early ‘90s and doing research studies and treating a lot of patients. And others, other researchers have entered the field and we now know a lot, a lot more about it. Fortunately, we have great treatments now. But you're right back then, no one had heard of it. And then, fortunately it's becoming much better now.
DR. AMY: So that's a great lead in. Let's talk about treatments. What are the most effective ways to …
DR. KATHARINE PHILLIPS: We have two really, really good treatments. And one of them is certain medications called serotonin reuptake inhibitors. SRIs for short, sometimes called SSRIs. These are great and they, think medicines like Prozac, Zoloft, Lexapro. They also treat depression, OCD, bulimia. They treat a whole broad range of disorders. There are a lot of misperceptions about them out there. The ones I use don't cause weight gain. There's seven of them, and they do differ somewhat in terms of possible side effects. But most people I treat have no side effects at all. And, you know, if they do, they often get better with time or there are things we can do to minimize them. In a study I did of Lexapro, which is one of the SRIs, that's a citalopram of 100 people, only four out of 100 people stopped the study because of side effects. So people, and the longer they're on them, the better they tolerate. So, but most people do have no side effects and do really well. And they're not addicting at all. They're not habit forming in any way. So the one problem with BDD is that, they're often not dosed high enough for BDD. For the obsessional disorders, like body dysmorphic disorder and obsessive compulsive disorder, we often need to use higher doses of these medications. So some people get these medications, but the doses off is often too low.
DR. AMY: And so then they think they don't work.
DR. KATHARINE PHILLIPS: Then they think it doesn't work or they miss, they don't take them every day and then they think they don't work, but it may be because you're not taking every day. So, and if a lower dose doesn't work, you try a higher dose. And, but, you know, any one trial, good trial, like for— the length depends on how quickly you raise the dose. But, for a three- to four-month trial, you have about a 75 percent chance of having a good, very meaningful improvement just with one medicine. And then if you continue it longer, a lot of people keep doing better and better over time. There are other medicines we can add in, which can be very helpful. They can be lifesaving because some of these patients are very high risk for suicide. And so it's something you have to take really seriously. And you know, if it, those patients absolutely have to be on serotonin reuptake inhibitor in life. You. Because these medications can save your life. So, and then cognitive behavioral therapy, and I've, uh, collaborated with some colleagues to develop and test cognitive behavioral therapy and some other researchers have as well. It's a great treatment. It's very practical. You learn skills. You don't talk too much about your childhood or, you know, it's a very practical treatment where you learn skills to evaluate your thinking. And evaluate, are these thoughts accurate? Are they helpful? Learn ways to develop more accurate and helpful thoughts. We help people learn how to cut back on those repetitive behaviors, those very time-consuming behaviors, like mirror checking and comparing, because those just add fuel to the fire. Those behaviors just keep the BDD thoughts going. So it's very important to cut back on those. And it's very hard to just do that on your own if you have BDD. So the therapist teaches strategies, right, to gradually cut back on those behaviors. And then we also help people feel more comfortable going out and being around other people and going out and socializing. And again, it's just not shoving someone out the door and saying, “You have to go to the mall.” That doesn't work. It's doing it gradually and giving strategies that the person, the patient learns strategies so that the anxiety is manageable. And then over time, they end up feeling very comfortable going out. We do a little bit of mirror, we do some mirror retraining, but that's not staring in the mirror for long periods of time. But we know that people with BDDs, the brain, their brains over focus on tiny details and have difficulty seeing the big picture. We can see this in studies of the brain and brain activity actually. And so what we do with mirror retraining is we try to help people not zero in on the things they hate. Eyes, eyebrows, ears, whatever it is, and try to see all of themselves. We try to help them develop a better, bigger picture view of how they look and not zero in on the little things they don't like. So it's a great treatment and patients eventually learn to become their own therapists and continue to implement the skills going forward. So I'd say for mild, milder BDD, I like to start with cognitive behavioral therapy, unless the patient has other, a lot, a number of other disorders that might do well with meds with an SRI, but it's also fine to take an SRI. If you have moderate BDD, you could do both treatments or one or the other. You could, you know, you can choose. And I say for severe BDD, you need both. I would recommend both the cognitive behavioral therapy and the medication. And there are two therapist treatment manuals out there that have been shown in studies to be effective. One that my colleagues and I have published. The first author is Sabine Wilhelm, and I'm also an author, and then one by Doctors Veal and Neziroglu. Those are available on Amazon. Therapists can use them to kind of guide their treatment of BDD.
DR. AMY: Fantastic. Thanks. Okay, so we need to take a break and let Teri read a word from our sponsor. When we come back from the break, Teri's going to share some of her own experience, just so that listeners understand why this topic was so important to us today. And then we want to talk to you about the most important ways that parents can communicate with their child if they think that this is happening, if they see red flags, when we come back.
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DR. AMY: And we're back talking with Dr. Katherine Phillips, an internationally renowned expert on body dysmorphic disorder. And the reason that we asked Dr. Phillips to be here today is because Teri and I had a discussion about a month ago, after she was on the news and she had this really emotional reaction to seeing herself on the news, and I'm going to let her share that story just to give you guys some insight about why we wanted to talk about this today.
TERI: Yeah. So, yeah. So I was interviewed with for work and ultimately when that little clip came out, I was like, “Ah, I look terrible.”
DR. AMY: And actually you said you look like a cow.
TERI: Okay, well, that's terrible. That is the word. That's what I used. So, I have a, I have nine kids. And so our family chats are practically like social media. And we have this group text and I posted, you know, had the clip on there and like, “This is cool, you guys, I'm about to do this.” And so my kids tuned in live and then posted it afterwards said, “Oh my gosh, that was awful. If I had to live in this arena, if this was my job, I would not be able to function. This would be terrible. It's just, there's, the people that were with me looked very, very thin.” And I said, I felt like a cow next to them. And I texted that. And I'm very ashamed and sorry that I did that. And I know that's hurtful to my kids, to my daughters. And that's something that I've gotten a lot better about, not speaking that way about myself. There's a lot on social media now about how, you know, memes and things, the mom tearing herself down, you know. You sit there and criticize everything about yourself as, you know, I, your daughter, know that I look just like you, you know. And so I know that that's out there, and I have gotten a lot better. Here's a quick little description, listeners, maybe this would be something to watch for in your own kids. Now this may be an overlap, Dr. Phillips, with anorexia, and I think it probably is. And maybe it's not a true BDD diagnosis, but it's perhaps some body dysmorphia behaviors. So when I was in middle school, before any sort of anorexia dieting behaviors began, I danced with a ballet company and had for my entire childhood. And at about 11, 12, 13, I started to become very obsessed about what I looked like and would change clothes, would spend, would get up much, much earlier because I had to change clothes so many times. I would have clothes strewn all over my room all the time. I had a difficult time keeping up with putting my clothes back away because I had to change clothes so many times. It was obsessive and I didn't realize that at the time. And my mom didn't know she did her best, you know, we didn't have information about this back then. And that began very young and that continued for most of my life into my adult life. I got started to get therapy and intervention for anorexia, and what I see now is body dysmorphia behaviors, about 20 years ago. And so it's been a long process and something I continually have to work on. And I have wounded my daughters. Five daughters, four sons. I'm sure I've wounded them all and I would love for you to speak to that heartbreak that if it is something that we struggle with as a parent, if there is that genetic component, as I said, I can see it in my grandmother, my mom, you know, all the females in the family trickling down. What can we do? What could you suggest to help our daughters if it is something we struggle with.
DR. AMY: What is that communication look like? So that I think what Teri is saying is, how do I not, how do I not add, you know, the nurture part of that risk in the way that we communicate with our daughters? And even our sons right because we know that this …
DR. KATHARINE PHILLIPS: Yes, sons too. Yes. First let me just say no one's perfect. And we all have to be able to forgive ourselves, and if we feel we've made a mistake, and we all make mistakes, right? So, I think we can strive to do our best as parents and friends, and, but, you know, no one's going to be perfect. So, I think, you know, I think if you struggle yourself with body image concerns, it is good to try not to do a lot of those repetitive behaviors in front of your kids. I think it's really important not to put yourself down in front of your kids and say, you know, “I look ugly” or because, you know, what are they supposed to do with that really? And especially when you're an attractive person, it's confusing, right? And then, “Oh, what are the standards I'm supposed to be meeting here?” So I think, I think it's important not to put yourself down in terms of appearance, not to put others down in terms of appearance. You know, I've treated many people over the years who say they just grew up with family members just constantly criticizing everyone on television. And now it's probably social media and you know, about how they looked. And that gives a message. Now, again, that's not the only thing that's going to cause BDD. It might not be a risk factor for that particular person. You know, we talked about how BDD is almost half genetically determined, but, you know, I mean, you have to think, be aware of the messages you're giving out. And I think it can also potentially be problematic to overemphasize appearance in a positive way. I think, you know, sometimes, you know, you run the risk of kids thinking that appearance is the most important aspect of you. And so I think it's really important. I mean, of course, it's fine to say, “Oh, you look so lovely today.” Or, oh, you know, someone gets a haircut, or your haircut, of course, it's fine to give some positive comment, but I think it can be a little risky to overdo it and have a child learn that appearance is the main thing that matters about them. And we want to foster a very wide scaffolding for self-esteem, a very wide base for self-esteem for people to stand sturdily upon. So, it's your kindness, it's your patience, it's your, are you, you know, your thoughtfulness. All these personality traits. Are you generous? Are you working hard enough at school, you know, to, to be proud of what you're doing? And so I think, um, you know, are you good at a sport? We want, we want our kids to have a solid basis for self-esteem, not just appearance. So I think you don't want to put too much emphasis on it, either positive or negative. And certainly, certainly don't want to tease our kids about their appearance or call them fat or … That's tough and that's tough on kids. Right? So, I think we want to be very careful not to criticize yourself, but not to criticize others either. I think it's just probably good for parents to keep physical appearance a fairly minimal part of the conversation that they have with their kids and in their family. Because, you know, there's so many other things that are more important in life.
DR. AMY: So, you know, what Teri did not share was that she got some backlash from her older daughters about sharing that comment. And, you know, kind of brought up some emotions, you know, from them that, “Hey, we struggle with this too. You know, now you're adding this.” So, how do you walk that back, right? Like, how do you say, you know, to your daughter or your son, “Hey, I have talked a lot about my own struggles, right? And I gotta say, I'm sorry for sharing so much.” I mean, what does that sound like? What language do you use?
DR. KATHARINE PHILLIPS: Well, I think if you ever feel you've made a mistake about anything, it's always good to apologize and say you're sorry if you upset the person, right? And, so I think you can apologize and say, “You know, I didn't mean to upset you and, um, I didn't mean to call myself a bad, a name, you know, and we all need to be kind. We need to be kind to others and kind to ourselves. I was just inadvertent. It was just, I should have thought more before I spoke.” You know, you can say it in different ways, but I think if you feel that anything you've done is hurtful to others to just say, “I'm sorry that I hurt you by doing what I did.” And that models volumes. That models so much it shows you can acknowledge when you do make an error because everybody does. You have enough empathy to recognize that what you did might have been hurtful to another person. And then just say that again, and maybe have a little conversation about how so many other things matters make up who we are as a person. You know, and how you look is one, one small piece of that.
DR. AMY: Yeah, I love that too. I mean, especially because that kind of mirrors part of the therapeutic process that you talked about, right? That we're not going to focus on just that small flaw, right? We're going to focus on all of these other things we like about ourselves that we are going well for ourselves.
DR. KATHARINE PHILLIPS: And that's another thing, you know, we do in cognitive behavioral therapy is we do work on self-esteem issues also, because people with BDD overvalue appearance, not because they're vain. I see it as something the disorder does to them. It causes them to see the world in terms of physical appearance. And they usually don't want to be extremely attractive. They usually just don't want to look so ugly. And, of course, they don't look that, they don't look ugly. They're misperceiving themselves. But we do work on appearance and helping them appreciate other aspects of themselves, their talents, their ability, their strength. Not to make them arrogant or vain, but just to honestly acknowledge things, positive aspects of themselves that they might, they probably aren't recognizing. You know, and often we don't recognize our strengths and our abilities and, or we minimize, “Oh, that's not important.” But no. Things like being a kind person, a generous person. Someone who's thoughtful with others, you know, all of these are pretty important things.
DR. AMY: Yeah. And listeners, Teri did bravely go back and have that conversation, you know, with her kids and apologize and say, “Hey, I'm getting help for the struggle. Right. And I did not mean to. publicly share that struggle in our family group chat.” I just want listeners to know that follow through on that as well. So Dr. Phillips, what type of doctor, what type of clinician is the first step for parents if they're, if they're afraid that their child might be struggling or they might be struggling themselves?
TERI: That's exactly, yeah, that's what I, and just the last few minutes that we've got, that's what I want to address is how do you speak to your kiddo if you're seeing those red flags? And yeah, just what Amy said, where to go.
DR. KATHARINE PHILLIPS: Yeah, if you're seeing some red flags, I think the important thing is not to tease your child and maybe boys are at greater risk of being teased because boys aren't supposed to be worried about how they look. But BDD affects almost as many boys as girls. And so be kind, be gentle. You can say, “You know, I noticed that, you know, you've been late for school the past few days because you've been, you know, stuck in the mirror trying, you know, working on your hair. Can we, you know, can we just talk a little bit about that?” And I think you want to understand, avoid blame. Don't say you're just being vain. Don't just yell at them and say, “Stop being late for school. Get out of the mirror.” Which, you know, you're, even if you're frustrated, try to just have, sit down, have a conversation and, you know, “I've just been noticing this, that you've been in the mirror a lot, and I've been noticing that, you know, your grades are slipping.” Of course, that's not always BDD, but it could be. Whatever you're noticing that's worrying you. I would just say to sit down with your child and say, you know, ask, “Are you willing to just tell me a little bit about this? I'd really, I'm here to be helpful. I'd like to understand, you know, what you're going through and try to be helpful to you.” Don't try to talk them out of their concerns. Don't say, “Oh, just be a man.” You know, if it's a boy, “Stop worrying about this.” Or tell them to just get over it or tell 'em, “Well, what do you mean? You're beautiful?” Well, they often are beautiful, but that doesn't help. That doesn't help to just say, “Oh, but you're gorgeous.” Or, well, you know, “Your nose looks fine.” So it's better just to listen and hear what their concerns are. And take it seriously. You know, I would ask in what ways are their body or their appearance concerns affecting them? And are they feeling sad about it? Are they feeling anxious? Use whatever words you think they might understand. It's okay to ask if you are worried about this. It's okay to ask if they have any feelings that life isn't worth living. That's okay to ask. You're not going to put the idea of suicide in someone's head by asking. Now, you know, you don't have to ask that, but if you have any worry about your kid's really depressed, I would definitely ask that. And ask, “Is this getting in the way of your day-to-day life? Is it making you more uncomfortable around your friends?” Or, you know, “Is this why you're late for school?” Or, “Why do you want me to pick you up from school early?” If that kind of thing is going on. So be alert to the clues. Don't disregard them. Don't tease your kid, don't try and talk them out of it, don't just say, “You look great, there's nothing wrong with your hair.” That doesn't work. Because people with BDD see themselves differently than you see them, and they see themselves, so they really think they're right, that they really do look abnormal, so they can't just be talked out of it. And see a professional who's familiar with BDD, a licensed clinician. Could be a psychiatrist, psychologist, social worker, but you know, someone who has a clinical license. And ideally someone who's familiar with BDD because not all clinicians are. And some people who say they treat BDD are really just treating eating disorders. So, you know, that's another thing. That's another potential little problem is, you know, is it, are they really an eating disorder expert or do they really know or do they know BDD? But there's a lot out there that's written about it. You know, I've published on and other people do as well, you know, doctors and therapists can read about it, even if they aren't that familiar with it. I think many of them by now have heard about it. They can read about it. We have, you know, a lot of information about good treatments out there. You know, in journals and various places that professionals look for their information. So I think you just want to get professional help if you have any worries about your kid. Don't try to treat them yourself. You need, you need a professional who knows something about body dysmorphic disorder and who can provide either the medication, which really can take the symptoms away, or can do cognitive behavioral therapy for BDD. And if they're well trained as a cognitive behavioral therapist, cognitive behavioral therapy is this very practical treatment, always has to be tailored to the symptoms that the patient has. And so, if they don't know how to use CBT, cognitive behavioral therapy for BDD, well they can use one of these manuals. It's like a guide that, you know, can enable them to treat the disorder.
TERI: So that was, yeah, for listeners to hear as well, that was a helpful process for me, a very, very helpful process. I went through a CBT workbook sort of class program with a therapist many years ago, and that was incredibly helpful. And I was able to stop so many of those paralyzing behaviors, like having to change clothes all the time and try on clothes all the time. And that was kind of life-changing for me. So, yeah.
DR. KATHARINE PHILLIPS: ery freeing to get control over those behaviors with either the therapy or the medication can take that away. So I'm so glad you had that experience.
TERI: Yes.
DR. AMY: So just to summarize that last section, speak to our children with curiosity and empathy as we try to ascertain, “Hey, what's really happening? What are you really thinking and feeling?”
DR. KATHARINE PHILLIPS: Yes. And you can even acknowledge that it can be hard sometimes for people to talk about these things, but that you'd really like to hear what they're experiencing and that you would really like to be helpful to them. And, you know, if you think they're feeling ashamed, you can say, “There's no reason to feel ashamed. This is a common problem.” You know, sounds like, or if, you know, “These behaviors are fairly common, but I know they can be a problem and, and it sounds like you, you know, you're maybe there, but maybe they're a problem for you. Are you, will you just talk with me about this?” I think if they won't open up very much to you, to the parent, you can just seek, you know, seek professional help and see if they'd be willing to, you know, just meet one for an evaluation with someone who's familiar, you know, clinician, again, a licensed clinician who's knowledgeable about the disorder. But I think if they can open up to you about what they're going through first, that may just offer them some relief to be able to share that with someone and for you not to be critical that they're so focused on their appearance so, you know, obviously you don't want to say they're vain or you don't want to say this is silly or they bully them because of it, right? Just to show that you are accepting and hearing and trying to understand what they're going through. That can be enormously helpful and the first important step towards getting professional help if you think that's needed.
DR. AMY: Fantastic. Dr. Katherine Phillips, thank you so much for joining us today and sharing your wisdom and expertise and experience with body dysmorphic disorder. We really appreciate you taking time out of your busy schedule to bless our listeners. So listeners, if you want more information about body dysmorphic disorder and everything that we talked about today, Dr. Phillips has a ton of work that you can look at. So her website is katharinephillipsmd.com. And that's Katharine with an A R rather than an E R. K A T H A R I N E, Phillips with two L's, md. com. We'll put that link in the show notes and of course on the website, with her podcast episodes so that you can just link right to that. She has several books on the topic. Again, lots of scientific articles for those of you who would like to dig in on the statistics. Anyway, like I said, we'll link all of that. Thank you so much for listening today. If you liked our show, we would love it. If you would follow us on social media at the brainy moms, leave us a five-star rating and review on Apple podcasts. And if you would rather watch us, we are on YouTube. That is all the smart stuff that we have for you today. So we're going to catch you next time.
Teri: See ya.